Shifting the HIV Paradigm from Care to Cure: Proceedings from the Caribbean Expert Summit in Barbados, August 2017.

The CCAS EXPERT SUMMIT convened an array of international experts in Barbados on August 27-31, 2017 under the theme "From Care to Cure-Shifting the HIV Paradigm." The Caribbean Cytometry & Analytical Society (CCAS) partnered with the Joint United Nations Programme on HIV/AIDS (UNAIDS) to deliver a program that reviewed the advances in antiretroviral therapy and the public health benefits accruing from treatment as prevention. Particular emphasis was placed on reexamining stigma and discrimination through a critical appraisal of whether public health messaging and advocacy had kept pace with the advances in medicine. Persistent fear of HIV driving discriminatory behavior was widely reported in different regions and sectors, including the healthcare profession itself; continued fear of the disease was starkly misaligned with the successes of new medical treatments and progress toward the UNAIDS 90-90-90 targets. The summit therefore adopted the mantra "Test-Treat-Defeat" to help engage with the public in a spirit of optimism aimed at creating a more conducive environment for persons to be tested and treated and, thereby, help reduce HIV disease and stigma at the individual and community levels.

South-to-North, cross-disciplinary training in global health practice: ten years of lessons learned from an infectious disease field course in Jamaica.

Global commerce, travel, and emerging and resurging infectious diseases have increased awareness of global health threats and opportunities for collaborative and service learning. We review course materials, knowledge archives, data management archives, and student evaluations for the first 10 years of an intensive summer field course in infectious disease epidemiology and surveillance offered in Jamaica. We have trained 300 students from 28 countries through collaboration between the University of the West Indies and U.S. partner universities. Participants were primarily graduate students in public health, but also included health professionals with terminal degrees, and public health nurses and inspectors. Strong institutional synergies, committed faculty, an emphasis on scientific and cultural competencies, and use of team-based field research projects culminate in a unique training environment that provides participants with career-developing experiences. We share lessons learned over the past decade, and conclude that South-to-North leadership is critical in shaping transdisciplinary, cross-cultural, global health practice.

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)

Medical curriculum reform at the Mona Campus of the University of the West Indies: responding to change - Poster abstract

The Faculty of Medical Sciences on the Mona Campus of the University of the West Indies is currently undertaking a thorough review of the undergraduate medical degree programme in order to improve its aims and objectives, its overall structure, flow and relevance. This paper reports on the rationale, method and progress of the review. The specially appointed Working Group took several factors into consideration in commencing the review. These included the need to identify an essential core of knowledge and skills in view of the burgeoning of medical knowledge, the need to give new emphasis to attitudinal attributes and the need to strengthen the teaching of ethics and the behavioural sciences. The Group intends to create a more student-centred approach to teaching and learning in the new curriculum. In laying the groundwork for the review, a compilation of the present courses conducted in the MBBS programme was first prepared. A foundation document containing agreed aims of the MBBS programme and ideal qualities of the new graduate was then drafted and approved by the Faculty Board. This document was used as a guide in creating a draft outline of a modular, systems-based curriculum. A number of ideas were drawn from curricula recently introduced in medical schools in Australia, the United Kingdom, and the United States of America. Consultation with Faculty representatives from Barbados and Trinidad campuses and with student representatives was done at a two day retreat. Course co-ordinators are now being appointed to oversee the design of the various systems-based modules and further consultation is planned before final implementation of the curriculum.(AU)

Experiences and socialization of Jamaican men with multiple sex partners

One of the goals of the Acquired Immunodeficiency Syndrome (AIDS) control programme in Jamaica is to encourage persons to have a single sex partner. Before this can be achieved in men, it is important to identify the demographic characteristics as well as the sexual attitudes and socialization of men who have multiples sex partners. A national survey was conducted on sexual decision-making in Jamaica in which a random sample of 3,001 persons was selected for study and 2,580 (86 percent) interviewed 979 were men. The following analyses included the 769 men who where sexually active. Thirty-four percent (34 percent), 95 percent CI, 30.6-37.4 percent) of these men said that they were currently having sex with more than one woman. Although condom use was higher in men with multiple sex partners. 33 percent of them said that they never used condoms. Independent predictors of having multiple sex partners were: not being in a stable union; being raised by fathers only; and having a secondary school education. There was no significant association with church attendance or with occupation. Compared with other males, men who had multiple sex partners started having sex at an earlier age and were more likely to engage in high-risk sex behaviours such as having sex with prostitutes and abusing drugs prior to coitus. They were also more likely to believe in the use of sex as a means to control their partners and were less likely to think that being married or involved in a long-term relationship was important. These data must be taken into considerations by the AIDS control programme in Jamaica when formulating policies to promoted monogamy. There may also be a need to implement parenting support or education programmes for single men who raise their sons.(AU)

