EVALUATION OF THE BAHAMAS HIV/AIDS PROGRAMME FINAL REPORT

Transcription

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

26 Figure 7: AIDS Cases and Status: Alive or Dead Source: CAREC (2004) The number of reported AIDS cases at end 2002 was 291, down from the peak of 385 recorded in 1997 as shown in Table 2 which follows. The slight increase in the number of new and cumulative AIDS cases in 2002 is likely to be the result of the three factors, viz. the improved diagnostic capacity to identify AIDS cases through laboratory testing and the addition of CD4 testing in 2001, ART, and the ability of individuals with an AIDS diagnosis to live longer through improved treatment of opportunistic infections. The annual incidence rate was just 93 per 100,000 population in ; a 24.4% reduction over the period (CAREC, 2004). Annual AIDS incidence for males stood at 181 in 2002, down from the peak of 239 in 1995, whilst the annual AIDS incidence for females had generally declined to 110 in 2002 after a peak of 159 in Overall there were more cases of AIDS among the males than among the females. Over the five year period , the male to female ratio was 1.51:1; this contrasts with the almost equal distribution observed for HIV cases in the previous years. This observation suggested that unprotected male-to-male sexual contacts may be playing a role in the epidemic in The Bahamas, while male-to-female unprotected sexual contact remained the major category in the transmission of HIV (CAREC, 2004). 5 i.e. (291/312,000) 8

27 Table 2: Annual AIDS Incidence, Sex Ratio, Cumulative AIDS Cases: Year Male Female Unknown Sex Ratio Total Cumulative Total Total Source: CAREC, The age distribution among AIDS cases, as shown in Figure 8, reveals that the age groups 0 9 years and years each accounted for 6% of the cases up to 2002; almost 73% of the cases belonged to the age group, by far the most productive age group (CAREC, 2004). Figure 8: Age Group Distribution: Source: CAREC,

28 In the age group, less than one year old, a reduction in the number of cases was observed. The number of cases fell from eleven in 1990 to only one over the three year period 2000 to Table 3 highlights a similar declining trend in AIDS per 1000 live births between 1994 and 2002 (CAREC, 2004). Table 3: Number of AIDS Cases in Infants Less than One Year Old and Rate per 1000 Live Births Year Number of Cases Rate per 100,000 population Source: CAREC, Table 4 reveals that among children aged 1 4 years, the number of AIDS cases declined to a total of 1 for the period , after peaking in 1992 at 10. In addition, a parallel declining trend in the rate per 1,000 live births was observed from 1997 to

29 Table 4: Number of AIDS Cases in the 1-4 Years Old Age Group and Rate per 100,000 Population Year Number of Cases Rate per 100,000 population Source: CAREC, 2004 In looking at AIDS mortality among children less than one year old, Table 5 shows that for the period 1994 to the end of 1999, the rate decreased from 2.8 per 1000 live births to 0.5 per 1000 live births (average of male and female) in Table 5: Age Specific (<1 year old) Mortality Rate and AIDS Specific Mortality Rate YEAR AIDS Mortality Rate and Rank MORTALITY RATE per 1,000 live births, rank per 1,000 live births per 1,000 live births 15.8 per 1,000 live births per 1,000 live births 12.5 per 1,000 live births per 1,000 live births, rank per 1,000 live births per 1,000 live births 10.0 per 1,000 live births per 1,000 live births: males 0.4 per 1,000 live births: females, rank per 1,000 live births: males 7.1 per 1,000 live births: females Source: HICS, MOH&E, Bahamas. Reproduced from CAREC (2004) In the 1 to 4 years old age group, the AIDS mortality rate declined from 2 per 10,000 in 1997 to 0.5 per 10,000 (average of male and female) in 1999 (Table 6). This observation underlines the improvement in child survival in The Bahamas (CAREC, 2004). 11

30 Table 6: Age Specific (1-4 years old) Mortality Rate and AIDS Specific Mortality Rate YEAR AIDS Mortality Rate and Rank MORTALITY RATE per 10,000 population 11.5 per 10,000 population per 10,000 population 4.1 per 10,000 population per 10,000 pop for males 1.7 per 10,000 pop for females 7.1 per 10,000 pop for males 10.0 per 10,000 pop for females per 10,000 population 14.8 per 10,000 population per 10,000 pop for males 8.0 per 10,000 pop for males 0.0 per 10,000 pop for females per 10,000 pop for males 0.3 per 10,000 pop for females Source: HICS, MOH&E, Bahamas. Reproduced from CAREC (2004) 2.5 per 10,000 pop for females 2.8 per 10,000 pop for males 1.4 per 10,000 pop for females According to CAREC (2004) in 1994, AIDS was the second leading cause of death among children in the 5 to 9 age group, but by the end of 1999 it was not listed among the 12 leading causes of death for children in this age group in The Bahamas, (see Table 7). Table 7: Age Specific (5-9 years old) Mortality Rate and AIDS Specific Mortality Rate YEAR AIDS Mortality Rate and Rank MORTALITY RATE per 10,000 population, rank per 10,000 population per 10,000 population 3.9 per 10,000 population per 10,000 pop for males 0.7 per 10,000 pop for females 7.8 per 10,000 pop for males 0.7 per 10,000 pop for females per 10,000 pop for both sexes 5.6 per 10,000 population per 10,000 pop for males 1.4 per 10,000 pop for females 8.2 per 10,000 pop for males 5.0 per 10,000 pop for females per 10,000 pop for both sexes, not listed among the first 12 leading causes of death 3.8 per 10,000 population Source: HICS, MOH&E, Bahamas. Reproduced from CAREC (2004) In summary, Tables 3 to 7 demonstrate that the threats posed by the HIV/AIDS epidemic to children in the age group 0 9 years, and infant mortality rate in general, seemed to have been minimized by 1999 due to the reduction in the incidence of AIDS in that age group.(carec 2004). Overall, deaths due to AIDS declined consistently to 133 in 2002, down from a peak of 303 in The annual mortality rate decreased to 80.4 per 100,000 in 2002, down from 97.2 per 100,000 population in Despite the downward trend, the impact of AIDS remained severe in terms of productive adults dying prematurely. In 2000 alone, deaths due to AIDS totaled 245 and an estimated 5870 years of potential life were lost due to HIV/AIDS. CAREC (2004) recorded the cumulative AIDS deaths as at the end of 2002 to be 4,382 with 12

