EVALUATION OF THE BAHAMAS HIV/AIDS PROGRAMME FINAL REPORT

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1 EVALUATION OF THE BAHAMAS HIV/AIDS PROGRAMME FINAL REPORT Submitted by: Health Economics Unit The University of the West Indies St. Augustine Republic of Trinidad and Tobago Submitted to: CARICOM Secretariat Pan Caribbean Partnership Against HIV/AIDS (PANCAP) Guyana March 2007

2 EXECUTIVE SUMMARY This report evaluates the National HIV/AIDS Programme (NAP) of The Commonwealth of The Bahamas from its inception in 1985 to It also outlines the country s national goal of moving towards universal access to HIV prevention, treatment and support services which it hopes to achieve by Some key findings of the report reveal that between 1985 and 1988, the number of newly reported HIV infections amounted to a combined total of 782. Thereafter, the incidence peaked at 734 in 1994 and descended to approximately 300 in The greatest change occurred in the year age group. This decline in new HIV infections can be attributed to the sustained involvement of the Government in the HIV/AIDS response which included blood screening, surveillance, and partner notification, and behaviour change communication and public awareness campaigns. In 1997 the number of AIDS cases crested at 385 and fell to less than 300 in Sero-prevelence surveys among pregnant mothers revealed that the prevalence of HIV in antenatal women declined from 4.3 percent to 2.9 percent between 1993 and There was also a reduction in the number of HIV infections among women of child bearing age. Further, individuals, who tested positive for HIV, among patients receiving care for STIs, declined from 9.2 percent in 1993 to 4.1 percent in Infection rates of blood donors remained low but declining. The most significant change attributed to the outreach and preventive interventions of the National AIDS Programme was the marked reduction of perinatal HIV transmission from HIV positive mothers to their infants. In 1992, the official figure showed that 30 percent of infants born to HIV-infected mothers in The Bahamas were also HIV positive. However, a 2006 report by the Ministry of Health noted that no children were born HIV positive to HIVinfected mothers who had accessed antenatal care in 2003 and Vertical transmission rates effectively decreased to less than 1 percent in AIDS has been identified as the leading cause of death in The Bahamas since Notwithstanding, The Bahamas has also witnessed a reduction in the AIDS mortality rate over time. The percentage of registered deaths due to AIDS declined from 18.4 percent in 1996 to 11.8 percent in In relation to the current status of reported AIDS cases, data shows that while 84 percent died in 1985 only 37 percent died in This reduction coincides with improved ability to enter individuals in care, to diagnose and treat opportunistic infections, and the increased affordability and availability of antiretroviral therapy (ART). The number of reported HIV/AIDS cases in The Bahamas at the end of 2005 was 10,479. Of these 6,853 were living and 3,626 were dead. Of the living, 1,631 were living with an AIDS diagnosis, while the remaining 5,222 have not yet progressed to AIDS. It is evident that the availability and affordability of antiretroviral therapy have contributed to the remarkable achievements of the NAP in The Bahamas. Those able to access ART jumped from approximately 16 percent in 2002 to 60 percent in This was brought i

3 about by the committed efforts of the Government of The Bahamas and the lobbying efforts of the Clinton Foundation for the provision of lower cost antiretroviral medications. In 2005 nearly all antenatal and pediatric clients were receiving ART. In spite of the increased access to ART, the greatest barriers to universal access seem to be insufficient human resources and infrastructure to adequately provide care and follow-up, fear of stigma and discrimination and lack of knowledge among HIV positive persons. In 2005, the achievements made and the barriers identified spurred the Government of The Bahamas to move towards the goal of universal access to HIV prevention, treatment, care and support services by This is to be achieved through the development of nationally agreed targeted plans or roadmaps, aimed at building a more comprehensive AIDS programme by In The Bahamas such a roadmap was developed under the guidance of the National HIV/AIDS Centre with technical and financial support from the UNAIDS Office. The process included a detailed review of strategic plans of 2005, and consultation with key stakeholders to identify accomplishments to-date, the status of key initiatives and strategic plans, key barriers and future actions and milestones. Attaining the goal of universal access by 2010 will help to stem the destructive tide of HIV/AIDS on the country s most precious resource, its human resource, and to ensure that the development objectives of the country can be achieved and maintained. ii

