Status and Trends of the Global Hiv/Aids Pandemic

STATUS AND TRENDS OF THE GLOBAL HIV/AIDS PANDEMIC:

THE CARIBBEAN SITUATION

Paper presented for Satellite Symposium

at the XI International AIDS Conference

Vancouver, B.C. Canada

by

Caribbean Epidemiology Centre (CAREC)

Special Programme on Sexually Transmitted Diseases (SPSTD)

Dr Bilali Camara, Epidemiologist, Head, SPSTD

Ms Cheryl O’Neil, Communication Adviser

Ms Pauline Russell-Brown, Behavioural Sciences Adviser

CARIBBEAN EPIDEMIOLOGY CENTRE (CAREC)/PAHO/WHO

July 5 - 6, 1996

Reprinted: 19 February 1998

INTRODUCTION

The HIV epidemic started in the Caribbean in the 1970s and has matured over the last fourteen years. The first AIDS case was reported from Jamaica in 1982. In 1983, eight AIDS cases were reported from Trinidad and Tobago, all of which were gay or bisexual men. But, by 1985 female and paediatric AIDS cases represented 29 percent of the total cases reported to CAREC. This shift occurred very quickly, clearly showing that AIDS was no longer a disease of gay or bisexual men. The predominant mode of transmission of the human immunodeficiency virus (HIV) is heterosexual. This chapter presents a summary of status and trends of HIV and AIDS in 19 of the 21 CAREC member countries (CMCs) for which data are available: 18 English-Speaking Caribbean countries and Suriname. Information from the Netherlands Antilles and Aruba, members of the CAREC system since January 1996, and from Haiti is presented for completeness and contrast. Projections of the incidence, and demographic and economic impacts of the epidemic are also presented.

1. AIDS SURVEILLANCE

Since 1975, CAREC has collected and analysed communicable disease surveillance data from its 19 member countries: Anguilla, Antigua and Barbuda, Bahamas, Barbados, Bermuda, Belize, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Christopher and Nevis, St. Lucia, St. Vincent and the Grenadines, Trinidad and Tobago, Turks and Caicos and Suriname. These countries have a combined population of approximately 6.2 million people and constitute the Caribbean Community. Levels of health and development vary but all the countries have fragile economies.

Surveillance for AIDS began in 1982 and in 1985 when the transfer of HIV antibody testing skills to member countries was initiated, quarterly reporting of cases to CAREC, using a standard PAHO form, was introduced. This form provides information on distribution of cases according to age, gender and transmission category. At the country level, more detailed information on cases, such as clinical presentation, is collected, but not analysed in most countries. By the end of 1989, all CMCs had reported at least one AIDS case.

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

1.1. AIDS Case Definition and Reporting

In the early years of the epidemic several AIDS case definitions were used in the Caribbean (WHO-Bangui, PAHO/WHO-Caracas, CDC, WHO-CDC), but by February 1994, in collaboration with national epidemiologists and laboratory directors, CAREC developed a standardised AIDS case definition to be used for surveillance by its member countries. This definition is a combination of clinical symptoms and conditions, both major and minor signs and indicator diseases, associated with at least a screening test for HIV by a repeated positive enzyme linked immuno assay (ELISA) in the absence of other known causes of immunosuppression.

In some of the more developed CMCs (Bahamas, Bermuda and Barbados) the CD4 count has been recently introduced into the AIDS case definition so that it now corresponds to the most recent CDC case definition.

1.2. AIDS Situation in CAREC Member Countries

As of December 1995, a total of 8,196 AIDS cumulative cases have been reported to CAREC by 19 member countries. This represents 134 AIDS cases per 100,000 population. Cumulative total of AIDS cases for 1982-1995 are presented in Table 1.

Since 1982 when the first case was described, the AIDS epidemic has continued to take an enormous toll on the Caribbean population. At the regional level, the annual AIDS incidence rate has increased steadily between 1982 and 1995. As shown in Figure 1, there is inter-country variation in AIDS incidence rates. However, in general, every four to five years the absolute number of new AIDS cases has doubled. Doubling time is only two years for Jamaica.