31 the overall AIDS case mortality rate being 71.27%, down from 84% at the inception of the epidemic in Table 8: AIDS Cases and Status: Year Alive Dead Total Total Source: CAREC, 2004 Deaths due to AIDS decreased from the inception of the epidemic with the rates for 2001 and 2002 being 57% and 46% respectively; this is indicative of an improved survival rate for persons living with HIV/AIDS in The Bahamas at end 2002 (CAREC, 2004). The modest decrease in AIDS mortality resulted in a decrease in the percent of registered deaths due to AIDS from 18.3% to less than 15% between 1996 and This reduction ran concurrently with the improved ability of the NAP to enter individuals in care, and to diagnose and treat opportunistic infections (Gomez, 2006). Further reductions were expected from the increased affordability and availability of antiretroviral therapy (ART) to eligible PLWHA from

32 1.4 HIV/AIDS Care and Treatment At the end of 2002, expert HIV/AIDS care and treatment was centred at the Princess Margaret Hospital (PMH) in Nassau and the Rand Memorial Hospital (RMH) in Freeport. Most of the care was provided to HIV-positive individuals through once-weekly adult, antenatal, and paediatric infectious diseases clinics at PMH. All pregnant women with HIV and all HIV positive children received antiretroviral therapy and regular follow-up in these outpatient settings. An additional 345 adults with an AIDS diagnosis had initiated ARV therapy. In total, 467 of the approximately 6000 HIV-positive persons received ARVs in the public health system serving the Commonwealth s population. Funds were insufficient to treat with ARVs the remaining 2505 persons who were estimated at end 2002 to have CD4 counts of <350 cells (Ministry of Health, 2002). 1.5 Volunteer Counselling and Testing (VCT) Individuals who requested an HIV test, or who were considered by providers to be engaging in behaviours placing them at risk for HIV, received a voluntary, confidential HIV test and pre/post test counselling (VCT) in the system of community health clinics. There were no stand-alone VCT centres in The Bahamas. All patients with a confirmed positive test for HIV were referred to either the PMH or RMH for evaluation of their HIV disease (Gomez, 2006). 1.6 Contact Tracing and Partner Notification The outstanding communication skills of public health nurses and other trained staff in the art of counselling, contact tracing and maintaining the confidence of clients made major contributions to the reporting of accurate HIV/AIDS data in The Bahamas. The compassionate professionalism of the medical staff in the HIV/AIDS clinics earned confidence and trust, of patients. Given such a warm atmosphere all HIV-infected patients are encouraged to bring their sexual contacts in for education, STI screening and testing for HIV. Those HIV infected patients who are unwilling or unable to reach past or current partners are assured that their identity would not be revealed. The patient s privacy is always highly regarded by the surveillance counselling team. Patients contacts were invited to come in for counselling only after informed consent was given voluntarily (Gomez, 2006; HIV/AIDS Centre, 2006). 1.7 Prevention of Mother-To-Child Transmission (PMTCT) In accordance with the protocol existing at the end of 2002, all HIV-infected pregnant women were referred to the PMH or RMH clinics for monitoring and care. Defaulters were traced and provided with additional counselling and support to improve adherence. AZT was administered to the mother during delivery and to the infant post delivery for six weeks. Mother and infant were visited at home by the postnatal home service team. Babies were followed-up in the HIV/AIDS Pediatric Clinic for evaluation and testing for HIV status. HIV-infected mothers were also counselled regarding the dangers of breastfeeding, and 14

33 provided with a supply of artificial milk. In combination, these measures resulted in a decrease in the rate of HIV-infected infants born to HIV-infected mothers (Gomez, 2006). Table 9 below shows that 23 antenatal HIV positive women did not receive ART under the PMTCT Programme in each of the years 2001 and In 2001, 12 or 52% of these women were neither located by the surveillance team nor referred to the PMTCT Programme. In 2002, the majority of these women fell into two categories, namely women who were neither located by the surveillance team nor referred to the PMTCT Programme or women who received no antenatal care under the Primary Health System. This situation posed a challenge to the NAP at the end of Table 9: Summary of Antenatal Clients Accessing PMTCT Care Client Status Total antenatal clients testing HIV Positive HIV-infected antenatal clients receiving ART under PMTCT Total HIV-infected antenatal clients not receiving treatment Antenatal HIV result negative but postpartum positive 0 0 Client received no antenatal care 0 7 Not located (antenatally)/not Referred 12 8 Refused 3 3 Client delivered prior to treatment 4 5 Client miscarried/aborted/intrauterine death prior to Treatment 4 0 Source: Gomez, Sexually Transmitted Infections (STIs) STI patients were being referred to the Sexually Transmitted Infections (STI) clinic located in Nassau which serves as the lone referral centre in The Bahamas for individuals with suspected STIs and as a walk-in clinic for individuals presenting with complaints. At the end of 2002, approximately 130 patients per week were seen in the clinic. Table 10 highlights that Chlamydia, Gonorrhea and Non-specific Urethritis were the dominant STIs during the period (Gomez, 2006). 15