4 ACKNOWLEDGEMENTS The Health Economics Unit (HEU), The University of the West Indies, St Augustine wishes to acknowledge and thank Principal Investigator Mr. Martin Franklin who led this process. Special acknowledgements are due to the Research Staff of the HEU for their various roles in contributing to this study: Patricia Edwards-Westcott, Kimberly-Ann Gittens-Baynes, Dr. Althea La Foucade, Christine Laptiste, Candice McKenzie and Leena Ramnath. Finally, we acknowledge the Secretariat of the Unit, Cheryl Theodore and Richelle Winchester for their logistical and administrative support. KARL THEODORE Team Leader Professor of Economics, Department of Economics/ Coordinator of Health Economics Unit Department of Economics The University of the West Indies St Augustine iii

5 TABLE OF CONTENTS Page No. EXECUTIVE SUMMARY... i ACKNOWLEDGEMENTS... iii TABLE OF CONTENTS... iv LIST OF TABLES... vii LIST OF FIGURES... ix LIST OF APPENDICES... xi ABBREVIATIONS AND ACRONYMS... xii TERMS OF REFERENCE & STRUCTURE OF REPORT... xv Detailed Terms of Reference... xv SECTION HIV/AIDS IN THE BAHAMAS : Demographic and Socio-Economic Profile The HIV Epidemic The AIDS Epidemic HIV/AIDS Care and Treatment Volunteer Counselling and Testing (VCT) Contact Tracing and Partner Notification Prevention of Mother-To-Child Transmission (PMTCT) Sexually Transmitted Infections (STIs) Coordination of the National AIDS Programme National AIDS Strategic Plan Epidemiological Surveillance and Research Treatment, Care and Support Prevention and Health Promotion Legal Framework Technical Cooperation The Bahamas Health Delivery System Princess Margaret Hospital (PMH) HIV/AIDS Services on the Family Islands HIV/AIDS Care in the Prison System The National TB Control Program The Sexually Transmitted Infections Clinic Substance Abuse and Mental Health Services Laboratory Services Pharmacy Services Hospice Services Manpower Resources in the Health Sector at the End of Manpower Assigned to The National HIV/AIDS Programme as at Prevention and Behaviour Change Human Rights Issues Support Spending on HIV/AIDS Monitoring and Evaluation Environment Limitations and Gaps as at the End of iv

6 SECTION THE STRATEGIC PLAN FOR SCALING UP HIV/AIDS CARE AND TREATMENT IN THE BAHAMAS Model of Care for the Strategic Plan Core Principles of the Strategic Plan Goals of the Strategic Plan Annual Targets of the Strategic Plan Cost and Funding of the Strategic Plan Achievements & Challenges of the Strategic Plan The HIV Epidemic The AIDS Epidemic Treatment and Care Voluntary Counselling and Testing (VCT) Prevention of Mother-To-Child Transmission (PMTCT) Contact Tracing and Partner Notification TB Control Programme Hospitalisation Post-Exposure Prophylaxis Research Human Rights Issues Prevention and Education Support The National HIV/AIDS Centre Challenges at the end of the Strategic Plan SECTION TOWARDS UNIVERSAL ACCESS TO HIV/AIDS PREVENTION, TREATMENT, CARE AND SUPPORT SERVICES 2006 TO Background The Resource Profile of the National HIV/AIDS Centre Definition of Universal Access Goals and Targets within the Roadmap Major Challenges faced and Actions needed to achieve the Goals and the Targets of the Roadmap Critical Success Factors for Sustained National Response to HIV/AIDS Lessons Learnt Recommended Practice Arising from The Bahamas Experience SECTION A COMPARATIVE ANALYSIS OF HIV/AIDS RESPONSE AND LESSONS LEARNT: BRAZIL, UGANDA AND THE BAHAMAS Brazil Brief Demographic Background National Response Treatment and Care Voluntary Counselling and Testing Prevention NGO Response FBOs v

7 4.2 Lessons Learnt Uganda National Response Treatment and Care Voluntary Counselling and Testing Prevention NGOs FBOs Lessons Learnt Conclusion REFERENCES APPENDICES APPENDIX 1 Milestones in the HIV/AIDS Response in The Bahamas APPENDIX 11 Milestones in the HIV/AIDS Response in Brazil APPENDIX 111 Milestones in the HIV/AIDS Response in Uganda APPENDIX 1V Comparative Table of the Milestones in the HIV/AIDS Response Bahamas, Brazil and Uganda vi