Improving community care for persons with the acquired immunodeficiency syndrome in Jamaica

A brief review of the HIV/AIDS epidemic in Jamaica is presented along with the details of a pilot programme aimed at training lay persons and practical nurses to assist with home care of persons with AIDS. Current (1997) estimates are that 2 to 4/1,000 Jamaican adults are HIV positive. 2,301 AIDS cases have been reported to the Epidemiology Unit of the Ministry of Health, 55 percent of whom have died. Males represent 62 percent of reported cases (1421) and children < 9 years old, 7 percent (170 cases). In 1981 a Family Centre was started at the University Hospital of the West Indies to provide support to persons with AIDS and their families. This initiative identified the need to provide special training to persons who would be responsible for caring the AIDS patient at home, where most patient preferred to be managed. All but three of the 41 persons trained in the pilot programme achieved the required standards of attendance and proficiency. Certificates valid for two years were issued and refresher courses will follow.(AU)

'Nuff Gal'? The practices of sexually active Jamaican men - abstract

A national survey was conducted in Jamaica comprising a random sample of 2580 persons aged 15 - 50 years. The sample comprised 979 men, of whom 920 (94 percent) had experienced sexual intercourse and 769 (79 percent) were sexually active in the previous year. 32 percent of the latter were having sex with more than one person. Their medium number of sex partners was 2 with the range being 2 to 10. Having multiple sex partners was associated with youth, being involved in a visiting relationship, not being raised by both parents and initiating sex at an earlier age. They also had significantly shorter relationships (2 vs 3 years) and more sex acts per month than monogamists. Men with multiple sex partners were more likely to engage in prostitution than monogamists while the prevalence of partner swapping and oral and anal sex was low. Although condom use was higher among men who had multiple sex partners, 33 percent of them never used condoms. There was no significant association between having sex with more than one person and either regular church attendance (at least once per week) or self-reported religiosity. The median age at first intercourse for all men was 15 years (range 6 - 30), the same as the age of their first partner. In only 33 percent of cases was the first partner someone with whom they had a relationship. The most common reasons for sex the first time were for the experience (59 percent), to express love (14 percent) and to "answer the call of nature" (14 percent) (AU).

Characteristics of Jamaicans who smoke marijuana before sex and their risk status for sexually transmitted diseases

Because of the high prevalence of marijuana smoking in Jamaica, it is important to know if this practice is associated with increased risk for STD infections. A national sample of 2,580 randomly selected Jamaicans, aged 15 to 49 years were administered a questionnaire to measure a number of health and behavioural variables. The results indicated that more persons who smoked marijuana before sex had a history of STD infections than non-marijuana smokers, the difference was significant among men (46 percent vs 26 percent, p < 0.001) but not among women (19 percent vs 8 percent, p = 0.09). There was no difference in age, however, more of the smokers were unmarried, poorly educated and unemployed than persons who did not smoke marijuana before sex. They were also more likely to engage in high risk sex behaviours and other risk taking behaviors than non-smokers. The results of multiple logistic analyses indicated that marijuana smoking before sex was an independent risk factor for STDs among men (Odd Ratio = 2.0, p = 0.04). Although it was not possible to determine if the association was causal, the increased risk for STDs among men who smoke marijuana before sex should be incorporated into the Jamaican STD/AIDS control programme by making special efforts to encourage condom use among marijuana smokers

Characteristics of Jamaicans who smoke marijuana before sex and their risk status for sexually transmitted diseases

Because of the high prevalence of marijuana smoking in Jamaica, it is important to know if this practice is associated with increased risk for STD infections. A national sample of 2,580 randomly selected Jamaicans, aged 15 to 49 years were administered a questionnaire to measure a number of health and behavioural variables. The results indicated that more persons who smoked marijuana before sex had a history of STD infections than non-marijuana smokers, the difference was significant among men (46 percent vs 26 percent, p < 0.001) but not among women (19 percent vs 8 percent, p = 0.09). There was no difference in age, however, more of the smokers were unmarried, poorly educated and unemployed than persons who did not smoke marijuana before sex. They were also more likely to engage in high risk sex behaviours and other risk taking behaviors than non-smokers. The results of multiple logistic analyses indicated that marijuana smoking before sex was an independent risk factor for STDs among men (Odd Ratio = 2.0, p = 0.04). Although it was not possible to determine if the association was causal, the increased risk for STDs among men who smoke marijuana before sex should be incorporated into the Jamaican STD/AIDS control programme by making special efforts to encourage condom use among marijuana smokers (AU)

