1. Latin America/Caribbean State of the Art HIV/AIDS Part One Paul R. De Lay, M.D. Chief, HIV/AIDS Division Global Bureau USAID March 13, 2001

2. HIV/AIDS Introduction The Epidemic and its Impact Interventions Appropriate for the Epidemic

3. Spread of HIV over time in Latin America and the Caribbean, 1984 to 1999 Estimated percentage of adults (15–49) infected with HIV 2.0% – 6.0% 1.0% – 2.0% 0.5% – 1.0% 0.1% – 0.5% 0.0% – 0.1% trend data unavailable outside region

7. HIV-1 Seroprevalence Among Pregnant Women from Capital City or Major Urban Centers in Selected Countries ASIA & OCEANIA THAILAND BURMA PAKISTAN LAOS INDIA VIETNAM LAC HAITI HONDURAS GUYANA BRAZIL BELIZE DOMINICAN REP. ARGENTINA BARBADOS JAMAICA TRIN. & TOB. 01020304050 % Seropositive AFRICA BOTSWANA SOUTH AFRICA LESOTHO MALAWI SWAZILAND ZIMBABWE ZAMBIA NAMIBIA RWANDA BURUNDI ETHIOPIA KENYA UGANDA TANZANIA COTE D'IVOIRE CAR LIBERIA MOZAMBIQUE BURKINA FASO TOGO NIGERIA CHAD CONGO CAMEROON GABON BENIN CONGO, (ZAIRE) 01020304050 % Seropositive

9. Characteristics of HIV Epidemics in LAC Region Complex (mix of concentrated and generalized) ? Mature Surveillance issues

10. Factors that influence the spread of HIV Viral Factors -HIV-1 strains -Viremia Local Genital Factors -Presence of STDs -Male circumcision -Use of vaginal products Sexual Behavior -Rate of partner exchange -Sexual mixing patterns -Type of intercourse -Size of and rate of contact with core groups -Level of condom use Demographic Factors -% sexually active age groups to other age groups -Male to female ratio -Urban:rural% -Migration patterns Economic and Political Factors -Level of poverty -War and social conflicts -Status of transport and mobility of population -Performance of health care system -Response to epidemic (from Piot-1994)

11. Comparison of average number of clients per sex worker versus % of young men to utilized sex workers Indonesia Philippines Cambodia Thailand

12. Comparison of HIV prevalence among female SWs and # clients per day IndonesiaPhilippines Cambodia Thailand

13. Infectious Disease Control Basic Principles 1: Modes of transmission Stages of the epidemic Epicenters/ “hot zones” Concept of “core transmitters” Those most likely to transmit/Those most likely to contract (“TMLTC”)

14. LAC Countries by Major Mode of Transmission IDUMSMHeterosexual Argentina Bahamas BermudaBrazilBarbados BrazilCosta RicaDominican Republic UraguayDominicaGuatemala MexicoGuyana PanamaHaiti PeruHonduras VenezuelaJamaica

15. Stages of the Epidemic Nascent Concentrated Generalized Mature

16. Basic Principles-2 Primary goal is to reduce: 1. Risk behaviors (through intensive interpersonal communications/ mass communication to achieve behavior change) 2. Efficiency of transmission (through reduction of cofactors, e.g. STDs, use of male/female condoms, microbicides)

17. Basic Principles-3 The most effective way to reduce risk behaviors and the efficiency of transmission is to “target” those most likely to transmit or contract infection--in practice, this is achieved through an emphasis on “Risk Populations” and “Risk Locations.”

18. RISK POPULATIONS Commercial sex workers Male migrant workers (e.g. truckers, construction workers, seafarers, urban skilled and unskilled) Military/police Civil servants Men who have sex with men (MSM) Injecting drug users University students STD patients (private and public sector) Youth (young men and women), single women

19. RISK LOCATIONS Brothels, bars, hotels, massage parlors, beauty salons, night clubs Truck stops, border crossings, bus terminals, train stations Military bases/Harbors Video parlors Worksites (mines, construction sites)

20. Essential Technical Elements of an HIV/AIDS Program Prevention Blood safety Universal precautions Sexual risk reduction Harm reduction Condom social marketing STI management Voluntary Counseling and Testing Stigma reduction PMTCT Surveillance and M&E Care and Mitigation Palliative care Psychosocial support Treatment of OIs OVC Use of ARVs Other mitigation activities

21. Supporting Elements for an HIV/AIDS Program Policy Reform (government commitment, allocation of resources, dealing with discrimination, stigma) Biomedical Research (STD Diagnostics, microbicides, Mother-to-child transmission interventions, preventive and therapeutic vaccines) Social Science Research Surveillance (biologic and behavioral) Improved distillation and use of research and “lessons learned”

22. Limitations of Family Planning Settings “…inherently weak interventions for often the wrong populations…” Behavior Change –(dual protection-can it work?) STI management –significant number of asx cases –vaginal discharge syndromic algorithm lacks sensitivity and specificity

23. Summarizing Recommendations for Interventions Epidemiologic Scenario Intervention Concentrated -MSM -IDU VCT Improved targeting GeneralizedImproved targeting VCT PMTCT ALLImprove surveillance ???CARE?????

24. -end of Part One Part Deux next………..