8 LIST OF TABLES Table No. Page No. 1. Reported HIV Cases, Sex Ratio, Total and Cumulative HIV Cases: Annual AIDS Incidence, Sex Ratio, Cumulative AIDS Cases: Number of AIDS Cases in Infants Less than One Year Old and Rate per 1000 Live Births Number of AIDS Cases in the 1-4 Years Old Age Group and Rate per 100,000 Population Age Specific (<1 year old) Mortality Rate and AIDS Specific Mortality Rate Age Specific (1-4 years old) Mortality Rate and AIDS Specific Mortality Rate Age Specific (5-9 years old) Mortality Rate and AIDS Specific Mortality Rate AIDS Cases and Status: Summary of Antenatal Clients Accessing PMTCT Care Number of Cases of Sexually Transmitted Infections Diagnosed at the New Providence STI Clinic, Health Personnel and Support Providers from the Public and Private Sectors in The Bahamas at End Manpower Assigned to HIV/AIDS Treatment and Care as at HIV/AIDS Spending in The Bahamas for Profile of Comprehensive HIV/AIDS Care Guiding Core Principles and Values in the Implementation of the Plan Targets, Objectives and Key Activities of Goal 1 of the Plan Targets, Objectives and Key Activities of Goal 2 of the Plan Targets, Objectives and Key Activities of Goal 3 of the Plan vii

9 19 Annual Targets for Care and Treatment to PLWHA in the Bahamas Patient Targets for Care and Treatment to PLWHA in the Bahamas by Category Budget for the Plan Summary of Antenatal Clients Accessing PMTCT Care Areas of Responsibility and Staffing by Unit for the HIV/AIDS Centre Major Challenges Faced and Actions Needed to Achieve the Goals and Targets of the Roadmap...63 viii

10 LIST OF FIGURES Figure No. Page No. 1 Annual HIV Incidence: HIV Trend among Males and Females: Age Group Distribution of HIV Cases: Sex and Age Distribution of HIV Cases Trends in HIV Mother-to-Child Transmission Rates Prevalence of HIV in Antenatal Women, STI Clients and Blood Donors, AIDS Cases by status: Dead or Alive Age Group Distribution: Top Structure of the HIV/AIDS Center Cumulative Number of Reported HIV Infections with Status as of December 31st, Cumulative Number of Non-AIDS HIV Infections by Sex as of December 31st, New Non-AIDS HIV Infections by Sex and Reported Year, Reported New HIV Infections and New Non-AIDS HIV Infections by Year Cumulative Number of Reported HIV Infections by Age and Sex as of December 31st, Prevalence of HIV in Antenatal Women, STI Clients and Blood Donors, New Cases of AIDS, By Sex and Year, August 1985 to December 31st, Current Status of Reported AIDS Cases as of December 31st, ix

11 18 AIDS Cases Alive by Age Group and Sex, December 31 st, Cumulative Number of HIV-Infected Clients Receiving Antiretroviral Therapy to December 31, PLWHA receiving ARV Therapy x

12 LIST OF APPENDICES Appendix No. Page No. Appendix I Milestones in the HIV/AIDS Response in The Bahamas...73 Appendix II Milestones in the HIV/AIDS Response in Brazil...75 Appendix III Appendix IV Milestones in the HIV/AIDS Response in Uganda...89 Comparative Table of the Milestones in the HIV/AIDS Response Bahamas, Brazil and Uganda...91 xi

13 ABBREVIATIONS AND ACRONYMS ABT ACTG AFB AIDS AIC ART ARV AZT BCC CAREC CARICOM CBO CCC CCNAPC CD4 CDC CFNI CHART CSW DOTS GDP ELISA Abbott Laboratories Acacia Research Corporation American Foundation for the Blind Acquired Immune Deficiency Syndrome AIDS Information Centre Antiretroviral therapy Antiretroviral The drug, Zidovudine. Brand Name - Retrovir. Behaviour Change Communication Caribbean Epidemiology Centre Caribbean Community Secretariat Community-based Organisation Caribbean Council of Churches The Coalition of National AIDS Program Coordinators A glycoprotein predominantly found on the surface of helper T cells. It is a receptor for HIV, enabling the virus to gain entry into its host. Centers for Disease Control and Prevention Caribbean Food and Nutrition Institute Caribbean HIV/AIDS Regional Training Initiative Commercial Sex Worker Directly Observed Therapies Gross Domestic Product Enzyme-Linked ImmunoSorbent Assay xii