34 Table 10: Number of Cases of Sexually Transmitted Infections Diagnosed at the New Providence STI Clinic, 2001 to STI Chancroid 2 2 LGV 6 4 Non-specific Urethritis Hepatitis B HPV Herpes Gonorrhea Chlamydia Secondary Syphilis 3 - Primary Syphilis 1 3 Latent Syphilis Total Source: Gomez, Coordination of the National AIDS Programme The Government commissioned the National AIDS Programme (NAP) within the Ministry of Health in 1985 and its main focus has been on increasing the quality of life of the wider population and of those individuals infected with HIV. Therefore, the programme incorporates prevention of transmission of HIV, and the comprehensive care of the individual infected with HIV. The national response involves public AIDS education programmes, voluntary counselling and testing, care, treatment and support, research and surveillance. Through these activities a number of achievements have been identified in The Bahamas Under the aegis of the NAP, the Government initiated public AIDS education programs, voluntary counselling and testing (VCT), care, treatment and support, research and epidemiological surveillance. Such surveillance began in 1985 with the screening of all donated blood products using the ELISA test, and was later expanded to include partner notification and contact tracing with the patient s permission. The Ministry of Health recognized the importance of coordinating its various departments from as early as the reporting of the first cases of AIDS in the country. Consistent with the classification of HIV/AIDS as a Sexually Transmitted Infection (STI), The Bahamas was able to initiate an immediate first line of attack based on the already excellent working relationship among the Infectious Diseases Ward of the Princess Margaret Hospital, the Comprehensive STI Clinic, the Blood Bank, other medical faculties, private physicians, the Department of Public Health, and other support services. The absence at that time, of well-defined and proven interventions as well as antiretroviral drugs, caused much confusion. The Bahamas, therefore adopted two intervention strategies. The first of these was epidemiological surveillance combined with health education, its main intervention in the identification and tracking of the progress of the disease throughout the 16

35 population. The second strategy was comprehensive patient care which entails the simple ideas of counting, contact tracing, and partner notification with the patient s permission. These have remained a part of the country s National AIDS Programme (Gomez, 2003). In 1988, the National AIDS Secretariat was established to advise the Ministry of Health on policy issues, relating to HIV/AIDS. Its mandate was to mobilize different sectors of the society in the fight against HIV/AIDS, coordinate prevention and education programs across the country, and act as a resource centre and clearing house for information (Gomez, 2003). The Secretariat conducts extensive outreach to Government ministries, NGOs, faith based organizations (FBOs), schools, civic groups, and the private sector. In 2002 the National AIDS Secretariat was given an enhanced mandate and renamed the National HIV/AIDS Centre. It was charged with responsibility for national oversight, planning, training, coordination and evaluation for the national response to HIV/AIDS. The Centre has direct line accountability to the Minister of Health, as shown in Figure 2 and manages funds from the national budget, local donors and international donors consistent with the priorities established in the (National HIV/AIDS Strategic Plan) NASP (Gomez, 2006). It is organized into the following six units: HIV Prevention Education Unit; Clinical Management, Care Support and Treatment Unit; Medical Research Unit; Laboratory Diagnosis Unit; Regional Training Centre Unit; and Focus on Youth & Youth Ambassadors for Positive Living. Each Unit is resourced by a coordinator and staff who report to the Managing Director: 17

36 Figure 9: Top Structure of the HIV/AIDS Centre Minister of Health Permanent Secretary Chief Medical Officer National AIDS Director Resource Committee Clinical& Lab Director HIV/AIDS Centre Managing Director HIV/AIDS Centre Non- Governmental Organisations Treatment, Care and Support Prevention Education CHART (Training) Focus On Youth HIV Specialty Laboratory Research Source: Gomez (2006) HIV/AIDS Centre 1.10 National AIDS Strategic Plan The country s first written National AIDS Strategic Plan (NASP) was developed in 2000 and integrated into the National Health Service Strategic Plan. The Ministry of Health (2002) lists the goals of the Plan as follows: To build an effective multi-sectoral response to the HIV/AIDS epidemic; To mitigate the socio-economic and health impact of HIV/AIDS in the society; To decrease individual vulnerability to HIV infection; To reduce the transmission of HIV infection; and To improve care and support and treatment services of people living with HIV/AIDS (PLWHA). 18

37 Further, the plan provided specific strategies and targets that were developed in consultation with multi-sectoral and multilateral partners and focused on five priority areas of the response namely; (1) Policy, advocacy, legal and human rights; (2) Integrated and multi-sectoral response; (3) Prevention; (4) Care, treatment and support; and (5) Monitoring, surveillance and evaluation. The strategies and targets were translated into work plans that guided the activities of the various partners involved in all areas of the National HIV/AIDS Programme over the period 2000 to Epidemiological Surveillance and Research Epidemiological surveillance and research are two key subsets of the expanded response to HIV/AIDS in most countries. In The Bahamas, an epidemiological database was established in Maintenance of this database over the period has allowed the country s NAP to identify epidemiological trends and make timely responses to these trends. 6 A baseline Knowledge, Attitude, Beliefs and Practice (KABP) survey was conducted in The results of this baseline and subsequent surveys continue to guide the development of the educational component of the AIDS program (Ministry of Health, 2001). Ina addition, a seroprevalence survey among pregnant women, STI patients, prison inmates and crack cocaine abusers, completed in 1991, revealed that 3% of all pregnant women seen in the Government antenatal clinics were infected with HIV. In response, the Ministry of Health implemented the policy of offering all pregnant women HIV screening after obtaining voluntary informed consent. The stakes were raised even higher when an HIV vertical transmission study conducted in 1992 in collaboration with the University of Toronto, revealed that 30% of infants born to HIV positive mothers in The Bahamas were infected with HIV. In 1993, the seroprevalence survey was repeated and an investigation was undertaken to examine genital ulcer disease and its impact on the spread of HIV. The repeat seroprevalence survey revealed that the percentage of HIV-infected women among all pregnant women seen in the Government antenatal clinics had increased to 4.3% (Ministry of Health, 2006). Through the national surveillance systems, it was established that two other epidemics contributed to the high prevalence of HIV disease in The Bahamas, namely, the widespread use of crack cocaine and the increased incidence of genital ulcer disease. Approximately 30% of the reported AIDS cases during the early years of the epidemic admitted to using cocaine. The widespread use of crack cocaine in the mid-80s led to persons engaging in high-risk behaviors, including having sex with multiple partners. Following the crack cocaine epidemic, the Sexually Transmitted Infections (STI) Clinic documented an alarming 6 Ministry of Health,

