Outcomes of indicators for the eMTCT HIV cascade in Barbados

OBJECTIVE: To evaluate the outcomes of indicators for the elimination of mother to child transmission (eMTCT) HIV Cascade. DESIGN AND METHODS: Pregnant patients seen in the public sector health care clinics delivering between Jan 1st, 2009 and Dec 31st, 2013 were studied retrospectively. HIV infected women and live births were identified from the Ladymeade Reference Unit and the Queen Elizabeth Hospital records. Extracted data was logged on an Excel Spread sheet, categorised in specific targets identified through a 5 year Regional initiative. Analysis was performed to determine the indicators for the eMTCT Cascade to evaluate outcomes in reaching the targets. RESULTS: In 5 years 15,436 births were recorded, 15,189 were live births. There were 9003 pregnant women who booked, and 8806 (98%) were HIV tested. There were 125 women (1.5%), averaging 25 per annum (ranging 1.2%-1.6%) who tested positive for HIV; 108 (86%) of these women (range 79%-100%) received ARVs during pregnancy. One hundred and twenty-one delivered infants, there were 124 live births and 1 stillbirth. Two infants tested positive by 2 successive DNA PCR tests during the period of study, in 2013. The eMTCT HIV rate was 0 for each of the first 4 successive years of study and 8% in 2013 (overall 1.7%). The eMTCT incidence rate x 1000 live births ranged 0 -0.7% (overall 0.13%). CONCLUSIONS: This study revealed that the 3 specific goals for eMTCT had been met during the previous 5 years. Efforts for continuing sustainability were needed.

Same-visit HIV testing in Trinidad and Tobago

BACKGROUND: The Ministry of Health (hereafter, Ministry) of Trinidad and Tobago is responsible for delivery of all health services in the country. The Ministry takes responsibility for direct delivery of care in the public sector and has initiated a process whereby those seeking HIV test results could obtain confidential reports during a single-visit to a testing location. The Ministry requested technical assistance with this process from the Caribbean Epidemiology Centre (CAREC). The United States Centers for Disease Control and Prevention (CDC) played an important role in this process through its partnership with CAREC. METHODS: Under the technical guidance of CAREC and CDC, the Ministry organized a technical working group which included representatives from key national HIV program services and technical assistance partners. This working group reviewed internationally-recognized best practices for HIV rapid testing and proposed a program that could be integrated into the national HIV programs of Trinidad and Tobago. The working group wrote a consensus protocol, defined certification criteria, prepared training materials and oversaw implementation of "same-visit" HIV testing at two pilot sites. RESULTS: A Ministry-of-Health-supported program of "same-visit" HIV testing has been established in Trinidad and Tobago. This program provides confidential testing that is independent of laboratory confirmation. The program allows clients who want to know their HIV status to obtain this information during a single-visit to a testing location. Testers who are certified to provide testing on behalf of the Ministry are also counselors. Non-laboratory personnel have been trained to provide HIV testing in non-laboratory locations. The program includes procedures to assure uniform quality of testing across multiple testing sites. Several procedural and training documents were developed during implementation of this program. This report contains links to those documents. CONCLUSIONS: The Ministry of Health has implemented a program of "same-visit" HIV testing in Trinidad and Tobago. This program provides clients confidential HIV test reports during a single visit to a testing location. The program is staffed by non-laboratory personnel who are trained to provide both testing and counseling in decentralized (non-laboratory) settings. This approach may serve as a model for other small countries.

Prevention of mother-to-child transmission of HIV in Haiti

OBJECTIVES: To describe the effectiveness of a program designed to reduce the rate of mother-to-child transmission (MTCT) of HIV at the primary HIV testing and treatment center in Haiti between 1999 and 2004. METHODS: All pregnant, HIV-positive women who attended the major HIV testing and treatment clinic in Port-au-Prince, Haiti, between March 1999 and December 2004 were asked to participate in an MTCT prevention program. Of the 650 women who participated, 73.3% received zidovudine (AZT), 2.9% received nevirapine (NVP), and 10.1% received triple-drug therapy when it became available in 2003 and if clinical/laboratory indications were met. Approximately 13.8% received no antiretroviral medication. All participants received cotrimoxazole prophylaxis and infant formula for their children. Kaplan-Meier survival analysis and the log rank test were used to evaluate program impact on child survival. RESULTS: Complete data were available for 348 mother-infant pairs who completed the program to prevent MTCT of HIV. The rate of MTCT in the study was 9.2% (95% CI: 6.14-12.24), in contrast to the historical mother-to-child transmission rate of 27% in Haiti. HIV-positive infants were less likely to survive than HIV-negative infants at 18 months of follow-up (chi(2) = 19.06, P < .001, log rank test). Infant survival improved with early pediatric diagnosis and antiretroviral treatment. CONCLUSIONS: The MTCT prevention program described proved to be feasible and effective in reducing vertical HIV transmission in Haiti. The authors emphasize the need to expand testing, extend services to rural areas, and implement early HIV diagnosis to reduce infant mortality.

