A review of immunization legislation for children in English- and Dutch-speaking Caribbean countries.

Objective: To assess the legislative frameworks concerning childhood vaccination in the English- and Dutch-speaking Caribbean and propose a model legislative framework for Caribbean countries. Methods: This study included a survey of 22 countries and territories in the Caribbean regarding legal vaccination mandates for school entry, budget allocations, sanctions, or exemptions. A legal consultant conducted a comprehensive search and analysis of legislation regarding vaccination among 13 Caribbean countries/territories. A comparative analysis of the legislation under five themes-legislative structure, mandatory vaccination, national immunization schedule, sanctions, and exemptions-formed the basis for the proposed model legislation. Results: Among the 22 Caribbean countries/territories, 17 (77%) had legislation mandating vaccination, 16 (94%) mandated vaccination for school entry, 8 (47%) had a dedicated budget for immunization programs, and 13 (76%) had no legislated national schedules. The source of legislation includes six (35%) using the Education Act, eight (47%) the Public Health Act, and five (29%) a free-standing Vaccination Act. Three countries/territories-Jamaica, Montserrat, and Saint Lucia-had immunization regulations. In 12 (71%) of the 17 countries with legislation, sanctions were included, and 10 (59%) permitted exemptions for medical or religious/philosophical beliefs. Conclusions: Several countries in the Caribbean have made failure to vaccinate a child an offense. By summarizing the existing legislative frameworks and approaches to immunization in the Caribbean, the analysis guides policymakers in making effective changes to immunization legislation in their own countries.

Achieving global equity for COVID-19 vaccines: Stronger international partnerships and greater advocacy and solidarity are needed.

Peter Figueroa and co-authors advocate for equity in the worldwide provision of COVID-19 vaccines.

The HIV epidemic in Jamaica: a need to strengthen the National HIV Program.

OBJECTIVES: To assess the status of the HIV epidemic and programmatic implementation in Jamaica while identifying strategies for achieving effective HIV control. METHODS: The assessment included a review of the core indicators of the UNAIDS Global Monitoring Framework, a desk review of program reports, and unstructured interviews of stakeholders. RESULTS: HIV prevalence among adults in Jamaica was 1.5% in 2018 with an estimated 32 617 persons living with HIV (PLHIV) and 27 324 persons (83.8%) diagnosed with HIV; 12 711 (39.0% of all PLHIV or 46.5% aware of their status) were on anti-retroviral therapy (ART) in the public health sector and 61.8% PLHIV on ART were virally suppressed. HIV prevalence among men who have sex with men remains high (31.4% in 2011, 29.6% in 2017) but has declined among female sex workers (12% in 1990, 2% in 2017). HIV prevalence among public sexually transmitted infection clinic attendees, prison inmates and the homeless has increased in recent years. During 2018 approximately 200 000 persons (14% of the population 15-49 years) were tested with 1 165 newly diagnosed PLHIV, indicating that many of the estimated 1 600 newly infected persons in 2018 were unaware of their status. CONCLUSIONS: Critical policy initiatives are needed to reduce barriers to HIV services, ensure young persons have access to condoms and contraceptives, affirm the rights of the marginalized, reduce stigma and discrimination, and introduce pre-exposure prophylaxis. While HIV spread in Jamaica has slowed, the UNAIDS Fast Track goals are lagging. The HIV program must be strengthened to effectively control the epidemic.

High prevalence of psychiatric and substance use disorders among persons seeking treatment for HIV and other STIs in Jamaica: a short report.

This cross-sectional study explored the range of psychiatric and substance use disorders and unmet need for mental health care among 84 HIV-positive and 44 HIV-negative public clinic attendees in Jamaica. We used a brief interviewer-administered diagnostic tool, the Client Diagnostic Questionnaire. Two-thirds (65.6%) screened positive for at least one psychiatric disorder; 30.5% screened positive for multiple disorders. The most common disorders were post-traumatic stress disorder (PTSD) (41.4%), alcohol abuse (22.7%), and depressive disorders (21.9%). One in fourteen (7.1%) participants with at least one diagnosis received care in the last 6 months. Adjusting for age and sex, PTSD was associated with non-adherence to antiretroviral treatment (AOR = 5.32), anxiety disorders (AOR = 5.82), depression (AOR = 4.29), and suicidal ideation (AOR = 8.17). Psychiatric and substance use disorders, particularly PTSD, were common among STI/HIV clinic attendees in Jamaica. Such clinics may be efficient places to screen, identify, and treat patients with psychiatric disorders in low- and middle- income countries.

