Cost-effectiveness of pneumococcal conjugate vaccination in Latin America and the Caribbean: a regional analysis

OBJECTIVE: In Latin America and the Caribbean, routine vaccination of infants against Streptococcus pneumoniae would need substantial investment by governments and donor organizations. Policymakers need information about the projected health benefits, costs, and cost-effectiveness of vaccination when considering these investments. Our aim was to incorporate vaccine, demographic, epidemiologic, and cost data into an economic analysis of pneumococcal vaccination of infants in Latin America and the Caribbean. METHODS: We previously used a structured literature review to develop regional estimates of the incidence of disease. Cost data were collected from physician interviews and public fee schedules. We then constructed a decision analytic model to compare pneumococcal conjugate vaccination of infants with no vaccination across this region, examining only vaccine's direct effects on children. RESULTS: Pneumococcal vaccination at the rate of diphtheria-tetanus-pertussis vaccine coverage was projected to prevent 9500 deaths per year in children aged 0 to 5 years in the region, or approximately one life saved per 1 100 infants vaccinated. These saved lives as well as averted cases of deafness, motor deficit, and seizure result in 321000 disability-adjusted life years (DALYs) being averted annually. At vaccine prices between US$5 and US$53 per dose, the cost per DALY averted from a societal perspective would range from US$154 to US$5252. CONCLUSION: Pneumococcal conjugate vaccine was highly cost-effective up to $40 per dose. Introduction of pneumococcal vaccine in the Latin American and Caribbean region is projected to reduce childhood mortality and to be highly cost-effective across a range of possible costs.

Characterization of invasive isolates of S. pneumoniae, H. influenzae, and N. meningitidis in Latin America and the Caribbean: SIREVA II, 2000-2005

OBJECTIVES: To analyze the phenotypical characteristics and the susceptibility to antibiotics of the circulating strains of Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis circulating in Latin America and the Caribbean from 2000-2005. Potential coverage by conjugate vaccines was evaluated. METHODS: Conventional methods were used to study the distribution of the serotypes or serogroups of 17 303 strains of S. pneumoniae, 2 782 strains of H. influenzae, and 6 955 strains of N. meningitidis isolated from cases of pneumonia, meningitis, sepsis, bacteriemias, and other invasive processes. The antimicrobial susceptibilities of the study strains were evaluated. The isolates came from 453 sentinel surveillance sites in 19 countries in Latin America and four in the Caribbean, as part of the SIREVA II (Network Surveillance System for the Bacterial Agents Responsible for Pneumonia and Meningitis) project. RESULTS: S. pneumoniae serotype 14 was the most frequently isolated (21.1 percent), especially in children under 6 years of age (29.1 percent). The potential coverages by hepta-, nona-, deca-, and trideca-valent antipneumonia conjugate vaccines were 59.0 percent, 73.4 percent, 76.5 percent, and 85.9 percent, respectively. Of the isolates, 63.3 percent were sensitive to penicillin. H. influenzae serotype b was present in 72.2 percent of the isolations from children under 2 years of age, whereas 8.6 percent produced serotypes a, c, d, e, and f, and 19.2 percent could not be serotyped. The rate of H. influenzae beta-lactamase-producing strains isolated from children under 2 years of age was 16.3 percent. The most frequent N. meningitidis serogroups were B (69.0 percent) and C (25.7 percent); 65.8 percent and 99.2 percent of the strains were susceptible to penicillin and rifampicin, respectively. CONCLUSIONS: These results highlight the importance of comprehensive epidemiological surveillance of S. pneumoniae, H. influenzae and N. meningitidis in Latin America and the Caribbean. The great heterogeneity found in the distribution of S. pneumoniae serotypes among the countries studied could reduce immunization coverage. Conducting a specific analysis of each country to adjust the introduction of new conjugate vaccines and determine the best immunization plan is recommended

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.

