AIDS in the Americas: a public health priority for the region.

PIP: 156 countries have reported over 250,000 AIDS cases to the WHO. Taking underreporting into account in developing countries, this figure grows to over 600,000 with 300,000 deaths. HIV-1 infection rates are estimated at between 5-10 million people. Projections indicate that there will be 5 million AIDS cases by 2000. AIDS is an unprecedented health problem that has enormous social, political, medical, and economic implications. The Americas account for 61% of the total cases reported to the WHO. Of the 46 countries in the Americas there have been 153,720 cases reported as of May 1, 1990. 96% of these cases were reported in the US, Brazil, Canada, Haiti, and Mexico. The geographic distribution of AIDS is not homogeneous because of a variety of factors. It was not introduced simultaneously in all countries; some were exposed later than others. Some countries have better detection systems. Excluding North America, the English-speaking Caribbean countries account for only 2% of the population, while the Latin Caribbean countries have 6%, yet they have 10% and 21% of the cases, respectively. Sexual transmission patterns reveal that bisexual men are the largest bridge between the homosexual and heterosexual community, not IV drug users. Studies show that blood donors who are paid are 18 times more likely to be HIV-1 positive in some areas. As AIDS prevalence increases in the heterosexual community, the rate of perinatal transmission also increases. This in turn increases the infant mortality rate because of increases in pediatric AIDS cases. Pediatric cases currently threaten much of the progress that has been made in developing countries in lowering the infant mortality rate. If this pandemic is to be stopped, prevention efforts must be increased as well as a shift in resources at the local, national, and global levels to find some effective method of containment.^ieng

HIV and HTLV-I infections in the Americas: a regional perspective.

With over 143,000 cases of AIDS reported to the World Health Organization from 145 countries and with an estimated 5 to 10 million people worldwide infected with HIV, AIDS has become firmly established as a global pandemic. In the region of the Americas over 100,862 cases of AIDS have been reported with indigenous transmission documented in 45 to 46 countries. While North America has the highest annual number of AIDS cases per population, with 72 cases/million, the Caribbean subregion has a disproportionately high number of cases, with annual rates as high as 200 to 300 cases/million population for some countries. Despite differences in absolute number of cases, there has been a remarkable similarity in the temporal rate of increase of AIDS in the countries of the Americas, reflecting delayed introduction of the virus to some areas with an early exponential increase similar to that observed initially in the United States. Although the modes of transmission of HIV are the same throughout the region, evidence of increasing bisexual and heterosexual transmission, particularly in the Caribbean subregion, has resulted in a lower male-to-female ratio of AIDS cases and increased perinatal transmission. Clinically, a resurgence of diarrheal diseases, respiratory infections, and tuberculosis has been documented in association with HIV infection in many tropical countries of the Americas. With relatively high rates of HTLV-I infection already established in the Caribbean subregion, the overall public health problems of the Americas will be markedly potentiated by further spread of these 2 human retroviruses. If HIV infection continues to penetrate the poor and less advantaged populations in Latin America and the Caribbean, the potential exists for a massive epidemic in the Americas that may rapidly parallel the situation in Africa.

PIP: The article describes in detail the extent and nature of HIV and HTLV-1 infections, and AIDS in the Americas. Surveillance statistics are provided for general populations, homosexual and bisexual men, IV-drug users, female prostitutes, hemophiliacs, heterosexual partners of HIV-infected persons, blood donors, and pregnant women. As of publication, over 100,862 AIDS cases have been reported in the region, with indigenous transmission documented in 45-46 countries. Clinical manifestations of HIV infection and AIDS are discussed. North America claims the highest annual AIDS cases per population at 72/million, while the Caribbean subregion has a disproportionately high number of cases, with annual rates reaching 200-300/million for some countries. The temporal rate of increase of AIDS cases has, however, been fundamentally comparable for all countries of the Americas. While HIV transmission modes are the same throughout the region, increasingly lower male-female ratios of AIDS cases, and more cases of perinatal transmission especially in Caribbean countries. Diarrheal disease, respiratory infections, and tuberculosis have also been documented as associated with HIV infection in many tropical countries of the Americas. Further, relatively high rates of HTLV-1 infection in the Caribbean will only exacerbate already significant public health problems faced by some countries of the region. Should HIV continue infiltrating poor, disadvantaged populations of Latin America and the Caribbean, HIV infection levels and AIDS could reach epidemic proportions similar to that witnesses in Africa.

STD control in less developed countries: the time is now.

PIP: This discussion of sexually transmitted diseases (STDs) in less developed countries covers incidence/prevalence, antimicrobial resistance, sequelae, future trends, and new opportunities for STD control -- technological changes, health service changes, and social and political changes. For most countries, current, population-based information on STD is lacking, yet STDs appear to be common problems in nearly all countries. The prevalence of gonococcal infection in non-STD clinic populations has been as high as 5-20%, and incidence estimates made in a few settings have ranged from 3-10% per annum. These observations may overrepresent the STD problem, yet they have been identified in countries in Asia, Africa, and the Americas. The prevalence of reactive serological tests for syphilis among antenatal clinic attendees has been as high as 10-15% in some countries of Africa and the Western Pacific. Chancroid infection is extremely common in many of the developing countries of Asia, Africa, and the Americas. Penicillinase-producing "N. gonorrhoeae" (PPNG) infections are a dramatic example of the emergence and worldwide dissemination of resistant gonococci since 1976. At this time PPNG isolates constitute over 10% of all gonococcal infections in nearly all southeast Asian and Africa settings where this problem has been explored. PPNG cause more than 50% of gonococcal infections in some settings. As a result of increasing PPNG prevalence, penicillin, previously the standard therapy for gonorrhea, has been replaced by alternative agents in many settings. A variety of antimicrobial agents are effective for PPNG infections, but these are too expensive or unavailable in many developing countries. Sequelae of STD produce enormous direct and indirect costs. Acute pelvic inflammatory disease (PID) caused by gonorrhea, chlamydia, and other STD agents is common throughout the world. In developing countries ectopic pregnancy is a common surgical emergency. Improved diagnostic tests, new approaches to treatment of STD, and development of vaccines provide opportunities for better STD control, as have changes in health care delivery. The promotion of the primary health care concept, a shift in emphasis of the international family planning programs, as well as a focus on support systems of health programs all are crucial to STD efforts, and their improvement enhances STD control possibilities. Also, greater discussion of the STD health problems has led to more serious consideration of these diseases and their control.^ieng

Combating AIDS in the Caribbean: a coordinated subregional approach.

PIP: The extent of the HIV epidemic in the Caribbean is described as related to the subregional coordinating project CAREC, or Caribbean epidemiology Center, an agency under Pan American Health Organization, for 19 English speaking countries and Suriname. By July 1990, 1702 AIDS cases had been reported to CAREC, out of 5726 cases in 27 Caribbean countries excluding Puerto Rico. 90% of the cases occurred in the 5 largest, Bahamas, Barbados, Bermuda, Jamaica and Trinidad and Tobago. Initially the transmission pattern was predominantly among male homo- and bisexuals, but not it is mostly heterosexual with a growing mother-to-child transmission. All countries are now screening blood or blood donors. CAREC is coordinating epidemiologic surveillance, helping national laboratories to screen by providing confirmatory tests, providing culture-relevant health education materials and AIDS information, assisting with surveys, holding training workshops for health care workers, and assisting member countries in designing education and counseling programs for high risk women.^ieng