The Expanded Program on Immunization in the English- and Dutch-speaking Caribbean (1977-2016): reasons for its success.

The year 2017 marks the 40th year of the establishment of the Expanded Program on Immunization (EPI) by the Pan American Health Organization (PAHO), the regional office of the World Health Organization (WHO) in the Americas, the first WHO region certified as eliminating poliomyelitis (1994), measles (2016), and rubella and congenital rubella syndrome (CRS) (2015). The English- and Dutch-speaking Caribbean subregion of the Americas paved the way in eliminating these diseases. This report highlights the innovative strategies used in this subregion that helped make the EPI a success. A review of published/unpublished reports and written and oral accounts of the experiences of Immunization Advisors and national EPI managers was conducted to identify the strategies used to strengthen the Immunization program in the subregion since its implementation by countries in 1977. The results show that these include strong collective political commitment, country-specific immunization legislation, joint use of a standard coverage monitoring chart, annual meetings of national EPI managers, collaborative development of annual national Plans of Action for Immunization, coordinated implementation of vaccination campaigns, subregional oversight of surveillance and laboratory support, a performance award system for countries, and subregional standardized templates for immunization manuals and procedural guidelines. Political will and support for immunization has been particularly strong in this subregion, where 99% of EPI costs are borne by governments. Dedicated health staff and multi-country agreement and application of strategies have led to high sustained coverage and good-quality surveillance, resulting in the absence of wild polio for 34 years, measles for 25 years, CRS for 17 years, and rubella for 15 years.

En el 2017 se celebra el cuadragésimo año de la instauración del Programa Ampliado de Inmunización (PAI) por la Organización Panamericana de la Salud (OPS), la Oficina Regional de la Organización Mundial de la Salud (OMS) para las Américas. Esta fue la primera región de la OMS que obtuvo la certificación de la eliminación de la poliomielitis (1994), el sarampión (2016) y la rubéola y el síndrome de rubéola congénita (2015). La subregión de habla inglesa y holandesa del Caribe en las Américas abrió el camino a la eliminación de estas enfermedades. En el presente artículo se destacan las estrategias innovadoras utilizadas en esta subregión que contribuyeron al éxito del PAI.Se llevó a cabo una revisión de los informes publicados e inéditos y de los relatos escritos y orales de las experiencias de los Expertos en Inmunización y los gerentes nacionales del PAI con el objeto de determinar las estrategias utilizadas con miras a fortalecer el programa de vacunación en la subregión, desde su introducción en los países en 1977. Los resultados ponen de manifiesto que los programas comportaban un fuerte compromiso político colectivo, legislaciones en materia de inmunización propias de cada país, la utilización común de un registro gráfico normalizado de monitoreo de coberturas de vacunación, reuniones anuales de los gerentes nacionales del PAI, la elaboración conjunta de planes de acción anuales nacionales sobre vacunas, la ejecución coordinada de campañas de vacunación, la supervisión de la vigilancia y el apoyo a los laboratorios a escala subregional, un sistema de reconocimiento al desempeño de los países y plantillas subregionales normalizadas de los manuales de vacunación y los procedimientos recomendados. La voluntad política y el apoyo a la vacunación han sido muy sólidos en esta subregión, donde los gobiernos sufragan 99% de los costos del PAI. La existencia de personal sanitario dedicado y los acuerdos multinacionales y la aplicación de las estrategias permitieron alcanzar una alta cobertura de manera sostenida y una vigilancia de buena calidad, cuyo resultado fue la ausencia de poliomielitis salvaje durante 34 años, de sarampión durante 25 años, del síndrome de la rubéola congénita durante 17 años y de la rubéola durante 15 años.