Obstetric care and severe pregnancy complications in Latin America and the Caribbean: an analysis of information from demographic health surveys

OBJECTIVE: To compile, consolidate, and analyze information obtained in surveys conducted by the MEASURE DHS [Demographic and Health Surveys] program, concerning obstetric care and pregnancy complications for women in Latin America and the Caribbean, in the five years before the survey. METHODS: This exploratory study utilized data from demographic surveys carried out in the 1990s in seven countries of Latin America: Bolivia, Brazil, Colombia, the Dominican Republic, Guatemala, Nicaragua and Peru. The study describes the characteristics of the women who were interviewed and of the obstetric care that they received in the five years before the respective survey, and it also estimates the occurance of prolonged labor and of hemorrhagic, hypertensive, and infectious complications in those five years. RESULTS: The median number of prenatal consultations ranged from 4.7 in Bolivia to 6.6 in the Dominican Republic. More than 40 percent of deliveries in Guatemala, Peru, and Bolivia were attended by traditional midwives, relatives, or other persons without formal training. The highest rates of deliveries performed in health care facilities (>90 percent) were in the Dominican Republic and Brazil. In Guatemala, Peru, and Bolivia more than 45 percent of deliveries were at home. The highest rate of cesarean delivery was in Brazil (36.4 percent), and the lowest rates (<12 percent) were in Peru and Guatemala. The rate of pregnancy complications reported by the women surveyed was 16.7 percent in Brazil, 17.9 percent in Guatemala, 42.1 percent in Colombia, 42.5 percent in Nicaragua, 43.0 percent in the Dominican Republic, 51.7 percent in Bolivia, and 51.8 percent in Peru. CONCLUSION: The reported occurance of severe pregnancy complications in the surveys we examined was well above the 15 percent rate reported in other scientific literature, suggesting that these complications may have been overestimated in the MEASURE DHS surveys. Prior validation of the questionnaires used for data collection is extremely important in the generation of high-quality data (AU)

Economic and health burden of rotavirus gastroenteritis for the 2003 birth cohort in eight Latin American and Caribbean countries

OBJECTIVES: To estimate the health and economic burden of rotavirus gastroenteritis in hospital and outpatient settings in eight Latin American and Caribbean countries (Argentina, Brazil, Chile, Dominican Republic, Honduras, Mexico, Panama, and Venezuela). METHODS: An economic model was constructed using epidemiological data from published articles, national health administration studies, and country-specific cost estimates. For each of the eight countries, the model estimated the rotavirus outcomes for the 2003 birth cohort during the first five years of life. The main outcome measures included health care costs, transporation cost, lost wages, and disease burden expressed in disability-adjusted life years. Estimates were discounted at a rate of 3 percent. Sensitivity analyses evaluated the impact of specific variables on the medical cost of treating rotavirus. RESULTS: For every 1000 children born during 2003 in the eight Latin American and Caribbean countries studied here, we estimated that rotavirus gastroenteritis would result in an average of 246 outpatient visits, 24 hospitalizations, 0.6 deaths, and US$7971 in direct medical costs during their first five years of life. The incidence of rotavirus-associated outpatient visits and the cost of outpatient visits were predicted to have the largest impact on the total medical cost per child. CONCLUSIONS: Rotavirus gastroenteritis is likely to result in substantial disease and economic burden to health systems in Latin America and Caribbean countries, and the foreseeable burden to health systems in Latin America and Caribbean countries, and the foreseeable burden should be important an consideration in evaluating the cost-effectiveness of vaccination (AU)

Potential cost-effectiveness of vaccination for rotavirus gastroenteritis in eight Latin America and Caribbean countries

OBJECTIVES: To estimate the costs, benefits and cost-effectiveness of vaccination for rotavirus gastroenterisits in eight Latin America and Caribbean countries: Argentina, Brazil, Chile, the Dominican Republic, Honduras, Mexico, Panama, and Venezuela. METHODS: An economic model was constructed to estimate the cost-effectiveness of vaccination from the health care system perspective, using national administrative and published epidemiological evidence, country-specific cost estimates and vaccine efficacy data. The model was applied to the first five years of life for the 2003 birth cohort in each country. The main health outcome was the disability-adjustment life year (DALY), and the main summary measure was the incremental cost per DALY averted. A 3 percent discount rate was used for all predicted costs and benefits. Sensitivity analyses evaluated the impact of uncertainty regarding key variables on cost-effectveness estimates. RESULTS: According to the estimates obtained with economic model, vaccination would prevent more than 65 percent of the medical visits, death and treatment costs associated with rotavirus gastroenteritis in the eight countries analyzed here. At a cost of US$24 per course (for a two-dose vaccine), the incremental cost-effectiveness ration ranged from US$269/DALY in Honduras to US$10656/DALY in Chile. Cost-effectiveness ratios were sensitive to assumptions about vaccine price, mortality, and vaccine efficacy. CONCLUSIONS: Vaccination would effectively reduce the disease burden and health care costs of rotavirus gastroenteritis in the Latin American and Caribbean countries analyzed here. From the health care system perspective, universal vaccination of infants is predicted to cost-effective, based on current standards (AU)