HIV risk behaviors of Latin American and Caribbean men who have sex with men in Miami, Florida, USA

OBJECTIVE: The goal of this study is to describe the sexual practices, drug use behaviors, psychosocial factors, and predictors of unprotected anal intercourse (UAI) in a sample of Hispanic men who have sex with men (MSM) born in Latin American and Caribbean (LAC) countries who currently reside in Miami-Dade County, Florida. METHODS: Hispanic MSM (N = 566) recruited from community and Internet venues completed a computer-assisted self-interview assessing sociodemographic factors, drug use, sexual behaviors, and psychosocial factors. We focused on the 470 men who were born in LAC countries, including Puerto Rico. We first examined separately, by country of origin, the sexual practices, drug use behaviors, and psychosocial factors of the sample. We then collapsed the groups and examined the factors associated with UAI in the previous 6 months for the entire sample of Hispanic MSM from LAC countries. RESULTS: In the previous 6 months, 44 percent of the sample engaged in UAI, and 41 percent used club drugs. At the multivariate level, psychological distress, higher number of sexual partners, club drug use, HIV-positive status at the time of immigration, and greater orientation to American culture were significantly associated with UAI in the previous 6 months. CONCLUSIONS: Many MSM born in LAC countries engage in HIV-related risk behaviors in the AIDS epicenter of Miami-Dade County, Florida. Culturally appropriate interventions should address these risk behaviors in this underserved population.

Uptake of health care services and health status of HIV-infected women diagnosed through antenatal HIV screening in Barbados, 1996-2004

OBJECTIVES: To study utilization of HIV-related health care services and to describe the health status of HIV-infected women diagnosed through antenatal voluntary counseling and testing (VCT) for HIV infection in Barbados. METHODS: This is a descriptive study. The study population includes all HIV-infected women in Barbados diagnosed as HIV-infected through VCT for HIV infection during 1996-2004. RESULTS: The median duration of HIV infection from time of diagnosis to the time of this report for the 163 women diagnosed during the study period was 72 months (low range, 9 months; high range, 117 months). Of the 163 women, 102 (62.6%) had attended the centralized HIV/AIDS clinic for follow-up (care, treatment, and monitoring), whereas 61 (37.4%) had never attended the clinic. The median time lag between diagnosis of HIV infection and first presentation to the HIV/AIDS clinic was 36 months (low range, 1 month; high range, 114 months). Of the HIV-infected women who attended the HIV/AIDS clinic, more than one-fourth had severe immunodeficiency at the time of their first follow-up visit. Of the 53 women undergoing highly active anti-retroviral therapy (HAART) at the time of the study, 23 (43.4%) began the therapy within three months of their first follow-up visit. CONCLUSIONS: Early HIV diagnosis through antenatal VCT is not enough to ensure that women with HIV will get adequate and timely HIV-related health care. These women suffer significant premature mortality, largely related to inadequate follow-up.

AIDS epidemic update 2007

In 2007, advances in the methodology of estimations of HIV epidemics applied to an expanded range of country data have resulted in substantial changes in estimates of numbers of persons living with HIV worldwide. Because estimates of new HIV infections and HIV-associated deaths are derived through mathematical models applied to HIV prevalence estimates, new estimates of HIV incidence and mortality in 2007 also differ substantially from earlier assessments. The AIDS epidemic update reports on the latest developments in the global AIDS epidemic and has been published annually since 1998. The 2007 edition provides the most recent estimates of the epidemic’s scope and human toll and explores new trends in the epidemic’s evolution. The major elements of methodological improvements in 2007 included greater understanding of HIV epidemiology through population-based surveys, extension of sentinel surveillance to more sites in relevant countries, and adjustments to mathematical models because of better understanding of the natural history of untreated HIV infection in low- and middle- income countries. These adjustments to the methodology used are explained in more detail in the box “New data lead to changes in assumptions and improved estimates.”