The reported AIDS case distribution by country depends on the quality of disease surveillance and reporting, and population size. However, the situation as shown in Figure 2 is closer in many instances to the real dynamics of the HIV/AIDS epidemic in the different CMCs which are among the countries with highest incidence of reported AIDS cases in the world. The seven countries with a cumulative number of AIDS cases more than 100 per 100,000 population at the end of 1995 are: the Bahamas (829.9), Bermuda (566.3), Turks and Caicos (340.1), Barbados (244.4), Trinidad and Tobago (164.4), St. Kitts and Nevis (126.3), and Dominica (103.1).

In the 19 CMCs, deaths attributed to AIDS increased from 8.3 per 100,000 in 1991 to 13.5 per 100,000 by the end of 1994. Current mortality rates indicate that AIDS has become an important cause of death especially among the young adult population.

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

TABLE 1: CUMULATIVE AIDS CASES PER COUNTRY

1982-1995

COUNTRY / CUMULATIVE AIDS CASES / POPULATION
ANGUILLA / 4 / 8,960
ANTIGUA & BARBUDA / 55 / 63,880
BAHAMAS / 2094 / 255,095
BARBADOS / 632 / 258,600
BELIZE / 113 / 190,792
BERMUDA / 343 / 60,565
BRITISH VIRGIN ISLANDS / 12 / 16,749
CAYMAN ISLANDS / 19 / 28,100
DOMINICA / 74 / 71,794
GRENADA / 76 / 94,806
GUYANA / 697 / 739,553
JAMAICA / 1531 / 2,366,067
MONTSERRAT / 2 / 11,935
St KITS & NEVIS / 53 / 41,960
St LUCIA / 76 / 151,300
ST VINCENT & THE GRENADINES / 78 / 113,951
SURINAME / 215 / 404,000
TRINIDAD & TOBAGO / 2080 / 1,235,000
TURKS & CAICOS / 42 / 12,350

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

Death rates among AIDS patients in the CMCs are high. By the end of 1995, out of the total 8,196 AIDS cases reported to CAREC only 2,953 (36%) were alive. At the regional level, during the first three years, total AIDS cases was equal to AIDS deaths. Since 1985 the pattern has changed but over the last seven years (1989-1995), the ratio of AIDS cases to AIDS deaths has remained the same and stands at 1.5:1. See Figure 3.

The age distribution of reported AIDS cases shows that 74 percent are in the 20-44 year age group, and 5 percent in children under 15 years old. This observation underlines the fact that AIDS is impacting negatively on the economically productive age group.

Since 1985, the predominant transmission pattern reported for AIDS cases reflects HIV transmission. Given the long incubation period between HIV infection and the AIDS disease and the fact that HIV antibodies will persist life-long in infected individuals, data on HIV from young age groups, that is, adolescents and young adults, are needed to understand the dynamics of the epidemic in any specific population subset.

The male-female sex ratio of reported AIDS cases has decreased each year since 1982 as shown in Figure 4 and has remained at 1.7 and 1.9 over the last two years. Heterosexual transmission of HIV is the predominant mode of transmission. Males are more affected by AIDS than females in all age groups with the exception of those 15-19 years. This observation suggests that female teenagers are more likely than any other group to be exposed to HIV infection in the Caribbean. Between 1985 and 1995, the reported female AIDS cases and paediatric AIDS cases have increased steadily. See Figure 5. In the region, paediatric AIDS has become a major concern because of its potential to compromise major achievements made in maternal and child health in recent decades.

Although the male homosexual population is relatively small, HIV transmission in this group remains important, especially if one considers the possibility of under-reporting because of prevailing sociocultural intolerance of homosexuality. Sexual preferences are not fully disclosed and, therefore, not accurately reported in the AIDS data received from the CMCs. This might explain the high percentage of cases classified "Unknown", 18 percent, in the AIDS distribution per transmission category in Figure 6.

Blood transfusion accounts for 0.5 percent of AIDS cases, reflecting the widespread practice of screening donor blood for HIV antibodies and the use of preselection interviews of blood donors to reduce the likelihood of selecting individuals with high risk behaviours and blood-borne communicable diseases.

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

Intravenous drug use (IVDU) is not common in the Caribbean. This method of transmission accounts for 2 percent of the reported AIDS cases. Bermuda and the Bahamas are the only two CMCs where IVDU is considered to be a risk factor.