38 increase in persons with genital ulcer diseases like syphilis, herpes, chancroid, and lymphogranuloma venereum (LGV). The genital ulcer disease epidemic led to a four-fold increase in HIV infection from 1985 to 1994 (Ministry of Health, 2002). In fact, the three epidemics (crack cocaine, genital ulcer diseases and HIV) together, caused the prevalence numbers for The Bahamas to increase disproportionately (HIV/AIDS Centre, 2006). The Ministry of Health (2001), records that the NAP participated in a field evaluation of rapid testing for HIV in 1994 with assistance from the United States Centers for Diseases Control and Prevention (CDC), and the Caribbean Epidemiology Centre (CAREC/PAHO). This exercise was of tremendous benefit and facilitated the expansion of the HIV/AIDS database. In addition, the Abbott Study examining the efficacy of the new Protease Inhibitor (PI) Abbott Laboratories (ABT 378/r) in children commenced in The US National Institutes of Health Acacia Research Corporation (ACTG 316) Nevirapine study was also undertaken in that year. Participation in high quality, scientific research provided the country s Ministry of Health and other national professionals and experts with critical information for application to the areas of medical management, pharmaceutical treatment and prevention in the NAP (Ministry of Health, 2001; Gomez, 2003) Treatment, Care and Support In response to the ACTG 076 study protocol of 1995, the Ministry of Health immediately implemented the Mother to Child Transmission (MTCT) programme of voluntary counselling and testing with consent for all women receiving antenatal care in the public health clinics. AZT was also administered by protocol to all HIV-positive pregnant women and their infants. The rate of transmission from mother to infant consequently fell from 30% in 1995 to 10% one year later. Funding for AZT was provided for the first two years by The AIDS Foundation, and later by the Ministry of Health (Ministry of Health, 2001). CD4 Testing and Triple ARV combination therapy were implemented in Triple ARV combination therapy was also introduced in the protocol for the treatment of all pregnant women and children that same year. Laboratory specimens for the CD4 tests are collected and processed for batch shipment to the Infectious Diseases Laboratory at the Hospital for Sick Children in Toronto, Canada once a week. Results are communicated to The Bahamas in approximately two weeks (Ministry of Health, 2002). Furthermore, the Government of The Bahamas made the commitment in 2002 to provide ART to all eligible PLWHA, i.e. patients with CD4 < 350 and viral load > 30,000. This initiative was made more affordable in subsequent years by the availability of lower cost antiretroviral medications, due in part to the effective lobby provided by the Clinton Foundation (National HIV/AIDS Centre, 2006) The Samaritan Ministry was launched in 1988 by the Roman Catholic Archdiocese of Nassau to provide practical and counselling support as a necessary component of the continuum of care. Samaritan Ministry has been working with the NAP to conduct training programs aimed at equipping volunteers from the interfaith community for outreach ministry to PLWHA, asymptomatic patients, families and friends. 20

39 Components of the training program carried out by the Samaritan Ministry are counselling, caring and ministering to people who are in crisis due to illness, loneliness, depression, hospitalization, and to those who are actually in the terminal stage of AIDS. Upon completion of the training each volunteer is assigned to a PLWHA in need with the consent of the individual. The volunteer visits the PLWHA once weekly, in hospital or at home, provides companionship, and helps to mend fractured family relationships, with the overall objective of fostering the physical, spiritual and emotional well-being of the individual (Gomez, 2003). In September 2002, the Ministry of Health made a commitment to expand comprehensive care and treatment to PLWHA. Accordingly, in 2002 the NASP was updated to the Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas Support came from the Clinton Foundation, CARICOM, Centers for Disease Control and Prevention (CDC), National Alliance of State and Territorial AIDS Directors (NASTAD), PAHO, Pangaea Global AIDS Foundation, and WHO. The AIDS Foundation of The Bahamas was formed in 1992 by the Zonta Club of Nassau. It consisted of a group of professional women led by the wife of the then Prime Minister, to provide social support and education to the PLWHA community. The Foundation has been extremely successful in raising funds through private sponsorships to support various aspects of the programme, such as prevention seminars and peer education training for youth organizations and the general public (Ministry of Health, 2001). Assistance is also provided by Imperial Life Financial, a leading business organization in The Bahamas, which signed a sponsorship agreement with the AIDS Foundation in 1994 for the very successful Annual Red Ribbon Ball. This event generates the majority of private funds available to the AIDS Foundation. Through this partnership, the AIDS Foundation makes available a three-building complex in Nassau for a range of activities under the NAP. These are the distribution of daily essentials to PLWHA, counselling, regular meetings of support groups, ongoing training of the Samaritan Ministries, and social events for infected and affected children, and a day room for relaxation by PLWHA (Ministry of Health, 2001) Prevention and Health Promotion The initial attempts at coordinating prevention education activities in The Bahamas were spearheaded by the AIDS Secretariat. This responsibility was later passed on to the National HIV/AIDS Centre. The NAP has always focused its efforts on HIV/AIDS information, education and communication to prevent HIV-infections and reduce stigma and discrimination. As the epidemic progressed, the NAP was instrumental in changing risky behaviour through the delivery of behaviour change communication and public awareness campaigns (HIV/AIDS Centre, 2006). Teenagers and young adults have now become the main target of the HIV prevention programme because this group is the fastest growing population of HIV infected persons in The Bahamas. The Ministry of Health has involved other Government ministries including Education, Tourism, Youth, Sports, and Culture in its prevention and education drive since the first cases were reported. HIV/AIDS educational programmes draw on the expertise of 21