Confidence intervals for biomarker-based human immunodeficiency virus incidence estimates and differences using prevalent data

Prevalent biologic specimens can be used to estimate human immunodeficiency virus (HIV) incidence using a two-stage immunologic testing algorithm that hinges on the average time, T, between testing HIV-positive on highly sensitive enzyme immunoassays and testing HIV-positive on less sensitive enzyme immunoassays. Common approaches to confidence interval (CI) estimation for this incidence measure have included 1) ignoring the random error in T or 2) employing a Bonferroni adjustment of the box method. The authors present alternative Monte Carlo-based CIs for this incidence measure, as well as CIs for the biomarker-based incidence difference; standard approaches to CIs are typically appropriate for the incidence ratio. Using American Red Cross blood donor data as an example, the authors found that ignoring the random error in T provides a 95% CI for incidence as much as 0.26 times the width of the Monte Carlo CI, while the Bonferroni-box method provides a 95% CI as much as 1.57 times the width of the Monte Carlo CI. Further research is needed to understand under what circumstances the proposed Monte Carlo methods fail to provide valid CIs. The Monte Carlo-based CI may be preferable to competing methods because of the ease of extension to the incidence difference or to exploration of departures from assumptions.

AIDS epidemic update: December 2004

The total number of people living with the human immunodeficiency virus (HIV) rose in 2004 to reach its highest level ever: an estimated 39.4 million [35.9 million-44.3 million] people are living with the virus. The number of people living with HIV has been rising in every region, compared with two years ago, with the steepest increases occurring in East Asia, and in Eastern Europe and Central Asia. The number of people living with HIV in East Asia rose by almost 50 percent between 2002 and 2004, an increase that is attributable largely to China's swiftly growing epidemic. In Eastern Europe and Central Asia, there were 40 percent more people living with HIV in 2004 than in 2002. Sub-Saharan Africa remains by far the worst-affected region, with 25.4 million [23.4 million-28.4 million] people living with HIV at the end of 2004. Just under two-thirds (64 percent) of all people living with HIV are in sub-Saharan Africa, as are more than three quarters (76 percent) of all women living with HIV. HIV prevalence in the Caribbean is the second-highest in the world, exceeding 2 percent in five countries, and AIDS has become the leading cause of death among adults aged 15-44 years in this region (AU)

Caribbean: HIV and AIDS statistics and features, end of 2002 and 2004

More than 440 000 [270 000-78 000] people are living with HIV in the Caribbean, including the 53 000 [27 000-140 000] people who acquired the virus in 2004. An estimated 36 000 [24 000-61 000] people died of AIDS in the same year. With average adult HIV prevalence of 2.3 percent, the Caribbean is the second-most affected region in the world. In five countries (the Bahamas, Belize, Guyana, Haiti and Trinidad and Tobago), national prevalence exceeds 2 percent. Overall, the highest HIV-infection levels among women in the Americas are in the Caribbean countries and AIDS has become the leading cause of death in the Caribbean among adults aged 15-44 years (Caribbean Epidemiology Centre, PAHO, WHO, 2004). Life expectancy at birth in 2010 is projected to be 10 years less in Haiti and in Trinidad and Tobago nine years less than it would have been without AIDS. Several countries and territories with economies that are most heavily affected by the epidemic in this region, including the Bahamas, Barbados, Bermuda, Dominican Republic, Jamaica, and Trinidad and Tobago. Yet most countries in this region have limited capacity to track the evolution of their epidemics, and are relying on data and systems that do not necessarily match the realities they are facing

Status and trends: analysis of the Caribbean HIV/AIDS epidemic 1982-2002

This publication which describes different epidemiological trends and patterns observed regionally and in each individual country is therefore the fruit of a productive collaboration between CAREC and Caribbean Health professionals working at the national level to develop and strengthen health information systems and disease prevention and control programmes... Since June 2003, much has been undertaken to recharacterise the HIV/AIDS epidemic in the region. This publication which CAREC hopes to see as an annual HIV/AIDS/STI report will be enriched with new data coming from efforts to recharacterise the epidemic