Working women's sexual risk taking in Jamaica

Although the rates of HIV are increasing among female populations in developing countries, there is little information available about factors influencing sexual risk taking among working class women. This paper describes some of the issues discussed by two groups of 58 women working in Jamaica: Informal Commerical Importers and women working in the Free Zone. These women discuss their economic vulnerability, expectations about the role of men as provides, multiple partners, perception of children as resources and concern about physical abuse as factors that could influence decisions about condom use. The implications of these findings are discussed for their impact of intervention programs targeting working class women in Jamaica.(AU)

Lessons from an STD/HIV preventive education project among Jamaican teenagers - abstract

Between August 1993 and June 1994, a project in teenage peer-to-peer education for HIV/AIDS and STD prevention was run in 20 school-based Red Cross clubs in Jamaica. First, 23 teenagers (21 girls and 2 boys) were trained to do small group teaching using lectures, story;-telling, games, and role-play. They in turn, taught approximately 100 learners from eleven (11) "intervention" clubs. Approximately 100 teenagers from nine other schools served as controls. The syllabus encompassed information about HIV/AIDS and STDs, options for prevention, reinforcement of social skills including decision-making, and practice in placing condoms on an artificial penis. Adults designed the curriculum and trained the peer educators but only participated in the peer-to-peer sessions for brief periods at the teenagers' request. Evaluation of the project was done by direct observation of some sessions, key informant interviews, focus group discussion and pre-and post-education questionnaires. The training programme helped to improve knowledge concerning the link between other STDs and HIV infection and the increased risk of contracting STDs when under the influence of alcohol or cocaine. Some teenagers confessed shyness to handle condoms even after learning. Participants reported that they (a) were challenged to improve their attitudes toward persosns with HIV/AIDS and (b) saw more clearly the relevance of practising safer sex and the need to actually adopt safer sex benefit from the project. This peer-to-peer approach was judged to be effective enough to be offered outside of Red Cross clubs (AU)

Use of disinfectants and antiseptics in Jamaican health care institutions - a knowledge, attitudes, beliefs and practices study - abstract

Little has been published concerning choices and use of disinfectants and antiseptics in Caribbean health care institutions. This paper reports some findings from a cross-sectional study of knowledge, attitudes, beliefs and patterns of use concerning those chemicals. The study was carried out among 176 distributors or users from 12 public health care institutions in the cities and major rural towns of Jamaica. Most respondents acknowledged no distinction between the terms "disinfectant" and "antiseptic". Pharmacies gave the most accurate definitions. Fifteen per cent of all respondents failed to give any definition. In general, female respondents were better informed than males. Bleach, "Savlon" (R) and phenolics were the most commonly used disinfectants, while alcohol was seldom acknowledged for this purpose. Disinfectants were supplied sometimes as concentrates and sometimes in diluted form; they were not always stored appropriately and were often over- or under-diluted. Few respondents knew the recommended strengths for effective disinfection and chemosterilization. Concerning disinfectants, a small number of ancillary workers and registered nurses listed "smell" as their most important characteristic. Some persons believed that all disinfectants are safe and effective for all purposes. When supplies were short, inappropriate substitution occurred in 37 percent of cases. Policy guidelines for cleaning and disinfection are urgently needed in Jamaican health institutions. Education of health workers should stress appropriate selection, storage, and monitoring of the use of disinfectants and antiseptics. Pre-employment and in-service training of workers in infection control, including disinfectant use, is highly recommended (AU)

Ganja smoking and sex in Jamaica - abstract

The characteristics and risk status for STD infections of Jamaicans who smoked marijuana before having sex were investigated. The study comprised 2580 individuals, aged 15 to 49 years, who were selected using a multi-stage random sampling technique. The results indicated that the prevalence of marijuana smoking before sex was higher among men (12 per cent) than among women (2 per cent). More Jamaicans who smoked marijuana before sex were unemployed and unmarried, had lower education levels and lived in poorer neighbourhoods than those who did not smoke. In addition, more of them were regular alcohol drinkers, took hard drugs and gambled. When their sex behaviour were examined, there was no difference in condom use; however, more marijuana smokers had multiple sex partners, had had STD infections and began having sex at an earlier age than the non-smokers. More male smokers had sex with prostitutes, viewed ponographic material and were involved in partner swapping than the men who did not smoke marijuana. The prevalence of anal and oral sex was higher in women who smoke marijuana before sex compared to the female non-smokers. The results of logistic regression analyses indicated (after controlling for the demographic and behavoral variables mentioned above (OR = 2.3, p<0.01) that men who smoked marijuana before sex had an increased risk of having STD infections. No increased risk was found in women who smoked marijuana before sex. Because of the high prevalence of marijuana smoking among men, it is important that their increased risk for STDs be considered by health authorities in the planning of STD/AIDS control programmes (AU)