40 volunteers and persons in non-governmental organizations, and have been successful in making the public aware of the threat of HIV/AIDS (Gomez, 2006). Two such efforts are the Health and Family Education curriculum and Red Cross Volunteers Program. The Health and Family Education curriculum administered by the Ministry of Education is age appropriate and includes topics on growth & development, human sexuality, disease prevention & control, substance abuse prevention and human relationships (HIV/AIDS Centre, 2006). The Red Cross initiated a junior volunteers HIV/AIDS training program in 1999 to encourage the delaying of the initial sex act, explain various barrier methods, and advocate sound care (Gomez, 2003). Focus on Youth (FOY) was started in 1998, and is a collaborative effort involving Wayne State University, the NAP, the Ministry of Education and the National Institute of Health (NIH). FOY s programme is designed to improve the knowledge of young people aged 8 to 25 years with respect to HIV/AIDS and other STI s. The programme includes modes of transmission and prevention, education on the proper use of a condom as well as techniques to abstain or postpone the first sexual encounter. Training is provided in decision making, communication, assertive refusal, advocacy skills and condom use. It also equips students to clarify personal values, resist pressures, and be skilled in communication and negotiating around risk behaviours. Research has shown that this programme has resulted in a significant increase in condom usage among sexually active females. FOY s HIV/AIDS education comprehensive life skills programme includes a parent education and participation component (Gomez, 2006). Another effort aimed at AIDS prevention among young people is the Youth Ambassadors for Positive Living (YAPL) Commonwealth Secretariat initiative. This is based on young people speaking to their peers on HIV/AIDS, drugs, child abuse, and teenage pregnancy. Its projects in The Bahamas are geared toward sensitizing young people on sexuality and positive living. YAPL works in high schools and colleges, churches and community youth groups, assisting in peer counselling, youth training and discussion forums. Youth Ambassadors educate while supporting their peers (Gomez, 2006). The HIV/AIDS Centre has used all available avenues in its attempt to stop the spread of HIV/AIDS. It has actively promoted HIV education and prevention activities through the use of mass media (radio, television, and press) as well as billboards and flyers. Health education and HIV/AIDS prevention education aimed at tourists and tourism workers is an ongoing activity through the Ministry of Tourism in cooperation with major hotels and their staff. The first Hotel Tourism Workshop was organized by the HIV/AIDS Secretariat in 2000 under the auspices of CAREC (Gomez, 2006). The effectiveness of programmes and educational activities of the NAP has been challenged by the difficulty experienced in reaching certain at risk groups. These hard-to-reach groups include commercial sex workers (CSW) and men who have sex with men (MSM). Further, a language barrier has been overcome by the development of programming and information for French Creole-speakers. These were developed and delivered through Creole-speaking staff and faith-community leaders (Gomez, 2006). 22

41 Public health nurses and volunteers routinely distribute condoms and informational materials at public events throughout the country. In 1996, a social marketing strategy targeting pregnant women was developed and executed across the country. This initiative aimed at improving attendance of pregnant women for antenatal care early in pregnancy (Gomez, 2006). The HIV/AIDS Centre also works closely with leaders within the faith community to deliver information and education on prevention, availability of treatment and care programs, and the reduction of stigma and discrimination (Gomez, 2006) Legal Framework In 1989, the Government enacted legislation making HIV infection a notifiable disease to be reported to the Department of Public Health, while in 1996 the Education Act was revised to entitle all 5 to 16 year olds to free education and included provisions for children regardless of their HIV status. The Employment Act was enacted in 2001 to protect employees or persons applying for employment from discrimination based on their HIV status. Under this legislation, an employee or applicant cannot be required to submit to an HIV test (Gomez, 2006) Technical Cooperation During the period 1985 to 2002, The Bahamas benefited from technical cooperation from other countries and international organizations. The Government of Canada, through the University of Toronto, provided collaboration on research projects, confirmatory testing on HIV patients, development of the MTCT programme, and early diagnosis of HIV in the newborn. The University of Washington, Seattle through Professor King Holmes, contributed to the understanding of the STI situation in the country. CDC facilitated the training of public health professionals in HIV/AIDS prevention and control strategies with funding from PAHO. The Institute of Human Virology, University of Maryland, through the Fogarty Programme, provided further training in current HIV/AIDS prevention strategies and clinical management for health care providers, including physicians, public health nurses, registered nurses and nurse midwives (Ministry of Health, 2001). Funding for the NAP was provided by PAHO/WHO Global Program over the period 1986 to 1996, and in part by UNAIDS from 1997 to 2002 through the PAHO/WHO local office (Ministry of Health, 2001). 23

42 1.16 The Bahamas Health Delivery System The Bahamas health delivery system was well positioned at the end of 2002 to successfully alter the course of the HIV epidemic. Over 85% of residents in The Bahamas received their care in the public sector. A strong, centralized public health system provided oversight for disease prevention activities, HIV surveillance, and the provision of health care and social services across all inhabited islands. Programs such as contact tracing and patient notification were integrated into both prevention and care, facilitating effective identification of potentially exposed persons. Consultation and referral patterns were well established between all levels of the public system from small clinics extending to tertiary care. Community health workers also played an active role in assessing follow-up care in the home, including directly observed therapies (DOTS) for TB and adherence support for persons taking ARVs. Health care financing and utilization data for the public system of care were correlated with specific interventions and heath outcomes (Ministry of Health, 2002) Princess Margaret Hospital (PMH) Princess Margaret Hospital (PMH) is one of the two centres for the delivery of HIV/AIDS care and support, and provides both inpatient and outpatient services. Adult, antenatal and pediatric infectious diseases clinics ran concurrently each Wednesday at the hospital s outpatient department. A second half-day clinic was held once weekly for post test counselling and the intake of new patients. All clinics were staffed by an infectious diseases specialist, pediatrician, medical house officers, infection control nurse practitioners with advanced training in HIV, public health nurses, social workers, nutritionists, community volunteers from the Samaritan Ministry, and a former Minister of Health who donated his time as a senior physician. This full range of medical, nursing, ancillary, and support services facilitated the one stop delivery of holistic, seamless patient care to PLWHA (Gomez, 2006). Two inpatient infectious diseases wards at the PMH with bed capacities for 20 men and 13 women serve adults. Patients admitted to these wards were followed up by the infectious diseases service under the direction of the Director of Infectious Diseases who also directed the outpatient clinics. Inpatient care for children with HIV/AIDS was provided on the general pediatric unit at PMH. Improvements in early diagnosis and treatment of opportunistic infections, appropriate prophylaxis, and aggressive efforts by the TB Control Programme contributed to a decrease in the utilization of inpatient beds by adults with HIV/AIDS (Gomez, 2006). The leading causes of admission to the wards were pneumonia, followed by TB for men and gastroenteritis among women. CNS Toxoplasmosis and Pneumocystis Carinii Pneumonia were among the significant causes of morbidity. In 2001, admissions to the men s unit totalled 248 while those to the women s unit totalled 211. The most likely source of these admissions was the 1200 plus persons living with AIDS. In sharp contrast, only 21 admissions were recorded in 2002 among the 467 receiving triple ARV therapy. In the case of children, the number of inpatient hospitalizations for HIV-related conditions decreased dramatically from over 100 percent census to an occasional child being admitted for management of drug regimens or an older child developing a first opportunistic infection 24

