10th PANCAP AGM 2010 HIV Prevention in the Caribbean: The Challenge

1. 10th PANCAP AGM 2010HIV Prevention in the Caribbean: The Challenge J Peter Figueroa Prof Public Health, Epidemiology & HIV/AIDS, University of West Indies Chair, UNAIDS HIV Prevention Reference Group

2. Outline • Theoretical Framework for HIV Prevention • Assess current prevention approaches • Prevention Priority Areas • Suggested approaches

3. HIV transmission dynamics R0= βx c x D • β : The average probability of transmission per sexual partnership • c: The average number of sexual partnerships formed per unit of time • D: The duration of infectiousness Thus, R0is the product of factors such as sexual behavior and sexual networks If R0 is > 1 the HIV epidemic continues to spread Ref: Anderson R

4. Underlying determinants Proximate determinants Biological determinants Demographic outcome Health outcome Theoretical Framework: Underlying, Proximate and Biological Determinants of HIV Transmission CRate of Contact of susceptible to infected persons New Partner Acquisition Mixing patterns Concurrency Abstinence Context & Culture Social vulnerability Programs Condom promotion Education & BCC STD referral Outreach testing IDU Risk Reduction HIV Transmission Mortality Condom use Concurrent STI Risky sexual practices ART BEfficiency of transmission per contact DDuration of infectivity ART Ref: Boerma JT and Weir SS. JID 2005:191:S61

5. The Spectrum of HIV Prevention

6. Assessing the Evidence for Prevention Interventions • Strongest – Randomized Controlled Trials • Fair – Observational studies • Weak – Other studies, anecdotal reports

7. HIV Prevention Research - The RCT Scorecard Ref: Wasserheit J (updated) Source: (2007)

8. HIV/STI Prevention ResearchRCT & Cohort Studies Ref: Wasserheit J (updated) Source: Wasserheit (2007)

9. Prevention Options & Challenges • Abstinence – efficacy 100%, effectiveness is virtually nil • Condoms – effective but use must be consistent • Female condoms – women do not like them • Be faithful – the spirit is willing but the flesh is weak • VCT & HIV testing– can be effective but may not be • Behaviour change communication – may be effective but of itself is not enough There is no magic bullet – “combination prevention”

10. Prevention Challenges • HIV vaccine – very difficult to develop • Microbicides – 8 failed, PR 2000 gel 30% effective • STI treatment – 1 RCT showed reduced HIV, 5 RCTs did not, considered to be important • Herpes suppressive treatment – 4 RCTs: HIV was not reduced • Pre-exposure prophylaxis – trials are underway • Male circumcision – 3 RCTs showed 60% reduction in HIV transmission from woman to man. There was no reduction in male to female transmission.

11. Increased risk of HIV transmission among HIV sero-discordant couples who get pregnant • 532 couples followed for 2 years in Kenya • 35.1% became pregnant • 41 HIV sero-conversions • HIV incidence = 4.6 per 100 couple years HIV transmission among couples who: Conceived 10.8% Did not conceive 5.9% Ref Brubaker S et al. 5th IAS Conference, July 2009. Abstract WELBC105

12. Mathematical Modelling Assumptions: 50% use over 10 years Ref . Lima V et al. 5th IAS Conference, 2009. Abstract WEAC105.

13. Principles in setting the Prevention Agenda 1.We must understand our epidemic In order to know where to focus prevention efforts 2.We must understand our culture & context In the Caribbean multiple partners and transactional sex are common 3.We must monitor and evaluate our response In order to know whether our efforts are effective

14. Principles in setting the Prevention Agenda 1.We must understand our epidemic • Who and Where were the last 1000 HIV infections? • Who are most at risk? • What are the drivers of the epidemic? • Proximate determinants • Underlying factors – social and cultural determinants

15. 1.We must understand our epidemic Factors driving the HIV epidemic in Caribbean • High risk behaviour of heterosexual men including: • unprotected sex with sex workers • multiple partners • transactional sex • Crack/cocaine use (< 1% in population) • High HIV rates among MSM due to unprotected anal intercourse with multiple partners. • High rates of bisexuality among MSM act as a bridge for HIV to reach the general population. • High rates of sexually transmitted infections • All sexually active persons are at risk because of sexual cultural patterns

16. 1.We must understand our epidemic Factors driving the HIV epidemic • Too many PLHIV are unaware of their HIV status • Testing those most at risk is key & • HIV testing of hospital admissions • Strong stigma and discrimination will ensure that MSM continue to hide and take risks • Unprotected anal intercourse • Bisexuality will remain common

17. 2.We must understand our culture & context % of Heterosexual Adults 15-49 years reporting two or more sexual partners in the past year Multiple Partners among heterosexual men & women are common in the Caribbean

18. Principles in setting the Prevention Agenda 3.We must monitor and evaluate our response • What programs and services do we have in place? • What is the coverage of our prevention services? • Are we using a combination of prevention approaches? • Are we targeting those most at risk? • Is our approach evidence based? • What is the impact?