O ano de 2017 marca o 40º aniversário da criação do Programa Ampliado de Imunização (PAI) pela Organização Pan-Americana da Saúde (OPAS), Escritório Regional da Organização Mundial da Saúde (OMS) nas Américas, primeira Região da OMS certificada como tendo eliminado a poliomielite (1994), o sarampo (2016) e a rubéola e síndrome da rubéola congênita (2015). A sub-região das Américas constituída pelos países do Caribe de língua inglesa e holandesa abriu caminho ao eliminar essas doenças. Este relato destaca as estratégias inovadoras usadas nesta sub-região que contribuíram para tornar o PAI um programa bem-sucedido.Foi realizada uma análise de informes publicados/inéditos e relatos orais e escritos da experiência dos assessores para assuntos de imunização e coordenadores nacionais do PAI visando identificar as estratégias aplicadas para consolidar o programa nos países da sub-região desde a sua implementação em 1977. Os resultados demonstram firme compromisso político coletivo, legislação de vacinação própria em cada país, uso conjunto de uma lista padrão para o monitoramento da cobertura, reuniões anuais dos coordenadores nacionais do PAI, desenvolvimento colaborativo de planos de ação nacionais anuais para vacinação, campanhas coordenadas de vacinação, supervisão sub-regional da vigilância e infraestrutura laboratorial, sistema de premiação dos países por bom desempenho, modelos padronizados para os manuais de vacinação e protocolos de procedimentos. A sub-região se caracteriza sobretudo pela vontade e apoio políticos para vacinação, sendo 99% do custo do PAI financiados pelos governos. Equipes de saúde diligentes, acordos entre vários países e emprego de estratégias são fatores que contribuem para elevada cobertura sustentada e vigilância de boa qualidade com a consequente não ocorrência de casos de poliomielite por vírus selvagem por 34 anos, de casos de sarampo por 25 anos, de casos de síndrome da rubéola congênita por 17 anos e de casos de rubéola por 15 anos.

A Framework for Sexual Decision-Making Among Female Sex Workers in Jamaica.

The Jamaican government has provided targeted HIV and sexually transmitted infection prevention, treatment, and other services for female sex workers (FSW) since 1989. HIV prevalence among FSW declined from 20 to 12% between 1989 and 1994, then to 9% in 2005, 5% in 2008, and 4.1% in 2011. This article distills the literature and two decades of experience working with FSW in Jamaica. Drawing on the constant comparative method, we put forward an innovative conceptual framework for explaining sexual decision-making and risk behaviors within both transactional and relational sexual situations. This framework helps fill the gaps in existing models that focus on individual behaviors. The model identifies interactions between environmental and structural elements of sex work, and three individual-level factors: risk perception, perceived relationship intimacy, and perceived control, as the four primary mediating factors influencing sexual decision-making among FSW. We propose that other factors such as violence, socioeconomic vulnerability, and policy/legal frameworks influence sexual decision-making through these primary mediating factors. This conceptual model may offer a useful framework for planning and evaluating prevention interventions among sex workers. However, it remains to be tested in order to establish its value.

Review of HIV in the Caribbean: significant progress and outstanding challenges.

This paper reviews the recent literature on HIV in the Caribbean and discusses the challenges faced. HIV incidence in the Caribbean has declined by 49 % in the past decade, coverage of persons living with HIV among those eligible for antiretroviral treatment as per national guidelines was 70 % in 2012, and some countries are meeting the target of virtual elimination of mother-to-child transmission. HIV prevalence in the Caribbean is 1 % with features of both a generalized and concentrated HIV epidemic. HIV prevalence among female sex workers has declined but remains unacceptably high among men who have sex with men. Social and cultural factors, gender norms, and strong stigma associated with HIV and homosexuality contribute to the continued spread of HIV. Caribbean countries and their partners have invested significant resources, creative effort and impressive research in strengthening the HIV response nationally and regionally. However, in order to control the HIV epidemic, leaders at all levels, and the people, must address fundamental structural barriers in society that deny marginalized persons their rights, undermine public health goals, and impede universal access to HIV prevention, treatment, and care.