Postal dose audits for radiotherapy centers in Latin America and the Caribbean: trends in 1969-2003

Since 1969 the International Atomic Energy Agency and the World Health Organisation (along with the Pan American Health Organization, working with countries in Latin America and the Caribbean) have operated postal dosimetry audits based on thermoluminescent dosimetry (TLD) for radiotherapy centres. The purpose of these audits is to provide and independent dosimetry check of radiation beams used to treat cancer patients. The success of radiotherapy treatment depends on accurate dosimetry. Over the period of 1969 through 2003 the calibration of approximately 5200 photon beams in over 1300 radiotherapy centres in 115 countries worldwide was checked. Of these audits, 36 percent were performed in Latin America and the Caribbean, with results improving grealtly over the years. Unfortunately, in several instances large TLD deviations have confirmed clinical observations of inadequate dosimetry practices in hospitals in various parts of the world or even accidents in radiotherapy, such as the one that occurred in Costa Rica in 1996. Hospitals or centres that operate radiotherapy services without qualified medical physicists or without dosimetry equipment have poorer results than do hospitals or centres that are properly staffed and equipped. When centres have poor TLD results, a follow-up program can help them improve their dosimetry status. However, to achieve audit results that are comparable to those for centers in industrialized countries, additional strengthening of the radiotherapy infrastructure in Latin America and the Caribbean is needed (AU)

Accrediation of diagnostic imaging and services in developing countries

In recent decades, medical imaging has experienced a technological revolution. After conducting several surveys to assess the quality and safety of diagnostic imaging services in Latin America and the Caribbean, the Pan American Health Organisation (PAHO) developed a basic accreditation program that can be implemented by the ministry of health of any developing country. Patterned after the American College of Radiology's accreditation program, the PAHO program relies on a national accreditation committee to establish and maintain accreditation standards. The process involves a peer review evaluation of: (1) imaging and processing equipment, (2) physician and technologist staff qualifications, (3)quality control and quality assurance programs, and (4) image quality and, where applicable, radiation dose. Public and private conventional radiography/fluoroscopy, mammography, and ultrasound services may request accreditation. The radiography/fluoroscopy accreditation program has three modules from which to choose: chest radiography, general radiography, and fluoroscopy. The national accreditation committee verifies compliance with the standards. On behalf of the ministry of health, the accreditation committee also issues a three-year accreditation certificate. As needed, the accreditation committee consults with foreign technical and clinical experts (AU)

West Nile virus activity in Latin America and the Caribbean

OBJECTIVES: West Nile Virus (Flavivirus: Flaviviridae; WNV) has spread rapidly throughout the Caribbean Basin since its initial detection there in 2001. This report summarizes our current knowledge of WNV transmission in tropical America. METHODS: We reviewed the published literature and consulted with key public health officials to obtain unpublished data. RESULTS: West Nile virus infections first appeared in human residents of the Cayman Islands and the Florida Keys in 2001, and in appparently healthy Jamaican birds sampled early in 2002. Serologic evidence of WNV infection in 2002 was detected in horses, chickens and resident free-ranging birds in Guadeloupe, the Dominican Republic, and eastern Mexico. In 2003, WNV spread in Mexico and northern Central America, and serologic evidence was detected in the Bahamas, Puerto Rico and Cuba. In 2004, the first serologic evidence of WNV activity in South American ecosystems surfaced in September-October in Colombia and Trinidad, where domestic animals circulated WNV-neutralizing antibodies. CONCLUSIONS: The sparse reports of equine, human and avain disease in Latin America and the Caribbean is puzzling. Isolates are needed to evaluate viral attenuation or other possible explanations for reduced disease burden in tropical ecosystems (AU)

Hacia un modelo de comunicaci¢n en salud p£blica en Am‚rica Latina y el Caribe / Towards a model of communications in public health in Latin America and the Caribbean

