Latin America/Caribbean State of the Art HIV/AIDS Part One Paul R. De Lay, M.D. Chief, HIV/AIDS...
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Transcript of Latin America/Caribbean State of the Art HIV/AIDS Part One Paul R. De Lay, M.D. Chief, HIV/AIDS...
![Page 1: Latin America/Caribbean State of the Art HIV/AIDS Part One Paul R. De Lay, M.D. Chief, HIV/AIDS Division Global Bureau USAID March 13, 2001.](https://reader031.fdocuments.in/reader031/viewer/2022022404/56649e735503460f94b7292f/html5/thumbnails/1.jpg)
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
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HIV/AIDS
• Introduction
• The Epidemic and its Impact
• Interventions Appropriate for the Epidemic
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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
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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Source: U.S. Census Bureau, International Data Base and unpublished tables.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
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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Source: U.S. Census Bureau, International Data Base and unpublished tables.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
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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Source: U.S. Census Bureau, International Data Base and unpublished tables.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
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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
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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.
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Characteristics of HIV Epidemics in LAC Region
• Complex (mix of concentrated and generalized)
• ? Mature
• Surveillance issues
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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)
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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
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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
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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”)
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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
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Stages of the Epidemic
• Nascent
• Concentrated
• Generalized
• Mature
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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)
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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.”
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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
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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)
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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
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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”
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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
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Summarizing Recommendations for
Interventions
Epidemiologic Scenario
Intervention
Concentrated
-MSM
-IDU
VCT
Improved targeting
Generalized Improved targeting
VCT
PMTCT
ALL Improve surveillance
???CARE?????
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-end of Part One
Part Deux next………..