1.3. Accuracy of Reporting

It is recognized that reported cases of AIDS represent an underestimation of actual cases. Although the magnitude of underestimation is not known precisely, gross under-reporting is not suspected in the Caribbean, particularly in the smaller CMCs that have few hospitals and health facilities. However, AIDS reporting remains an issue in two countries, Guyana and Suriname, because of their size, geographic distribution of the population, the limited health coverage, fragility of surveillance systems and the relative inaccessibility of minority and migrant populations in the hinterland.

The total reported AIDS cases in 1995 represents approximately 70 to 79 percent of the estimated AIDS cases for that year. The level of under-reporting is estimated to be 20 to 30 percent. Adjusting for under-reporting, the real number of AIDS cases would be between 2,065 and 2,295 cases.

1.4. Reported AIDS Cases among Minorities

The first results of a study among West Indians of African descent regarding AIDS created much controversy in Trinidad and Tobago. Because of the sensitivity of this subject in the Caribbean environment and the discrimination which could consequently come from this type of study, CAREC has no immediate plans to survey minority groups. The Maroons or "Bush Negroes" and the Amerindians in Suriname and Guyana are two minorities which could be targeted in the future by CAREC. Such an activity must be undertaken with care to avoid stereotyping and to ensure that the individual and community rights are fully respected.

2. STATUS AND TRENDS IN HIV INCIDENCE AND PREVALENCE

2.1.HIV infection rates among blood donors reported between 1985 and 1994 by CAREC member countries is low. As shown in Table 2, the average HIV prevalence is 0.36 percent. This is explained by individual self selection, the use of preselection interviewing and an increasing focus on the recruitment and maintenance of regular blood donors in CMCs. The level of HIV seroprevalence among blood donors varies between countries and does not correspond to the level of the prevalence of AIDS in many instances.

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

TABLE 2: Number of Blood Donors Tested and % ELISA Positive in the CMC's

1985-1994

COUNTRY / Number Tested / %
ELISA Positive
ANTIGUA & BARBUDA / 223 / 0.00
ANGUILLA / 1,168 / 0.42
BAHAMAS / 16,822 / 0.73
BARBADOS / 25,318 / 0.22
BELIZE / NA / NA
BERMUDA / 16,346 / 0.02
BRITISH VIRGIN ISLANDS / 1,404 / 0.00
CAYMAN ISLANDS / 2,248 / 0.13
DOMINICA / NA / NA
GRENADA / 3,517 / 0.14
GUYANA / 15,082 / 1.12
JAMAICA / 104,063 / 0.34
MONTSERRAT / 2,206 / 0.27
ST LUCIA / 7,900 / 0.04
ST KITTS & NEVIS / 1,159 / 0.35
ST VINCENT & THE GRENADINES / 6,074 / 0.31
SURINAME / 21,059 / 0.10
TRINIDAD & TOBAGO / 61,212 / 0.44
TURKS & CAICOS / NA / NA

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

2.2.Sentinel surveillance data collected during 1995 among pregnant women in St. Lucia, St. Vincent and the Grenadines and Montserrat has shown a low prevalence. In Jamaica and Trinidad and Tobago where seroprevalence studies have been repeated in this group, moderate increasing trends in a context of low HIV seroprevalence have been observed. However, in a 1995 sentinel survey of pregnant women in Jamaica a 10 fold increase in HIV prevalence was observed in Kingston, 4 per 1000 population compared to 4 per 100 pregnant women. This increase could be attributed to differences in survey methodology. This last result, however, seems to be closer to the reality in a context where the number of AIDS cases is doubling every two years.

2.3.Prostitution or Commercial Sex Work (CSW) is generally illegal in the Caribbean and not socially accepted, making empowerment of CSWs very difficult. Serosurveys conducted among CSWs have shown high HIV prevalence rates. A serosurvey of CSWs conducted in 1995 by the Epidemiology Unit of Jamaica estimated that 12 percent of CSWs in Kingston were HIV positive, compared to 22 percent of CSWs in Montego Bay and 31 percent in St. James parish.

2.4.Among gay and bisexual men, HIV transmission remains important, accounting for 40 percent of the transmission in Trinidad in 1983; 15 percent in Jamaica in 1986 and 30 percent in Jamaica in 1995. Male prostitution and the social discrimination against homosexual men impact negatively on AIDS prevention efforts in the Caribbean.