Objective. So far, there have been no bibliometric or scientometric studies that make it possible to examine, with quantitative, retrospective, and comprehensive criteria, the scientific output on public health in Latin America and the Caribbean (LAC). Further, the weakness of the existing information systems makes it impossible to examine the relevance, quality, and impact of this scientific output, with a view to evaluating it in terms of social needs and existing patterns of scientific communication. This article presents the results of a bibliographic analysis of the scientific output in the area of public health in Latin America and the Caribbean. The ultimate goal of the analysis is to build a model of scientific communication in this field, to help researchers, managers, and others working in the area of public health to make decisions and to choose actions to take. CONCLUSIONS. This research produced a preliminary model of communications in public health in LAC countries that will hopefully lay the groundwork for further research to develop a model of scientific communication in LAC nations (AU)

Los trastornos mentales en America Latina y el Caribe: asunto prioritario para las salud publica / Mental disorders in Latin America and the Caribbean: a public health priority

OBJECTIVE: The growing burden of mental disorders in Latin America and the Caribbean has become too large to ignore. There is a need to know more about the prevelance of mental disorders and the gap between the number of individuals with psychiatric disorders and the number of those persons who remain untreated even though effective treatments exist. Having that knowledge would make it possible to improve advocacy, adopt better policies, formulate innovative intervention programs, and apportion resources commensurate with needs. METHODS: Data were extracted from the community-based psychiatric epidemiological studies published in Latin America and the Caribbean from 1980 through 2004 that used structured diagnostic instruments and provided prevalance rates. Estimates of the crude rates in Latin America and the Caribbean for the various disorders were determined by calculating the mean and median rates across the studies, by gender. In addition, data on service utilization were reviewed in order to calculate the treatment gap for specific disorders. RESULTS: Non affective psychosis (including schizophrenia) and an estimated mean one-year prevalence rate of 1.0 percent; major depression, 4.9 percent; and alcohol use abuse or dependence, 5.7 percent. Over one-third of individuals with nonaffective psychosis, over half of those with an anxiety disorder, and some three-fourths of those with alcohol use abuse or dependence did not receive mental health care from either specialized or general health services. CONCLUSIONS: The current treatment gap in mental health care in Latin America and the Caribbean remains wide. Further, current data likely greatly underestimate the number of untreated individuals. The epidemiological transition and changes in the population structure will further widen the treatment gap in Latin America and the Caribbean unless mental health policies are formulted or updated and programs and services are expanded (AU)

Child and adolescent mental health in Latin America and the Caribbean: problems, progress, and policy research

The nations of Latin America and the Caribbean (LAC) have many countrasts in the advances that they made in the areas of child and adolescent mental health policy, research, and training. Within the LAC countries there exist the most sophisticated of child mental health programs based on comprehensive primary care models (Chile), strong advocacy programs with government support at the highest levels (Brazil and Costa Rica), and state-of-the-art research and training programs (Argentina, Brazil, and Chile). Of particular note is the strong understanding and utilization of a rights-based framework for services development throughout LAC. On the other hand, the LAC nations have some of the most intractable child mental health problems seen anywhere on the globe. Inhalant use is endemic in parts of Brazil and Mexico, street children with overt mental health problems go totally unattended in Brazil and elsewhere, and youth crime is epidemic in some LAC cities (AU)

Global child survival initiatives and their relevance to the Latin American and the Caribbean region

We review two series of papers published in the Lancet: the Child Survival Series (2003) and the Neonatal Survival Series (2005). Both series drew attention to the nearly 11 million annual deaths of children under the age of five years, and to the fact that almost 4 million of these deaths occur in the first month of life. We show that two thirds of these deaths could be prevented through universal coverage with existing, low-cost interventions that are failing to reach most children in the world. The series also highlighted the importance of reducing inequities both between and within countries. The relevance of these series to Latin America and the Caribbean is examined. Although substantial progress has been made in reducing mortality and improving coverage, two major challenges remain: how to improve the quality of health interventions, and how to reach the most disadvantaged children in the Latin American and Caribbean Region (AU)

Global child survival initiatives and their relevance to the Latin American and Caribbean Region

We review two series of papers published by The Lancet:the Child Survival Series (2003) and the Neonatal Survival Series (2005). Both series drew attention to the nearly 11 million annual deaths of children under the age of five years, and to the fact that almost 4 million of these deaths occur in the first month of life. We show that two thirds of these deaths could be prevented through universal coverage with existing, low-cost interventions that are failing to reach most children in the world. The series also highlighted the importance of reducing inequities both between and within countries. The relevance of these series to Latin America and the Caribbean is examined. Although substantial progress has been made in reducing mortality and improving coverage, two major challenges remain: how to improve the quality of health interventions, and how to reach the most disadvantaged children in the Latin American and Caribbean Region(AU)