14 FBO FOY FTE HIV HPV KABP MDG MoD MoH MSM MTCT NACP NAP NASTAD NASP NGO NHIRU OI PAHO PEP PI PLWHA PMH PMTCT Faith-Based Organisation Focus on Youth Full Time Employees Human Immunodeficiency Virus Human Papillomavirus Knowledge, Attitudes, Beliefs and Practices Millennium Development Goals Ministry of Defence Ministry of Health Men who have sex with men Mother to Child Transmission National AIDS Control Programme National AIDS Programme National Alliance of State and Territorial AIDS Directors National HIV/AIDS Strategic Plan Non-Governmental Organisation National Health Information and Research Unit Opportunistic Infection Pan American Health Organisation Post-Exposure Prophylaxis Protease Inhibitor Persons Living With HIV/AIDS Princess Margaret Hospital Prevention of Mother to Child Transmission xiii

15 PN-DST/AIDS RMH STI TASO TB UN UNAIDS UWI HARP VCT WHO YAPL National AIDS Programme (Brazil) Rand Memorial Hospital Sexually Transmitted Infection The AIDS Support Organisation Tuberculosis United Nations Joint United Nations Programme on HIV/AIDS University of the West Indies HIV AIDS Response Project Volunteer Counselling and Testing World Health Organisation Youth Ambassadors for Positive Living xiv

16 TERMS OF REFERENCE & STRUCTURE OF REPORT This Final Report represents the last deliverable under the terms of reference set out below, for the review of the expanded response to HIV/AIDS in The Bahamas. Detailed Terms of Reference 1. Literature Search a. History of HIV/AIDS in The Bahamas b. Comparative History of HIV/AIDS in two other countries, Brazil and Uganda c. Summary of the National Strategic Plan for HIV/AIDS in The Bahamas i. Priority Areas ii. Strategies by Priority Area iii. Targets iv. Measurement and Evaluation Framework v. Implementation Strategy vi. Cost d. Comparative Summaries of the National Strategic Plans for HIV/AIDS in Brazil and Uganda e. The Surveillance Systems in Bahamas, Brazil and Uganda f. Measurement and Evaluation Systems for HIV/AIDS g. Lessons learnt from the National Response to HIV/AIDS in both Brazil and Uganda h. Existing Reports arising from the evaluation of National Programs in the Caribbean i. Reports arising from the evaluation of National Programs in Brazil and Uganda 2. Primary and Secondary Data Collection a. Surveillance Data for Bahamas b. Data on Prevention Program in Bahamas c. Data on Treatment, Care & Support Program in Bahamas d. Data on Advocacy and Human Rights Program in Bahamas e. Data on Cost of the National Response in Bahamas f. Capacity & Ownership of the Public Sector re. the Implementation of the National Response g. Capacity & Ownership of the Private Sector re. the Implementation of the National Response h. Capacity & Ownership of the NGOs & CBOs re. the Implementation of the National Response i. Past, Current and Projected Expenditure re. the Implementation of the National Response j. Leadership of the Response 3. Data Analysis & Evaluation a. Epidemiology of HIV/AIDS in Bahamas b. Prevention Program data in Bahamas c. Treatment, Care & Support Program data in Bahamas xv

17 d. Advocacy and Human Rights Program data e. Capacity of the Public Sector re. the Implementation of the National Response f. Capacity of the Private Sector re. the Implementation of the National Response g. Capacity of the NGOs & CBOs re. the Implementation of the National Response h. Cost of the Response i. Sustainability of the Response in Bahamas 4. Identification of Strengths and Weaknesses of the National Response 5. Definition of Achievements of the National Response to date 6. Identification of Key Factors that are likely to impact the National Response over the medium term 7. Identification of Challenges to the National Response over the medium term 8. Comparative Analysis of Achievements and Challenges with National Programs in Brazil and Uganda 9. Identification of relevant Best Practices from Brazil and Uganda 10. Writing select inputs to the Final Report The report summarizes the available secondary data on the expanded response to HIV/AIDS in The Bahamas over the period Accordingly, this report presented in two volumes and is further subdivided into four continuous sections. Volume 1 consists of Sections 1 to 3, which deal solely with HIV/AIDS in The Bahamas. Volume 2 contains one section, Section 4 and presents comparisons of the response to the HIV/AIDS epidemic in Brazil and Uganda. Section 1 reviews the behaviour of the epidemic and national response during the period Section 2 examines and analyzes the implementation of the Strategic Plan, and provides an update of the epidemic and the national response during that three year period. In Section 3, a summary of the country s roadmap for scaling up towards universal access to HIV/AIDS Prevention, Treatment, Care and Support Services over the is presented. Critical success factors for the sustained national response are also considered and the lessons learnt from the country s National HIV/AIDS Programme as well as recommended practice arising from the experience are discussed. Section 4 charts the response to the epidemic in Brazil and Uganda with a comparison of the three countries and application for the wider Caribbean. Three appendices are provided as part of this report. These list milestones in the HIV/AIDS responses in The Bahamas, Brazil and Uganda.. xvi