43 before their HIV status was recognized. At end 2002, care for children with HIV was almost entirely provided through the outpatient clinic setting (Ministry of Health, 2002) HIV/AIDS Services on the Family Islands HIV/AIDS Services on the Family Islands were provided through an extensive network of community health clinics and health clinics that deliver primary health care and preventive health services to Island residents under the direction of the Department of Public Health. The five larger Family Islands were served by polyclinics that also serve as a conduit to social services. The remaining populated islands are served through a system of main and satellite clinics, with the majority staffed by a physician, family nurse practitioner, nurse midwife, or other skilled public health nurse. All Family Island nurses are trained in HIV counselling and testing. Welfare officers and case workers are also distributed across population centers and island regions to provide social services. Under the system of universal access to health care and social services in The Bahamas, Island residents who cannot obtain the care needed locally may use Government subsidized air, fast ferry, or mail boat transportation to get to an appropriate health care facility. Arrangements were in place for PLWHA travelling long distances to receive their ARVs from a limited supply provided to the local nurse or pharmacist. All HIV-positive pregnant women travelled to Nassau in the eighth month of pregnancy and remained at the PMH until their baby was born. Arrangements for lodging for patients from the Family Islands who require accommodations during the time that they access care at PMH (Ministry of Health, 2002) were facilitated by the Department of Public Health. 25

44 HIV/AIDS Care in the Prison System HIV/AIDS Care in the Prison System was provided at the prison facility in New Providence. The inmate population at end of 2002 was 1,500 and all incoming inmates were given an HIV test as part of the incoming physical examination. Routine care for common illnesses and complaints were handled in the prison sick bay, which is staffed by full time physicians and nurses. Inmates needing specialist care for HIV/AIDS were transported to PMH and returned to prison. The capability to draw lab specimens and transport them to PMH coupled with training support provided by the PMH Infectious Diseases Specialist to prison staff allowed much of the care needed by inmates to be provided on site at the prison (Gomez, 2006) The National TB Control Program The National TB Control Program worked closely with the NAP in light of the overlapping vulnerabilities among persons affected by either condition. The activities of the TB Control Program included investigations of reported cases, screening of potential contracts, oversight of care and treatment of confirmed and suspected patients at PMH, and coordination of follow-up care in the community including directly observed treatment service (DOTS). All suspected cases of active TB were hospitalized on the infectious diseases ward at PMH for additional laboratory investigation. Confirmed cases received a repeat chest X-ray and AFB sputum test before discharge back in the community where they were followed up by community workers. All patients newly diagnosed with an HIV infection were screened for TB. The protocol of care required that combination antiretroviral therapy be administered to all persons co-infected with HIV and TB (Ministry of Health, 2002) The Sexually Transmitted Infections Clinic The Sexually Transmitted Infections Clinic operated during weekday business hours, catering to roughly 130 patients per week. New patients were given a physical examination, and associated diagnostic laboratory tests including an HIV test with consent. Treatment was provided and patients were given a follow-up clinic appointment for their HIV test result. All patients with positive HIV test results were referred to the PMH adult infectious diseases clinic for follow-up and evaluation (Gomez, 2006) Substance Abuse and Mental Health Services Substance abuse and mental health services were provided in The Bahamas by the Sandilands Rehabilitation Center and the Community Counselling and Assessment Centre. The former provided inpatient and community mental health services, while the latter offered individual and group services. Additionally, limited mental health counselling services were available on the other larger islands of The Commonwealth. Persons receiving HIV/AIDS care through the PMH infectious diseases clinics were referred out to these facilities for care as needed. A limited counselling support service was provided within the clinic setting by 26

45 the social worker and community volunteer from the Samaritan Ministry Program (Ministry of Health, 2002) Laboratory Services Laboratory services to inpatient and outpatient clinic populations as well as community health clinics across the country were provided at the PMH and the RMH. A full range of laboratory services was available including haematology, chemistries, microbiology, serology and blood bank support. All HIV tests were performed at the PMH laboratory using the Abbott Murex ELISA and Abbott determined Rapid Tests. Tests not available in either the public or private sector included CD4 cell count tests, viral load tests, and Western confirmatory tests. The collection of laboratory specimens for these tests and the subsequent batch shipment to the Infectious Diseases Laboratory at the Hospital for Sick Children in Toronto, Canada continued on a once weekly basis. In the first 10 months of 2002, a total of 653 viral load tests and 1,190 CD4 cell count tests were processed in Toronto (Ministry of Health, 2002) Pharmacy Services Pharmacy services were provided at the central pharmacies at the PMH and the RMH, and at on-site pharmacies located in the community polyclinics. At the end of 2002, The Bahamas National Drug Agency (BNDA) managed the national drug formulary and the system for procurement and distribution of pharmaceuticals (Ministry of Health, 2002) Hospice Services Hospice services were provided at the All Saints Camp which possessed the capacity to provide shelter and basic services to 70 persons at the end of The camp was managed by volunteers and financed primarily by the private sector. It was eligible for per diem payment from the National Insurance Board for indigent persons who board at the camp for health reasons. A private physician provided medical support on a voluntary basis once weekly. PLWHA with advanced AIDS, those in recovery for substance abuse or mental illness, and those in a transitional crisis were cared for at the camp (Ministry of Health, 2002). It must be noted that models of comprehensive care were well established in The Bahamas. For example, in 1999, The Bahamas became the first country to eliminate congenital rubella syndrome. This was achieved by linking surveillance with vaccination of both adult males and females. The combination of this commitment and leadership with HIV specific resources and the experience of the response provided The Bahamas with the capability to successfully mount its NASP. 27