Creating options in family planning for the private sector in Latin America

The countries of Latin America and the Caribbean are facing the gradual phaseout of international-donor support of contraceptive commodities and technical and management assistance, as well as an increased reliance on limited public sector resources and a limited private sector role in providing contraceptives to the public. Therefore, those nations must develop multisectoral strategies to achieve contraceptive security. The countries need to consider information about the market for family planning commodities and services in order to define and promote complementary roles for the public sector, as well as to better identify which segments of the population each of those sectors should serve. While it is unable to mandate private sector participation, the poublic sector can create conditions that suport and promote a greater role for the private sector in meeting growing needs of family planning users. Taking steps to actively involve and expand the private sector's market share is a critical strategy for achieving a more equitable distribution of available resources, addressing unmet need, and creating a more sustainable future for family planning commodities and services (AU)

Autoinforme de salud general en adultos mayores de America Latina y el Caribe: su utilidad como indicador / Self-reported general health in older adults in Latin America and the Caribbean: usefulness of the indicator

OBJECTIVES. To evaluate self-reported general health (SRGH) as a health indicator and to analyze its covariates in people 60 years old or older living in private homes in seven cities of Latin American and the Caribbean.METHODS. This cross-sectional descriptive study was based on data from the Health, Well-Being, and Aging survey (Salud, Bienestar y Envejecimiento, or "SABE survey"), which was carried out in 1999 and 2000 in Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; and Sao Paulo, Brazil. The survey looked at the demographic and socioeconomic characteristics of the participants, several health indicators (self-reported chronic diseases, depression, and cognitivefeatures), the social and family suport network, the use of health services, reported and observed functionality, the respondent's income, and the durable consumer goods in the household. In probit regression models, self-reported fair or poor health was used as the dependent variable. The marginal effect of each categorical explanatory variable was used to indicate the difference between the probability of reporting poor health by persons who did or did not have a given characteristic. RESULTS. In all the cities studied the self-reporting of "excellent" health was very low (6 percent or less). The results of the multivariate analysis of the relationships between SRGH and covariates showed: (1) the relative importance of several health indicators as covariates of SRGH, (2) the association between sociodemographic characteristics and SRGH, and (3) the differences or similarities found among the seven cities with respect to the relationships studied. The level of self-rated good health was highest in Buenos Aires and Montevideo (60 percent), followed by Bridgetown and Sao Paulo (around 50 percent) and Havana, Santiago, and Mexico City (between 30 percent and 40 percent). The respondents evaluation of their memory was the factor that was most strongly related to SRGH, followed by satisfaction with nutritional status and satisfaction with life.CONCLUSIONS. The SRGH captured multiple facets of the health of the older adults, such as suffering from chronic diseases, the degree of satisfaction with the level of nutrition and with life, perception of memory, and any functional problems .... (AU)

Enfermedades cronicas y limitacion funcional en adultos mayores: estudio comparitivo en siete ciudades de America Latina y el Caribe / Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean

OBJECTIVE. To identify the relationship between selected chronic diseases and the presence of disability in inhabitants 60 years old or older in seven cities of Latin America and the Caribbean. METHODS. In 2000 and 2001 a descriptive cross-sectional study was conducted with a sample of 10 891 persons 60 or older in seven cities: Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; and Sao Paulo, Brazil. This research was part of the Salud, Bienstar y Envejecimiento (Health , Well-Being, and Aging) project (known as the "SABE project"). The dependent variables in the study were difficulty in performing basic activities of daily living, and difficulty in performing instrumental activities of daily living. Compiled from self-reports, the independent variables were : age, sex, educational level, living alone or with other person (s), self-assesed health, and the presence or not of hypertension, diabetes mellitus, cancer, chronic obstructive pilmonary disease, ischemic heart disease, cerebrovascular diseases, and osteoarthritis. The presence of depression and cognitive impairment in the participants was evaluated, and body mass index was also calculated. To compare the degree of influence of the different variables on disability, a standardized coefficient for each association was calculated. RESULTS. In the seven cities studied, the variables that showed a direct association with difficulty in carrying out basic activities of daily living and instrumental activities of daily living were: suffering from a higher number of noncommunicable diseases, from cerebrovascular diseases, from osteoarthritis, or from depression; being older; being female; rating one's own health as bad, and the presence of cerebrovascular diseases, osteoarthritis, or cognitive impairment. CONCLUSIONS. Our research provides the first systematized description of the associations between disability and chronic noncommunicable diseases in older adults in Latin America and the Caribbean. Difficulties that older adults have in carrying out instrumental activities of daily living are the first ones to appear. Therefore, follow-up mechanisms should be established that make possible the early detection of this disability (AU)