Characteristics of HIV-infected childbearing women in Barbados

Objective. To describe the demographic profile, social and family characteristics, and life-style traits of HIV-infected childbearing women in the Caribbean nation of Barbados in comparison to a control group of HIV-negative women. Methods. Data for this report were drawn from the Pediatrics HIV Surveillance Program of the Queen Elizabeth Hospital in Barbados. The data covered all HIV-infected women in the country who delivered between 1986-2000, with similiar data coming from a control group of HIV-negative childbearing women ... Additional data were collected from interviews with the women. Results. There were 182 HIV-infected women who delivered during the study period, and a group of 202 childbearing women served as controls. In comparison to the control group, the HIV-infected women were younger, more often multiparous, and more likely to have been unemployed at the time of their pregnancy. The HIV-infected women also had had an earlier onset of sexual activity, had had more sexual partners during their lifetime, and were more likely to be involved with an older sexual partner. At the time of giving birth most of the HIV-infected women were asymptomatic for AIDS and were living with either their parents (mother or father or both) or the baby's father. In addition, at the time of their six-weeks-postnatal visit, the large majority of the HIV-infected women who were diagnosed prior to childbirth, increased significantly over the study period, rising from 25 percent during 1986-1990 to 82 percent during 1996-2000. Slightly over one-fifth of the HIV-infected women had had one or more subsequent pregnancies after they had learned that they were infected. Conclusions. The early age of sexual activity as well as repeated pregnancies, especially from different and older partners, may have contributed significantly to both vertical and horizontal HIV transmission in Barbados. Future studies of HIV incidence and its trend among childbearing women could be important for monitoring the HIV epidemic in this country. Many of the HIV-infected childbearing women in our study were unemployed, sick, and had multiple children. Therefore, to help them to plan for and cope with the disease and also the care of their children beyond the perinatal period, there is a need to provide the women with repeated counseling with continued follow-up and, where necessary, additional economic, social, and medical support (AU)

HIV/AIDS curriculum development for health science students - a position paper with implications for research [abstract]

At present, the Caribbean is second to Sub-Saharan Africa in the cumulative prevalence of reported cases of the acquired immunodeficiency syndrome (AIDS). Therefore, there is an urgent need to broaden the exposure of our teritiary-level health science students to education and training relating to human immunodeficiency virus (HIV) disease, including AIDS. In addition to the teaching/learning agenda, there are immediate opportunities for research in medical education and sociology related to HIV/AIDS. The broad goals of training must include reinforcing the knowledge and skills to remain HIV-free and teaching students to contribute to the care and counselling of persons infected with, and affected by, HIV. At present, there are few infectious disease specialists in the Caribbean, so other professionals must be co-opted to train students in HIV prevention and care. To accomplish the task satisfactorily, we must identify teachers, augment their training and adjust our curricula. In approaching curriculum development, teachers must consider the characteristics of the learner, including age, gender, life experience and students' perception of their risk of contracting HIV. A variety of clinical, social and medico-legal issues can be explored through teaching about HIV/AIDS. Learning objectives should include not only the acquisition of technical knowledge and communication skills, but also the demonstration of growth in attitudinal areas of compassion and empathy. Teaching should be systematic rather than "opportunistic", ie every student should be exposed to an agreed core of relevant material pertaining to HIV/AIDS. Ideally, the curriculum should give every health science student the opportunity to knowingly meet persons living with HIV/AIDS in a supervised setting. The need to respect the patient's privacy and confidentiality must be exemplified by the teacher/mentor. Today's teachers must escape from the traps of denial and procrastination. We must make haste to strengthen our new professionals to confront this dangerous epidemic. (AU)

Clinical profile of patients newly diagnosed with human immunodeficiency virus [abstract]