18 VOLUME 1 AN OVERVIEW AND ANALYSIS OF HIV/AIDS IN THE BAHAMAS:

19 SECTION 1 HIV/AIDS IN THE BAHAMAS : Demographic and Socio-Economic Profile The Bahamas, officially The Commonwealth of The Bahamas is an archipelago of 700 islands and 2400 uninhabited islets and cays in the Atlantic Ocean. It lies 50 miles off the east coast of Florida and the United States, north of Cuba and the Caribbean, and northwest of the British dependency of the Turks and Caicos Islands. It is an English speaking country with an estimated population size of 303, 770 which takes into account the effects of mortality due to AIDS. 1 At the beginning of 2003, the overall life expectancy for the average Bahamian was 70 years of age with the male and female life expectancy being 66 and 74 respectively. The crude birth rate was 18.4 per 1,000 population and the annual population growth rate was 1.3%. Total fertility rate was 2.1 per woman of child bearing age, and both the maternal mortality rate and the infant mortality rate were below the 2000 levels of 38.0 per 100,000 live births and 14.7 per 1,000 live births respectively. The literacy rate among Bahamians 15 years old and over was 95.5% with gender variation showing females (96.4%) are more literate than males (94.7%). The country s GDP grew by 1.4% in 2002 (HEU, 2006) 1.2 The HIV Epidemic Between 1985 and 1988, the number of newly reported HIV infections (incidence) amounted to a combined total of 782. Thereafter, the incidence peaked at 734 in 1994; 394 of these were male and 340 were female. A sustained decreasing trend was observed over the next eight years with the number of newly reported infections being 408 in 2002 (CAREC, 2004). The HIV incidence rate peaked at 268 per 100,000 population in This was followed by a declining trend which reached 132 per 100,000 3 in 2002, with the greatest change noted in the year old group (CAREC, 2004; Figure 1). 1 Source: 2 Source: Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas Based on a population of 310,000 in

20 Figure 1: Annual HIV Incidence: Source: CAREC, 2004 The distribution of males and females among the reported HIV cases, was approximately equal in This was in contrast to the early years of the epidemic when significantly more males than females were infected (Figure 2). The decrease in the number of cases during the eight years ( ) translated into a reduction of 42.7% among females and 46% among males. This observation underlines the fact that, irrespective of gender, the Bahamian population as a whole had begun by the end 2002 to demonstrate adherence to the prevention measures aimed at minimising HIV transmission (CAREC, 2004). Figure 2: HIV Trend among Males and Females: Source: CAREC,

21 Figure 3 below highlights that over the 1985 to 2002 period the majority (approximately 65%) of the HIV positive cases occurred in the age group. In addition, 21% of the HIV cases over the same period were among the age group. Figure 3: Age Group Distribution of HIV Cases: Source: CAREC, The sex and age distribution among the more sexually active group (15-49) has shown that with the exception of the age group where females are predominant, males are more affected by HIV (see Figure 4). 3

22 Figure 4: Sex and Age Distribution of HIV Cases Source: CAREC, The HIV epidemic continued to be impacted by two other epidemics namely, the widespread use of crack cocaine and the genital ulcer disease. There has been a consistent pattern of increasing cocaine use since As many as 55 persons received cocaine-related services at the Community Counselling Centre in Nassau in Concurrently, the drug treatment services at the Community Counselling Centre were being increasingly utilized, with the largest numbers ever seen for marijuana (191), alcohol (128) and poly drug use (147) being recorded in Whereas, injection drug use remained uncommon among the Bahamian people, there was some evidence of it among Haitian-born residents by 2003 (Ministry of Health, 2002). According to CAREC (2004), the cumulative HIV cases reported over the 1985 to 2002 period was 8,124, of which 4,382 (almost 50%) evolved to AIDS with 3,123 deaths. The corresponding cumulative rate of 2,901 per 100,000 4 population represents a high number of HIV cases for the small population of The Bahamas, and classified the epidemic in the country as just short of generalized = 8124/280,000 where the denominator represents the population for 1993 (the median year of the period) 4

