The UNAIDS report on the HIV epidemic in South America and the Caribbean describes a region which witnessed a 10% increase in total HIV prevalence in the past year, and where prejudice means that resources are often not directed to the communities most in need of HIV prevention.
In South America and the Caribbean a total of 2 million people are now thought to be infected with HIV, this includes 200,000 new HIV infections in the last year. In the same period 100,000 people are thought to have died because of HIV, the highest regional figure outside southern Africa.
Twelve countries in the region and have HIV prevalence rates of over 1%, with six Caribbean countries having a prevalence rate amongst pregnant women equal to or above 2%.
All the main modes of HIV transmission are present in most South American and Caribbean countries, and the UNAIDS report highlights significant levels of risky behaviour including early age of sexual debut, unprotected sex with multiple partners, and the sharing unclean injecting equipment.
However, between countries there are significant variations in the communities most affected by HIV. In the countries of South America HIV is mainly being transmitted via injecting drug use and sex between men, whilst in Central America sex (both between men and women and between men) is the principal mode of transmission. In the Caribbean, heterosexual sex, often in the context of prostitution, accounts for most cases of HIV transmission. However in Puerto Rico injecting drug is the main mode of transmission.
Haiti and the Domician Republic
The national HIV prevalence in Haiti has remained stable at between 5-6% since the late 1980s, although prevalence varies within the country from 13% in the poorest north-west to 2-3% on the border with the Dominican Republic. Haiti has some of the worst healthcare facilities in the entire region, and the country is struggling to cope with an estimated 30,000 AIDS deaths a year. The UNAIDS report suggests that the Haitian epidemic could spread further given that 60% of the population is under 24 and condom use is low, even though there is good knowledge about condoms.
In the neighbouring Dominican Republic, prevention efforts appear to have successfully stabilised HIV prevalence amongst 15-24 year olds, and the prevalence of HIV in pregnant women fell from 3% in the capital Santa Domingo in 1995 to less than 1%. Increased condom use appears to be a key factor. However, in some cities the prevalence amongst sex workers is as high as 12%, and little is known about the HIV risk behaviours amongst men who have sex with men.
Central America
Although regional HIV prevalence is 1% there are considerable variations between countries with men who have sex with men often accounting for the bulk of infections. In Nicaragua less than 1% of sex workers are HIV-positive, the figure rising to over 10% in Honduras. Amongst men who have sex with men the HIV prevalence figures ranges from a low of 9% in Nicaragua to a high of 18% in El Salvador.
Columbia and Peru
High HIV prevalence is also present amongst men who have sex with men in Columbia and Peru. In the Columbian capital of Bogotá, 18% of men who have sex with men are though to be HIV infected, the corresponding figure for the Peruvian capital of Lima being 22%. The UNAIDS report notes that 10% of men surveyed in Lima said that they had has sex with another man, and that 90% of these men also said that they had sex with women, suggesting that bisexuality could act as an important bridge for HIV-transmission between men and women particularly as “consistent condom use appeared to be a rare exception, especially during heterosexual intercourse.”
Brazil
Prevention efforts in the 1990s (including the provision of antiretroviral drugs and initiatives targeted at high risk communities) have helped keep national HIV prevalence below 1% in Brazil. However, UNAIDS says that “Brazil cannot rest on its laurels” as HIV prevalence rates of up to 6% have been measured amongst pregnant women in areas where access to healthcare is poor. “This has raised fears”, says the report, “that serious epidemics might be underway but undetected in some disenfranchised communities.”
Stigamitised communities
”The epidemics will not be vanquished until countries come to terms with the hidden but widespread realities of injecting drug use and male-to-male sex”, stresses UNAIDS stigma “can only fuel silent epidemics that are under way in this region.” Because of discrimination, says the report, funding is not directed to the communities most in need of HIV prevention efforts, particularly men who have sex with men. A need is also highlighted for improved epidemiological and behavioural surveillance data, and stronger political and social mobilisation.
Access to antiretrovirals
UNAIDS estimates that around 50% of people in need of antiretroviral therapy in the region are receiving it. However, access varies enormously from just 25% coverage in some countries to 75% in others. Increases to national HIV budgets, international partnerships and a four-fold increase in external aid should help improve antiretroviral access.
UNAIDS. AIDS epidemic update. 23-25, 2003.