46 1.17 Manpower Resources in the Health Sector at the End of 2002 An inventory of the health personnel and support providers from the public and private sectors in The Bahamas at end of 2002 is provided below. Table 11: Health Personnel and Support Providers from the Public and Private Sectors in The Bahamas at End 2002 Public Sector Private Sector Total No per 10,000 Category Male Female Total Male Female Total Population Physicians Dentists Hospital Administrators Professional Social Workers Associate Professional Social Workers Nutritionists/ Dieticians Registered Nurses/Nurse Practitioners Enrolled Nurses/Trained Clinical Nurses Nursing Assistants/ Community Health Aides Radiographers Laboratory Technologists/ Technicians Pharmacists/ Dispensers Physiotherapists Occupational Therapists Dental Assistants Public/ Environmental Health Inspectors Statisticians <1 Source: Gomez,

47 1.18 Manpower Assigned to The National HIV/AIDS Programme as at 2002 Manpower assigned to the NAP as at 2002 is summarized in Table 12 below. These resources amount to the equivalent of 35.5 full time incumbents. Manpower from the Samaritan Ministry and the All Saints Camp was assigned on a voluntary basis. The annual salaries for the staffing shown in Table 12 amounted to US$747,132. Table 12: Manpower Assigned to HIV/AIDS Treatment and Care as at 2002 Priority Area Unit/Agency Number of Full Time Employees Prevention/Education AIDS Secretariat 8.0 Treatment and Care PMH Inpatient Treatment 3.0 Treatment and Care PMH Adult Clinic 2.8 Treatment and Care PMH Antenatal Clinic 1.5 Treatment and Care PMH Child Health Clinic 2.1 Treatment and Care Rand Memorial Clinic 0.9 Treatment and Care Home Visits/ Social Work 4.2 Treatment and Care Contact Tracing 4.2 Treatment and Care Prison Health 0.7 Treatment and Care STI Clinic 0.8 Treatment and Care Samaritan Ministries Program 3.0 Treatment and Care Substance Abuse Clinic 0.7 Treatment and Care All Saints Camp 3.0 Surveillance PMH Laboratory 0.1 Program Support Drug procurement and distribution 0.2 Program Management Administration and Policy 0.5 Total 35.5 Source: Ministry of Health, Prevention and Behaviour Change The NAP maintained its focus on HIV/AIDS information, education and communication in an effort to prevent HIV-infections and reduce stigma and discrimination. At the end of 2002, the focus for HIV prevention remained centered on teenagers and young adults as this population had the highest incidence of new cases. The Ministry of Health continued to involve other Government ministries including Education, Tourism, Youth, Sports, and Culture. The National HIV/AIDS Centre continued to coordinate efforts aimed at educating the population through prevention education related activities. National health promotion, as an integral part of the NAP, continued to provide communities and individuals with information and skills to advance their own health needs. The Adolescent Health Unit also played an integral part in the HIV/AIDS prevention programme. 29

48 The Focus on Youth delivered its HIV/AIDS education comprehensive life skills programme within the Ministry of Education s Health and Family Education Curriculum. The Youth Ambassadors for Positive Living (YAPL) initiative had expanded their work in high schools and colleges, churches and community youth groups with funding from both CARICOM and the Commonwealth Secretariat. Youth groups such as The Bahamas Red Cross, Girl Guides, and the Pathfinders continued to execute programmes within their respective target populations to prevent the spread of HIV/AIDS in their target groups (Gomez, 2006). An alliance with the media resulted in the media disseminating AIDS messages to the public throughout The Commonwealth of The Bahamas. On television, radio, and to lesser extent the print media, prevention efforts were mounted to increase knowledge and personal health skills of specially targeted populations. At the end of 2002, greater awareness existed of lifestyles and risky behaviours that contribute to HIV transmission. Public service messages were produced as mini-daytime dramas, but with two endings. Such clever presentation allowed the viewer to interact with romantic or potentially sexual scenarios; by making the right decision for the character on the screen, the viewers also reinforced the safe choices that would protect them in real life (Ministry of Health, 2001). The mass media campaign initiated in 1996, coupled with the training provided for health professionals in diagnosis, care and referral skills, the support services provided by public and private CBOs, and the no cost access to AZT, had a positive impact on the MTCT program in that: Attendance of pregnant women at antenatal clinics in the early stage of pregnancy improved; HIV infected mothers were identified early, and were referred to the specialty HIV/AIDS clinics for appropriate care and intervention; There was a marked reduction in vertical transmission through early clinic attendance, AZT intervention and improved clinic care; The prevalence of HIV in antenatal patients declined from 5.4% in 1993 to 3% in Health education and HIV/AIDS prevention education aimed at tourist and tourism workers was an ongoing activity under the Ministry of Tourism in cooperation with major hotels and their staff. Public health nurses and volunteers routinely distributed condoms and informational materials at public events throughout The Bahamas. Condom promotion activities using bartenders as lay educators were being well received. Condoms were placed in hotels, guest houses, restaurants and bars, and places frequented by student spring breakers (Ministry of Health, 2001; Gomez, 2003). The HIV/AIDS Centre continued to work closely with leaders within the faith based communities to deliver information and education on prevention, availability of treatment and care programs and the reduction of stigma and discrimination. In recognition of the dominant role played by the tourism sector in the economy of The Bahamas, the Centre facilitated health education and HIV/AIDS prevention education for tourists and tourism workers under the aegis of the Ministry of Tourism and in cooperation with major hotels and their staff (Gomez, 2006). 30