Reduction in time to viral suppression among persons living with HIV in Jamaica between 2017-2019.

INTRODUCTION: HIV viral suppression is important for effective treatment and for reducing new infections. In 2019, only 66% of persons on antiretroviral treatment (ART) in Jamaica were virally suppressed. We aim to compare time to viral suppression by ART initiation year and type of treatment site to understand the implications for programming. METHODS: We assessed time to viral suppression among 4560 persons who received viral load testing either pre or post ART initiation from 2017-2019. We used descriptive statistics and Kaplan-Meier estimates to compare survival curves by ART year (2017, 2018, 2019), sex and type of treatment site (public and non-governmental organizations). Persons were censored if suppression was not achieved. Mixed effects Cox regression was used to determine the effect of covariates on the likelihood of viral suppression. We report hazard ratios and 95% confidence intervals. RESULTS: Pre-ART viral load testing decreased from 36% in 2017 to 30% in 2019. For post-ART viral load tests, approximately 78% (n = 1589) of persons achieved suppression, 51% (n = 809) were female and 86% (n = 1341) used a public treatment site. The median time to suppression decreased by 3 months from 2017 to 2019. The likelihood of suppression was almost 2 times greater in 2018 (HR = 1.56, CI = 1.39-1.75) and 3 times greater in 2019 (HR = 3.17, CI = 2.76-3.64) compared to 2017. NGO treatment sites were also significantly associated with the likelihood of viral suppression compared to public sites. CONCLUSION: Pre-ART viral load testing and the time to viral suppression decreased over three years. Initiating ART after 2017 and early use of NGO treatment sites were found to significantly increase the likelihood of achieving suppression. This demonstrates improvements in the national HIV response but there is need to increase the number of persons on ART and achieving viral suppression.

Correction: HIV program outcomes for Jamaica before and after "Treat All": A population-based study using the national treatment services database.

[This corrects the article DOI: 10.1371/journal.pone.0255781.].

Factors associated with discussing HIV pre-exposure prophylaxis (PrEP) among Jamaican medical providers.

BACKGROUND: The Ministry of Health and Wellness of Jamaica has endorsed the use of pre-exposure prophylaxis (PrEP) as an HIV prevention strategy; however, PrEP was not included in the national HIV prevention program in 2021. METHODS: A cross-sectional online study involving physicians in Jamaica was conducted in 2021 to describe PrEP awareness, beliefs, attitudes, and practices. The study also assessed individual and social factors associated with discussing PrEP with patients and willingness to prescribe PrEP. FINDINGS: The mean age and standard deviation (SD) of the 69 physicians who completed the survey were 45.5 ± 13.6 years. Most of the participants (80%) reported that they were somewhat familiar with PrEP. PrEP attitude and perceived comfort in prescribing PrEP were moderate among participating physicians, with a mean and SD of 3.9 ± 0.8 and 3.6 ± 0.9 respectively. Six percent of physicians reported that they had prescribed PrEP and 17% had discussed PrEP with their patients in the past year. However, most (90%) reported that they were willing to prescribe PrEP after being informed about it. In the unadjusted model, identifying as Christian (compared to non-Christian) and reporting stronger homophobic beliefs were associated with reduced odds of discussing PrEP with patients. In the multivariable model, only homophobia remained statistically significant (OR, 0.24; 95% CI: 0.07-0.63). CONCLUSION: The findings suggest that physicians in Jamacia may be willing to prescribe PrEP; however, homophobia is a barrier to discussions, underscoring the need for the Ministry of Health and Wellness to recognize the role that homophobia plays in the national HIV program to further reduce HIV incidence in Jamaica.

Establishing priorities to strengthen National Immunization Technical Advisory Groups in Latin America and the Caribbean.