23 Table 1: Reported HIV Cases, Sex Ratio, Total and Cumulative HIV Cases: Year Male Female Unknown Sex Ratio Total Cumulative Total Total Source: CAREC, 2004 In-country data from the HIV/AIDS Centre however, places the cumulative HIV cases as at the end of June 2002 at 9,106; of these 6000 are HIV-positive; 1200 were confirmed as having AIDS and 4800 cases had not progressed to AIDS. Monitoring of the prevalence of HIV continues through seroprevalence surveys in subpopulation groups of persons attending antenatal clinics, the sexual transmitted infection clinic (STI), and the blood bank, and during prison intake. The number of HIV infections among women of childbearing age was diminishing. Seroprevalence surveys confirmed that the HIV prevalence among pregnant women had been declining gradually over the period. In 1993, the HIV prevalence rate was 4.3%; then fell to 3.0% in 2002 due to sentinel surveillance of patients receiving antenatal care. This reduction corresponds to a 30 percent decline in the seroprevalence rate (CAREC, 2004). Seroprevalence rates among STI patients also showed a declining trend over the period. In 1993, the related seroprevalence rate was 9.2%; this was reduced by 41% to 5.4% in 2002 (CAREC, 2004). Infection rates among persons admitted to the prison had decreased to 3.4% in Ten percent (10%) of the prison population were infected with HIV but very few of these had symptomatic disease. Further, no prisoner was receiving ARV therapies at end Sentinel surveillance activities continued among these target populations, and among those in treatment for substance abuse (Ministry of Health, 2006). Surveillance and partner notification strategies coupled with blood screening, behaviour change communication and public awareness campaigns continue to be the backbone of the 5

24 national response. Also included was a focused effort to identify and enter HIV positive persons into appropriate care and support services (National HIV/AIDS Centre, 2006). The impact of the outreach and preventive interventions was seen in the marked reduction in perinatal HIV transmission (MTCT) from HIV positive pregnant women to their children. All HIV positive mothers were being counseled regarding the dangers of breastfeeding. In combination, these measures resulted in a decrease in the rate of HIV-infected infants born to HIV-positive mothers to 5 percent in 2002 (Figure 5). Figure 5: Trends in HIV Mother-to-Child Transmission Rates Source: Gomez, 2006 Sentinel surveillance of patients in antenatal care confirmed a drop in prevalence from 4.3% to 2.7% between 1993 and Among patients receiving care for STIs, the percent testing positive for HIV had decreased from 9.2% to 4.4% between 1993 and 2001 (Ministry of Health, 2002). This is supported by the data in Figure 6. 6

25 Figure 6: Prevalence of HIV in Antenatal Women, STI Clients and Blood Donors Antenatal STD Clients Blood Donors Percent (%) Antenatal STD Clients Blood Donors Year Source: Gomez, The AIDS Epidemic The first clinical case of AIDS was reported in the Commonwealth of The Bahamas in The HIV/AIDS epidemic in The Bahamas is seen as a heterosexual one (CAREC, 2004) and is concentrated among Bahamian citizens living on a few large islands. Approximately 82% of individuals with HIV disease and 86.5% with AIDS lived on New Providence, 7% with HIV disease and 8% with AIDS lived on Grand Bahama, while Abaco and Eleuthera together accounted for 7.5% and 3% of HIV disease and AIDS cases, respectively. All other islands combined had the remaining 3.5% of HIV disease and 2.5% of AIDS cases. Bahamian citizens made up 87% of persons with HIV/AIDS. Persons of Haitian descent made up the majority of the remaining cases and this proportion appeared to be increasing (12% in 2000, up from 9% in 1998) (Gomez, 2006; HIV/AIDS Centre, 2006). It is evident that AIDS mortality has impacted The Bahamas. AIDS became the leading cause of all deaths in The Bahamas in 1994 and the leading cause of death among all persons years of age in 2000 (National HIV/AIDS Centre, 2006A) and (Ministry of Health, 2006). In 1997 the number of AIDS cases reported peaked at 385; 226 of these were male and 159 were female. Eighty-two of these cases were alive and 303 or 79% were dead at the end of that year. However by 2002 a tremendous reduction was noted in the fatality rate. The rate of AIDS deaths to total AIDS cases fell from 84% in 1985 to 57% in 2001 and further to 46% in 2002, (Figure 7) 7

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