2.5.HIV prevalence rates for STD patients show wide inter-country variation. An average rate of 1 percent has been observed in St. Vincent and the Grenadines and 28 percent in Guyana. The variation in prevalence rates is mainly due to differences in health policies and service systems regarding STD and HIV treatment. Recent data on the double infections, STD and HIV, published in 1995 by the Epidemiology Unit in Jamaica shows an increasing rate of HIV infection of 6 percent.

HIV prevalence in the general population as well as in special high risk behaviour groups is rising slowly but steadily. Targeted interventions associated with strong political commitment could positively affect the situation and achieve a levelling of HIV prevalence similar to that demonstrated in Kingston, Jamaica among the CSWs whose seroprevalence has remained at the same level, 12 percent, between 1989 to 1995.

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

The present situation in the Caribbean for CAREC's 19 member countries can be summarized as follows:

 There are an estimated 16,000 - 18,000 people living with HIV/AIDS in 19 CAREC member countries;

The sex-ratio among people living with HIV/AIDS in the region as of July 1, 1996 could be estimated between 1.5-1.9 males to one female;

The total number of births in the Caribbean was estimated at 140,200 in 1995. When we consider that the seroprevalence among pregnant women is 0.5 percent, the total number of children born with HIV infection is estimated to be 211;

Early in the HIV/AIDS epidemic, homosexual males appeared to be the most affected group. However, between 1985 and the present, the heterosexual population appeared to have become the most affected. In this heterosexual population, marginalized groups, for example, migrant farmworkers, prostitutes, crack-cocaine users and their partners may be most affected subgroups.

3. IMPACT OF PREVENTION PROGRAMMES

3.1 Behaviour Change

There is universal agreement that, in the absence of a protective vaccine or a cure for AIDS, the most effective means of controlling the spread and transmission of the HIV is to reduce risk-associated behaviours while enhancing those behaviours that maintain health. Health behaviour can be defined as “those personal attributes such as beliefs, expectations, motives, values, prescriptions, and other cognitive and emotional states and traits; and overt behaviour patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement" (Gochman, 1982). In this section of the presentation, the term behaviour is reserved for a variety of overt behaviours and actions - primarily risk behaviours and preventive health behaviours (activities undertaken by an individual who believes him/herself to be healthy, for the purpose of preventing or detecting illness in an asymptomatic state). The focus is on sexual behaviour at the individual level and includes condom use, and partner reduction behaviour and treatment seeking behaviours.

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Status and Trends of the Global HIV/AIDS Pandemic: The Caribbean Situation

3.1.1 Sexual Behaviour

The literature on sexual behaviour in the Caribbean presents a fairly consistent picture of heterosexual behaviour - one that reflects age and gender differences and strong social and cultural norms. In general, the prevailing pattern is one of:

 Early introduction/initiation of sexual activity. (By age 18 years the vast majority of Caribbean youth have had their first sexual encounter. For some males, first intercourse occurs as early as age six (Trinidad & Tobago Youth Response Survey, 1995). For girls, sexual initiation occurs later: on average, two years later than boys (Jagdeo, 1986; Russell-Brown, 1986; Powell and Jackson, 1988; Aymer and Pichery, 1993; Boxill, 1993; Chevannes, 1993). There is some evidence that age at first sex is undergoing intergenerational decline among males (Chevannes, 1985).

 Cultural acceptance of sexual experimentation for boys and young men (casual sex - serial monogamy - is an accepted part of a cycle that moves from unstable relationships toward stable relationships).

 Multiple concurrent partnerships which are socially acceptable for males.

 A perception of sex as natural and necessary for maintaining good health. Repression of sexual urges is believed to result in poor mental and physical health.

 Sex being independent of marriage and love.

 Unprotected first sexual intercourse and sexual intercourse with a "steady" partner (PAHO n.d.).

 Low approval rate of condom use among males and females.

 A discrepancy between strong cultural and moral taboos and actual sexual practice.

Poor partner communication on sexual needs and concerns.

Repression of same sex preferences. This may contribute to widespread bisexual practices (Royes, 1993; Hassad, 1993).