Following the COVID-19 pandemic, the Americas faced a significant decline in vaccination coverage as well as increased vaccine hesitancy. The objective of this paper is to summarize the challenges and opportunities outlined by the National Immunization Technical Advisory Groups (NITAGs) in Latin America and the Caribbean (LAC) and prioritize targeted interventions. The exploratory survey included open-ended questions on two primary components: challenges, and opportunities. Free-text comments presented by each NITAG were collated and classified using indicators and sub-indicators of the NITAG Maturity Assessment Tool (NMAT). Opportunities were classified thematically, and priority actions were generated from the responses. All 21 NITAGs in LAC, representing 40 countries, 76 % of which have been active for over a decade, responded to the survey. The most common challenges were establishment and composition (62 %), integration into policymaking (62 %), resources and secretariat (52 %), and stakeholder recognition (48 %). The distribution of responses was seen across the whole sample and did not suggest a more pronounced need in relation to year of establishment. Opportunities included maximizing the Regional NITAG Network of the Americas (RNA) to facilitate collaboration, information sharing, visibility, and communication; existing global, regional, and systemic analyses; the World Health Organization/Pan American Health Organization (WHO/PAHO) templates for standard operating procedures; twinning programs with mature NITAGs; and NITAGs in governance structures. Action plans were outlined to formalize the establishment of NITAGs and broaden their composition; strengthen decision-making and access to data resources; and enhance the credibility of evidence-based recommendations and their uptake by policymakers and the public. NITAG challenges are not unique to LAC. NITAGs have outlined a short-term prioritized action plan which is critical to enhancing NITAG value and importance in countries.

Randomized controlled trial on the effectiveness of counseling messages for avoiding unprotected sexual intercourse during sexually transmitted infection and reproductive tract infection treatment among female sexually transmitted infection clinic patients.

BACKGROUND: The effectiveness of counseling messages to avoid unprotected sex during short-term treatment for curable sexually transmitted infections is unknown. METHODS: We randomized 300 female STI clinic patients 18 years or older with cervicitis and/or vaginal discharge in Kingston, Jamaica, in 2010 to 2011, to 1 of 2 counseling messages for their course of syndromic treatment: abstinence only or abstinence backed up by condom use. At a follow-up visit 6 days afterward, we collected vaginal swabs to test for prostate-specific antigen (PSA), a biological marker of recent semen exposure, and administered a questionnaire assessing sexual behavior. RESULTS: No differences were found in the proportions of women testing positive for PSA at follow-up in the abstinence-plus-condom group (11.9%) and abstinence-only group (8.4%) (risk difference, 3.5; 95% confidence interval, -3.5 to 10.5). There also was no significant difference in reporting of unprotected sex between groups. Reporting a history of condom use before enrollment significantly modified the effect of counseling arm on PSA positivity (P = 0.03). Among those reporting recent condom use, 10.3% in the abstinence-only arm and 4.8% in the abstinence-plus-condom arm tested positive for PSA. Conversely, among those not reporting recent condom use, 6.5% in the abstinence-only arm and 17.3% in the abstinence-plus-condom arm had PSA detected. CONCLUSIONS: We found no evidence to support the superiority of either counseling message. Post hoc analyses suggest that women with recent condom experience may benefit significantly more from abstinence-plus-condom messages, whereas women without such experience may benefit significantly more from abstinence-only messages. Providers should weigh individual condom use history when determining the most appropriate counseling message.

Trends and factors associated with initiation of HIV treatment among PLHIV in Jamaica, 2015-2019.