19. 3.We must monitor and evaluate our response What is our Coverage of those most at Risk? Note: These are illustrative figures and do not represent a country

20. Prevention in the Caribbean We need a significant increase in prevention program coverage, quality & resources in order to achieve universal access and fully control the HIV epidemic. This means building our prevention capacity and developing our own expertise and prevention specialists with the help of high level technical assistance.

21. CRSF: Lessons re Prevention based on PANCAP experience 2002 - 2006 • Renewed emphasis on prevention is needed • HIV testing services have to be expanded • Prevention programmes among most at risk is crucial • Further development of behaviour change communication strategies is required • Acceptability & access to condoms must be increased • The supply of safe blood has to be sustained • Reduced transmission of HIV from mother to child is achievable

22. Prevention Priorities • MARPs especially MSM; SW & their clients • Target sites where persons go to meet new sex partners (PLACE method) • HIV rapid testing & risk reduction counseling • Prevention of mother to child HIV transmission • Reaching youth in and out of school especially girls involved in transactional sex • Tourism sector – address sex tourism • Workplace and targeted community programs • Condom promotion & skills We must build capacity and improve quality

23. How to reduce high HIV rates among MSM? • Challenge, empower, & support MSM to take more responsibility for promoting safe sex among MSM • More public education about the risk of anal sex • Ensure access to condoms & lubricants • Get the buggery act repealed using a test case • Take action when discrimination occurs • Measures to reduce social vulnerability among MSM such as safe spaces, programs for street boys, social support and counseling

24. Expand HIV Testingas an entry point to prevention & treatment Many PLHIV are unaware of their HIV status Test: • All pregnant women • All persons with a STI – public & private sectors • All adult hospital admissions, A & E departments • Most at risk populations eg SW, MSM • Selective Family Planning clinics • Private sector labs on a walk in basis • Fast track HIV testing at public clinics

25. Reducing HIV Stigma & Discrimination • Anti-discrimination policies and laws are needed • Model acceptance and support of PLHIV and promote positive images and stories • Focusing on rejection, stigma and horror stories reinforces negative images and is self-defeating • Support more PLHIV to disclose to a wider circle of family, friends and co-workers • Media campaigns & public events that include prominent persons alongside PLHIV

26. Towards a Policy on Male Circumcision in the Caribbean • Most policy makers & physicians would be reluctant to promote circumcision among adult males • It is unlikely to be cost beneficial with an HIV prevalence of 1% • Surgical waiting lists are already very long and there are many other more pressing health problems • Still need to promote consistent condom use • Most men will be reluctant to be circumcised

27. Towards a Policy on male circumcision in the Caribbean • A viable policy to consider may be: to promote circumcision of male infants • This may be a worthwhile investment in the future • There would still be many issues to resolve

28. Reducing Social Vulnerability • Social programs & opportunities for the poor including education and employment • Policies that address critical social needs and rights of vulnerable populations • Greater gender equity and reorientation of gender roles • Expanding HIV prevention to the youth and those most at risk eg CSW, MSM • Safe sex education and life skills in schools and parenting programs

29. Suggestions to consider Give higher priority to sustainable approaches that build the capacity of countries to: • Respond effectively to the HIV epidemic • Train competent HIV program leaders/managers • Train persons properly in HIV prevention – both leaders and outreach staff • Train specialists in Monitoring & Evaluation How do we: • Institutionalise the capacity to reproduce the human resources needed

30. Suggestions to consider Give higher priority to: • Technical assistance that transfers skills and technology and builds capacity of country programs • Ensure that innovative approaches and best practices in countries are identified, shared and replicated • Promote more horizontal technical assistance between counties • Promote more exchanges between countries so that HIV staff can experience different settings

31. Focus on Sustainability • Continue to build strong partnerships • Improved co-operation among partners to enhance synergies and reduce duplication • Integration of HIV with other health and social programs • More emphasis on strategic structural changes – policy, laws, social & cultural norms

32. Conclusions • We have committed ourselves to universal HIV prevention services • This must be supported by an evidence based approach and a conceptual framework • We must know our HIV epidemic & our culture • We must monitor and evaluate our response • We need to target those most at risk • We must build our HIV prevention capacity in order to expand coverage and improve quality • Structural changes to reduce social vulnerability and change social norms & gender inequity is important