1. Group Discussion Guyana, The Bahamas T & T, Jamaica Barbados, Haiti Suriname, Curacao

2. Successes (1) Reduction of deaths due to care and treatment Reduction of deaths due to care and treatment Increased HIV testing Increased HIV testing E.g. increased VCT centers in Barbados E.g. increased VCT centers in Barbados Decrease incidence of mother to child transmission Decrease incidence of mother to child transmission Decreased Incidence/Prevalence rates Decreased Incidence/Prevalence rates Observed in both Jamaica and Trinidad Observed in both Jamaica and Trinidad Guyana dropped 2.5% to 1.5% Guyana dropped 2.5% to 1.5% Haiti dropped 6.4% to 2.2% Haiti dropped 6.4% to 2.2% Medical patient management system in place Medical patient management system in place

3. Successess (2) Increased capacity to perform diagnostic testing in country Increased capacity to perform diagnostic testing in country Viral load now performed in Bahamas, T&T, Jamaica Viral load now performed in Bahamas, T&T, Jamaica CD4 performed in all countries CD4 performed in all countries Barbados can also to resistance testing Barbados can also to resistance testing Higher CD4 thresholds to initiate antiretroviral therapy (250-350 cells/mm3) Higher CD4 thresholds to initiate antiretroviral therapy (250-350 cells/mm3) Means more patients on antiretroviral therapy Means more patients on antiretroviral therapy Development of National Reference Laboratory Capacity Development of National Reference Laboratory Capacity Bahamas: Expansion of equipment & staff Bahamas: Expansion of equipment & staff Guyana: Infrastructure in place, hopeful operation soon Guyana: Infrastructure in place, hopeful operation soon Trinidad and Jamaica implemented LIS Trinidad and Jamaica implemented LIS Increase in Prevention Programs Increase in Prevention Programs Free ARV therapy in all countries Free ARV therapy in all countries

4. Successes (2) Increased uptake of PMTCT program Increased uptake of PMTCT program Initiation of DNA-PCR testing for early infant diagnosis Initiation of DNA-PCR testing for early infant diagnosis In Bahamas/Guyana, samples sent to South Africa with support from Clinton Foundation In Bahamas/Guyana, samples sent to South Africa with support from Clinton Foundation In T&T samples sent to CAREC In T&T samples sent to CAREC Countries have a National AIDS Coordinating Program Countries have a National AIDS Coordinating Program Includes increased capacity for monitoring & evaluation Includes increased capacity for monitoring & evaluation Increase in access points for PLHIV Increase in access points for PLHIV Bahamas: strengthening referral system to national treatment centers Bahamas: strengthening referral system to national treatment centers Guyana: Increased care & treatment sites by incorporating HAART into regional hospitals and select health centers Guyana: Increased care & treatment sites by incorporating HAART into regional hospitals and select health centers Same with Trinidad & Tobago Same with Trinidad & Tobago Haiti: increase in youth participation in services Haiti: increase in youth participation in services

5. OPPORTUNITIES Cross-Country collaboration and technical support (sharing knowledge, etc.) Standardization of Guidelines Coordination of pharmaceuticals & lab reagents when supply stock-outs occur Coordination of training Examples: Guyana ahead with rapid testing (could help Bahamas) Bahamas already testing viral load (could help Guyana) Use technology to improve access to hard-to-reach areas Example: Haiti using manual CD4, Guyana – mobile clinic

6. OPPORTUNITIES To Provide & Share Research To Provide & Share Research To build on prevention based on the success of Care and treatment by integrating care treatment and prevention To build on prevention based on the success of Care and treatment by integrating care treatment and prevention Increase diagnostic capability for pediatric infection Increase diagnostic capability for pediatric infection Team approach to management Team approach to management Government Support/Political Will Government Support/Political Will Using infrastructure created by HIV response to build overall health care infrastructure Using infrastructure created by HIV response to build overall health care infrastructure Use existing care & treatment services as a model for decentralization of services Use existing care & treatment services as a model for decentralization of services

7. COMMON BARRIERS Procurement (medication and reagents) & Supply chain management (including cold chain) Procurement (medication and reagents) & Supply chain management (including cold chain) The Absence of higher level testing in some countries (Resistance testing & viral load) The Absence of higher level testing in some countries (Resistance testing & viral load) Different treatment regimes in countries Different treatment regimes in countries Lack of testing to date on HIV infection to know if infection is new or old Lack of testing to date on HIV infection to know if infection is new or old Lack dissemination of information Lack dissemination of information

8. COMMON BARRIERS Human Resources Stigma and Discrimination Immigration and Emigration Bahamas: immigration presents cultural and language barriers Guyana: emigration of skilled staff Haiti: contact tracing Coordination of care for patients that move between Caribbean islands Sustainability of HIV programmes Integration of vertical programs Changes in government & regulations Power struggle and turf war (Information Hording)

9. Needs (1) Funding Funding Staff & Human Resources (particularly trained staff) Staff & Human Resources (particularly trained staff) Training Training Examples: Examples: Bahamas: development of a national rapid testing algorithm Bahamas: development of a national rapid testing algorithm Lab certification/accreditation Lab certification/accreditation Training in new technologies, retraining in existing ones Training in new technologies, retraining in existing ones Increased involvement of private sector Increased involvement of private sector Infrastructure: Easier transport for patients & specimens, consistent power supplies, etc. Infrastructure: Easier transport for patients & specimens, consistent power supplies, etc. Equipment Maintenance Equipment Maintenance

10. Recommendations Fix all the needs and challenges! Fix all the needs and challenges! Develop a method of coordination between Caribbean islands that could be used for: Develop a method of coordination between Caribbean islands that could be used for: Patient care Patient care Training & technical assistance Training & technical assistance Supply chain issues Supply chain issues Create a common regional policy? Create a common regional policy? Methods to reduce stigma & discrimination: Methods to reduce stigma & discrimination: More education on HIV More education on HIV Integration of HIV services to primary care Integration of HIV services to primary care Opt-out testing Opt-out testing Implementation of a sustainability plan and planning for succession Implementation of a sustainability plan and planning for succession Continue to integrate HIV care into primary care: Continue to integrate HIV care into primary care: E.g. integrate HIV programs into existing clinics E.g. integrate HIV programs into existing clinics E.g. integrate other STI screening at VCT sites E.g. integrate other STI screening at VCT sites