INTRODUCTION: Jamaica did not achieve the UNAIDS 90-90-90 targets in 2020. This study aimed to examine trends and factors associated with uptake of HIV treatment among people living with HIV (PLHIV) in Jamaica and to assess the effectiveness of revised treatment guidelines. METHODS: This secondary analysis used patient-level data from the National Treatment Service Information System. The baseline sample was 8147 PLHIV initiating anti-retroviral treatment (ART) between January 2015-December 2019. Descriptive statistics were used to summarize demographic and clinical variables and the primary outcome timing of ART initiation. Multivariable logistic regression was used to assess factors associated with ART initiation (same day vs 31+ days), using categorical variables for age group, sex and regional health authority. Adjusted odds ratios and 95% confidence intervals are reported. RESULTS: Most persons initiated ART at 31+ days (n = 3666, 45%) after the first clinic date or on the same day (n = 3461, 43%). Same day ART initiation increased from 37% to 51% over 5 years and was significantly associated with males (aOR = 0.82, CI = 0.74-0.92), 2018 (aOR = 0.66, CI = 0.56-0.77), 2019 (aOR = 0.77, CI = 0.65-0.92). late HIV diagnosis (aOR = 0.3, CI = 0.27-0.33) and viral suppression at the first viral load test (aOR = 0.6, CI = 0.53-0.67). ART initiation at 31+days was associated with 2015 (aOR = 1.21, CI = 1.01-1.45) and 2016 (aOR = 1.30, CI = 1.10-1.53) compared to 2017. CONCLUSION: Our study shows that same day ART initiation increased between 2015-2019, however it remains too low. Same day initiation was associated with the years after Treat All implementation and late initiation before Treat All, providing evidence of the strategy's success. In order to achieve the UNAIDS targets, there is a need to also increase the number of diagnosed PLHIV retained on treatment in Jamaica. Further studies should be conducted to understand important challenges to accessing treatment as well as differentiated care models to improve treatment uptake and retention.

Prevalence of SARS-CoV-2 antibodies after the Omicron surge, Kingston, Jamaica, 2022.

A cross-sectional SARS-CoV-2 serosurvey was conducted after the Omicron surge in Jamaica using 1,540 samples collected during March - May 2022 from persons attending antenatal, STI and non-communicable diseases clinics in Kingston, Jamaica. SARS-CoV-2 spike receptor binding domain (RBD) and/or nucleocapsid IgG antibodies were detected for 88.4% of the study population, with 77.0% showing evidence of previous SARS-CoV-2 infection. Of persons previously infected with SARS-CoV-2 and/or with COVID-19 vaccination, 9.6% were negative for spike RBD IgG, most of which were unvaccinated previously infected persons. Amongst unvaccinated previously infected people, age was associated with testing spike RBD IgG negative. When considering all samples, median spike RBD IgG levels were 131.6 BAU/mL for unvaccinated persons with serological evidence of past infection, 90.3 BAU/mL for vaccinated persons without serological evidence of past infection, and 896.1 BAU/mL for vaccinated persons with serological evidence of past infection. Our study of the first reported SARS-CoV-2 serosurvey in Jamaica shows extensive SARS-CoV-2 population immunity, identifies a substantial portion of the population lacking spike RBD IgG, and provides additional evidence for increasing COVID-19 vaccine coverage in Jamaica.

Prevalence of SARS-CoV-2 Antibodies after the Omicron Surge, Kingston, Jamaica, 2022.

A cross-sectional SARS-CoV-2 serosurvey was conducted after the Omicron surge in Jamaica using 1,540 samples collected during March â€" May 2022 from persons attending antenatal, STI and non-communicable diseases clinics in Kingston, Jamaica. SARS-CoV-2 spike receptor binding domain (RBD) and/or nucleocapsid IgG antibodies were detected for 88.4% of the study population, with 77.0% showing evidence of previous SARS-CoV-2 infection. Of persons previously infected with SARS-CoV-2 and/or with COVID-19 vaccination, 9.6% were negative for spike RBD IgG, most of which were unvaccinated previously infected persons. Amongst unvaccinated previously infected people, age was associated with testing spike RBD IgG negative. When considering all samples, median spike RBD IgG levels were 131.6 BAU/mL for unvaccinated persons with serological evidence of past infection, 90.3 BAU/mL for vaccinated persons without serological evidence of past infection, and 896.1 BAU/mL for vaccinated persons with serological evidence of past infection. Our study of the first reported SARS-CoV-2 serosurvey in Jamaica shows extensive SARS-CoV-2 population immunity, identifies a substantial portion of the population lacking spike RBD IgG, and provides additional evidence for increasing COVID-19 vaccine coverage in Jamaica.