OBJECTIVE: Comprehensive medical examination of newly presenting patients infected with the human immunodeficiency virus (HIV) is important to establish health status and stage disease progession. This study was conducted to determine the clinical and epidemiological characteristics of persons newly diagnosed with HIV presenting a primary care clinic for sexually transmitted infections (STIs). METHODS: A retrospective analysis of the medical records of 125 patients (aged 13 years and over) was undertaken over a 12-month period. All patients were serologically confirmed positive for HIV. Information abstracted included socio-demographic factors, presenting complaints and medical examination findings. The EPI Info 6 software was used for data entry and analysis. RESULTS: Most patients (64 percent) were between 20 and 39 years old (range 14-68 years; M:F= 1:1.4). Five percent were homosexuals/bisexuals. Sixty-five per cent used a condom less than half the time and 10 percent never used condoms. Males were more likely than females to have had multiple sex partners during the last three months (p= 0.01). Initial assessment revealed that 53 percent were asymptomatic, 24 percent symptomatic and 21 percent had AIDS at time of presentation. The most common presentation was generalised by lymphadenopathy (67 percent), which was significantly higher than skin rash (27 percent), oral candidiasis (24 percent), cough (24 percent), weight loss (24 percent), and pallor of mucous membranes (19 percent. p< 0.001). Co-infection with syphilis occurred in five percent of patients. CONCLUSIONS: This study confirms that young people continue to account for the majority of cases of newly diagnosed HIV infection. Heterosexual mode of transmission predominates and women are disapropriately affected. HIV infection should be considered as a differential in patients who have persistent generalized lymphadenopathy and other risk factors. (AU)

The legal and ethical issues related to the control of HIV

If it can be proved that an alleged assailant, being aware of his/her actions, intentionally exposed another to HIV, then legal actions should be taken to ensure that the individual is not afforded the circumstances to continue to spread the virus. (AU)

Availability of HIV care in Central America

Central America is an area with a growing human immunodeficiency virus (HIV) epidemic, but with marked limitations in its health care infrastructure. Estimated adult HIV infection rates range from 0.20 percent in Nicaragua to 2.01 percent in Belize. Hospitals and clinicans with experience in HIV care exist mainly, if not only, in capital cities and principal economic centers. Nationally sponsored social security systems in each country consistently offer a wider range of services than do ministry of health systems. Estimated access to the social security system ranges from 0 percent in Belize and 10 percent of the population in Honduras to 95 percent in Costa Rica. Combination antiretroviral therapy is not available through the ministries of health and zidovudine is only sporadically available for prevention of perinatal transmission. Combination therapy is available through the social security system in the countries of Guatemala, Panama and Costa Rica only. A wide variety of antiretroviral agents are available through private pharmacies in all countries except Belize. With the exception of Costa Ricans, most people with HIV infection in Central America have limited access to HIV-specific health services and limited or no access to antiretroviral agents. (AU)

Fourth-generation enzyme-linked immunosorbent assay for the simultaneous detection of human immunodeficiency virus antigen and antibody

The VIDAS HIV DUO Ultra, a fourth-generation immunoassay under development for the simultaneous detection of human immunodeficiency virus type 1 (HIV-1) p24 antigen and antibodies to HIV-1 and HIV-2, was evaluated. The enzyme-linked fluorescence immunoassay, performed on the automated VIDAS instrument, is claimed to detect early and established HIV infection. The assay was challenged with a total of 2,847 samples that included 74 members of 10 seroconversion panels, 9 p24 antigen-only-reactive members of a panel of group M clades, 503 consecutively collected samples from individuals seeking care in the University of Maryland Medical System, 1,010 samples from U.S. blood donors, 1,141 samples from patients in a high-incidence population in Trinidad, 83 samples from a clinic for sexually transmitted diseases in the Bahamas, 10 confirmed HIV-1 group O samples, and 16 confirmed HIV-2 samples from the Cote d'Ivoire. Reference tests were U.S. Food and Drug Administration-licensed HIV antibody screening, p24 antigen tests, HIV confirmatory assays, and the Roche Diagnostics Amplicor HIV-1 Monitor. The VIDAS HIV DUO Ultra demonstrated 100% sensitivity and 99.5% specificity overall, with a 99.7% specificity in low-risk individuals. The analytical sensitivity, as assessed by seroconversion panels and p24 antigen in samples, was equivalent to the sensitivity of the reference assays used to characterize these panels. The VIDAS HIV DUO Ultra is accurate, offers potential advantages over conventional HIV testing for time and cost savings, has walk-away capability, and correctly identifies both early and established HIV infections.

HIV/AIDS and children in the English-speaking Caribbean

This unique book provides an overview and informed discussion of HIV/AIDS as it impacts children and adolescents in the English-speaking Caribbean. With contributions from noted HIV/AIDS experts in Jamaica, Trinidad, Barbados and Grenada, it examines the biopsychosocial, environmental, spiritual and policy issues that affect HIV/AIDS prevention/service delivery issues for Caribbean youths (AU)