Falls among elderly persons in Latin America and the Caribbean and among elderly Mexican-Americans

OBJECTIVE. To estimate the prevalence of risk factors for falls among community-dwelling elders in Latin America and the Caribbean and among elderly Mexican-Americans in the southwestern United States. METHODS. Data for the study came from a project called Health, Well-Being, and Aging in Latin America and the Caribbean (Salud, Bienestar y Envejecimiento en America Latina y el Caribe) (the "SABE project") (surveys from seven cities, with a total of 9 765 subjects and from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) (1 483 subjects). RESULTS. The overall prevalence of falls across the seven SABE cities and the H-EPESE ranged from 21.6 percent in Bridgetown, Barbados, to 34.0 percent in Santiago, Chile. In multiple logistic regression analyses, female gender, increased age, high depressive symptoms, and having any functional limitations were significant independent risk factors for falls in most of the cities studies as well as among the elderly Mexican-Americans. In several of the cities, significant risk factors also included diabetes, urinary incontinence, and arthritis. CONCLUSIONS. The prevalence of falls had a large variation among the countries studied. Some of the risk factors that we identified could be modified so as to help prevent falls in older people in these populations. The factors deserving attention include depressive symptoms, functional limitations, diabetes, and urinary incontinence (AU)#

Sistemas de proteccion social para el adulto mayor en America Latina y el Caribe / Social protection systems for older adults in Latin America and the Caribbean

Only one half (50.1 percent) of all older adults in Latin America currently receive benefits under some form of social protection system for the elderly, either through social assistance or social security programs, or have access to a savings plan for old age in the form of individual capitalization accounts (ICA) based on mandatory or voluntary contributions. The other half enjoys no social protection at all; its consumer and health needs are covered through accrued assets, voluntary family transfers, or charitable deeds. Social security pension plan reforms and the creation of social-security-based savings plans for old age in the form of ICA have failed to yield the expected results in terms of coverage and benefits. Over-all, reforms have led to the dismantling of social-security-based social protection systems for the elderly without creating alternative mechanisms for social protection. This document describes the various social protection systems and savings plans for old age that are in place in countries of the Region and looks at current challenges in terms of correcting "government failures" and applying policies that will redress "market failures", so that the working population can count on having enough resources to satisfy its consumer and health needs after retirement (AU)

HIV prevention programs of non-governmental organizations in Latin America and the Caribbean: the Global AIDS Intervention Network project

Objective: The objective of this paper is to describe HIV prevention programs conducted by nongovernmental organizations (NGO) that are meeting this challenge. Methods: One NGO undertaking HIV prevention program was evaluated in each of the 23 countries participating in the Global AIDS Intervention Network (GAIN) Project throughout Latin America and the Caribbean. A two-stage selection process was used: (1) a search in databases and other information sources; (2) identification of NGOs that were best established and most acrively engaged in HIV prevention activity. Executive directors were questioned about staffing, budget issues, populations served and barriers faced by these entities. Results: The 23 NGOs conducted 58 direct-service programs and had been conducting HIV prevention activities for a mean of 8 years (SD = 4.45;range 1-18 years). Average annual program budget was US$ 205,393 (range: US$ 10,000 to US$ 1,440,000). The NGOs reported a mean of 4.5 full-time employees (range 0-15, SD = 4.7). Many relied on volunteers (median = 10, mean = 51, range 0-700, SD = 150) to conduct HIV prevention activities. The NGOs provided prevention services for the general community (82.6 percent), children and adolescents (34.8 percent) and men who have sex with men (30.4 percent). Activities conducted by NGOs included train-the-trainer activities (43.5 percent) and face-to-face prevention activities (34.8 percent). Obstacles cited included lack of funding (60.9 percent) and HIV-related stigma and discrimination (56.5 percent). Conclusions: The strategies used by NGOs to overcome barriers to prevention are a testament to their ingenuity and commitment, and serve as examples for NGOs in other world regions. (AU)