Factors influencing doctors' knowledge and prescribing habit concerning antimicrobial drugs: issues emerging from a pilot study - abstract

Although many antimicrobial drugs are available in Jamaica, hitherto no surveys have been done to assess doctors' knowledge and usage of these drugs. The authors report on a pilot study of this kind carried out at the Spanish Town Hospital. Thirty-three of 39 doctors on staff were available and completed a questionnaire which enquired about knowledge of certain older and newer antimicrobials, sources from which doctors were first introduced to the drugs

Determinants of condom use among gay and bisexual men in Jamaica - abstract

Ano-genital intercourse plays a major role in the homosexual transmission of HIV. A random sample of 101 gay and bisexual men aged 15-61 years was surveyed using a questionnaire. This study sought to assess age, knowledge and beliefs (identified in the Health Belief Model) as determinants of condom use. Ninety-seven per cent identified AIDS as a very serious problem and 92 percent endorsed consistent use as an effective measure to reduce the risk of HIV infection. Only 45.5 percent perceived themselves to be at risk of HIV infection. Eighty-seven per cent of the respondents reported being engaged in ano-genital sex in the past year. The levels of consistent condom use (always) for insertive and receptive ano-genital sex were 52.6 percent and 50 percent, respectively. Age and knowledge along with health beliefs relating to personal susceptibility to HIV infection, severity of AIDS, effectiveness of condom use, and cues to action, such as seeing or knowing someone with AIDS, did not predict condom use. Subjects who reported feeling "uncomfortable" or "afraid" when they asked their partner to wear a condom were more likely than those who reported "comfortable" to have never used condoms (P<0.0001). Perhaps those subjects who reported never using condoms lack the skills to negotiate condom use. Intervention programmes should therefore focus more on developing and enhancing skills and self-esteem (AU)

What church leaders know about human immunodeficiency virus infection and how they are responding to the AIDS epidemic: a study from Kingston and St. Andrew, Jamaica - abstract

In Jamaica, several churches are integrally related to the health services and approximately 66 percent of Jamaicans identify with Christian denominations. Church leaders work closely with health service teams, are generally respected and can be important allies or opponents in issues of public importance such as the current epidemic of human immunodeficiency virus (HIV) disease. With this background knowledge, a survey was carried out to determine what church leaders know about HIV infection and the acquired immunodeficiency syndrome (AIDS), their attitudes to important issues raised by the AIDS epidemic and their level of involvement in HIV/AIDS related activities. A representative sample of 71 leaders from the nine main church groupings in Kingston and St. Andrew, Jamaica, was recruited. Seventy (98.5 percent) participated in a self-administered questionnaire survey. Sixty-one respondents (87 percent) knew the meaning of the acronym. AIDS, while 68 (97 percent) knew the correct cause of AIDS. There was nearly 100 percent accurate knowledge about the recognised modes of transmission and prevention of HIV, but a significant minority of respondents were wrong concerning transmission by mosquitoes, fomites and coughing. Only 40 (57 percent) identified "complete abstinence" as a method of prevention of HIV. Attitudes expressed towards persons with HIV/AIDS were less favourable if the person was a male homosexual or a female prostitute than a male heterosexual or a female non-prostitute, respectively. A substantial minority of respondents admitted to having feelings of resentment, fear, avoidance, scorn and anger towards persons with HIV. Nevertheless, a large majority said they felt "helpful" towards all persons with HIV. Sixteen (23 percent) felt that AIDS is a "punishment from God", while 12 (17 percent) were undecided. Only 11/70 (16 percent) said that they were involved in activities related to HIV or AIDS prevention or treatment, while only six (9 percent) had received training specifically for counselling persons with HIV disease. Forty (57 percent) said that they would be willing to work directly with HIV-positive persons. The findings of this study regarding knowledge levels are similar to data from national knowledge and practices (KAP) studies and reinforce the need for public education to continue dispelling myths about spread of HIV by mosquitoes, fomites and coughing. The data also indicate the need to strengthen the educational programme for church leaders in order to influence their attitudes and increase their practical contribution to HIV prevention and care programmes (AU)