49 Programmes and information targeted specifically at hard-to-reach groups such as commercial sex workers (CSW) and men who have sex with men (MSM) continue to be limited by the difficulty in reaching these groups. Lay persons trained in the French-Creole language, Creole-speaking staff and faith-community leaders deliver information and customized programmes to the Creole-speaking population (Gomez, 2006) Human Rights Issues In addition to public policy advocacy conducted by the National HIV/AIDS Centre, there were a number of community and faith-based organizations that undertook advocacy roles, namely The Bahamas National Network for Positive Living (BNN+) - a network and support group for Bahamians living with and affected by HIV/AIDS, the AIDS Foundation, and the Samaritan Ministry. Through their networks, these organizations worked to increase awareness of issues of stigma and discrimination and promote access to treatment and care. However, stigma and discrimination remained a significant barrier to the participation of PLWHA in public advocacy efforts. More so, fear of stigma and discrimination remained one of the greatest barriers to universal access to ART (Gomez, 2006). Notwithstanding the fact that the country s Sexual Offences and Domestic Violence Act includes a provision that makes it a criminal offence for an HIV-infected person to engage in sexual intercourse with another person without disclosing his/her status, no one had been prosecuted under this provision by end This observation underscores the point that while The Bahamas possesses strong legislative and policy protections against discrimination in many sectors, there were still gaps, such as protections based on sexual orientation and preference (Gomez, 2006) Support The Government of The Bahamas, through its social services, provided PLWHA with food stamps and a stipend to assist in meeting the cost of rental accommodation. In special cases, the AIDS Foundation provided a subsidy to cover the expenses of a caregiver. The HIV/AIDS Centre also organized summer camps and a back to school initiative for children who are HIV-positive. Commissioned members of Samaritan Ministry provided personalized support to PLWHA and their families. The Samaritan Ministry operated a drop-in centre in Nassau where PLWHA were referred for group sessions, food, clothing and individual counselling. The HIV/AIDS Foundation was assisting in the establishment and funding of housing for PLWHA by end Faith-based organizations continued to offer counselling with a view to providing hope to PLWHA and building their self esteem. The All Saints Camp maintained its status as a home to numerous HIV-infected persons. 31

50 1.22 Spending on HIV/AIDS Spending on HIV/AIDS in The Bahamas was US$5,655,570 in 2002 (Ministry of Health, 2002). The breakdown of the total priority areas of the response is shown in Table 13. Inpatient medical care accounted for 64% of the total expenditure. Table 13: HIV/AIDS Spending in The Bahamas for 2002 Medications Antiretroviral drugs $1,000,000 Drug procurement $17,247 OI drugs $27,859 Total $1,045,106 Outpatient Primary & Specialty Medical Care Personnel $377,345 Specialty care providers $38,740 Total $416,085 Inpatient Medical Care Personnel $146,000 Hospital Operating Costs $3,485,028 Total $3,631,028 Laboratory Services CD4 tests $63,600 Viral load monitoring $78,975 ELISA tests $76,524 Other tests $82,292 Shipping Costs $4,160 Total $305,551 Prevention and Education Personnel $143,000 Supplies $5,000 Total $148,000 Training and Technical Assistance Staff training $15,000 Technical assistance consulting $15,000 Total $30,000 Program Support Administration $24,800 Transportation $55,000 Total $79,800 Total Expenses for 2002 $5,655,570 Source: Ministry of Health,

51 1.23 Monitoring and Evaluation Environment In The Bahamas, the HIV/AIDS Centre is the unit responsible for coordinating all HIV/AIDS monitoring and evaluation activities in cooperation with the National Health Information and Research Unit (NHIRU), and the Surveillance Unit of the Department of Public Health. The Centre, collaborated with the Surveillance Unit, and undertook a limited number of monitoring and evaluation activities such as serological and behavioural surveillance, programme monitoring and evaluation, and research. The HIV/AIDS Centre and NHIRU maintained a database of indicators on the HIV/AIDS disease and the impact of the response within the country, collected largely through surveillance and surveys. These indicators formed the basis of an evidence-based approach to developing strategies and planning programmes. The National Health Information and Research Unit provided epidemiological and statistical expertise which supported the monitoring and evaluation activities coordinated among the various units of the Centre. The Centre is working towards adopting a holistic monitoring and evaluation framework, establishing a Monitoring and Evaluation Unit, and securing the required resources and technical expertise (Gomez, 2006; HIV/AIDS Centre 2006) Limitations and Gaps as at the End of 2002 The empirical data at the end of 2002 confirmed that the Government of The Bahamas, working through the Ministry of Health, sought to provide a comprehensive continuum of medical care and support services to PLWHA. Further, the broad-based public health response had reduced the number of new infections. However, concerns existed with respect to the number of PLWHA who continue to decline and die in hospital of infections that could have been averted with ARV treatment. The potential to extend lifesaving care to all those affected has been severely restricted by limited resources for costly medications, a lack of trained health care professionals, and infrastructure systems to support the delivery of clinical care such as laboratory services. As more individuals living with HIV infection progressed to AIDS, the system has struggled to keep pace with providing acute care and prophylaxis to all becoming ill. Specifically, the Ministry of Health (2002) lists the limitations to the delivery of comprehensive care and treatment to all patients who require it at end 2002 as follows: Inadequate funds to pay for ARV therapies for all patients who meet clinical criteria for ARV treatment (it is estimated that 2,850 patients meet the clinical criteria, yet only 467 persons receive these therapies); Societal stigma of HIV/AIDS preventing people at risk of infection and those already infected from seeking services; The outpatients clinics at the PMH are already overcrowded and the number of clinic days cannot be expanded. New options must be identified to treat additional patients in other venues; There is an existing shortage of trained health professionals with expertise in HIV/AIDS care to meet the needs of the expanding number of patients receiving 33

52 ARVs, exacerbated by inappropriate deployment of existing human resources to fill related services and pharmacies; The level of social support interventions, nutrition services, mental health services, and oral health care is compromised due to inadequate numbers of personnel to provide these services in the clinic setting and through home visits in the community; Community polyclinics are at capacity for all patient categories, and these do not currently treat HIV patients. Insufficient human resources and inadequate space limit comprehensive HIV/AIDS care. An increased patient load and the intensity of services necessary for treating people with HIV/AIDS requires additional staff, new training, and modification of existing pharmacy and laboratory capacities at these sites; Medical records are not yet computerized in The Bahamas, and there is no common patient identification system in place linking community clinics, hospitals and ancillary services; The availability of specialized laboratory services such as CD4 counts and viral loads is limited under the current arrangement with the Hospital for Sick Children in Toronto. In the event that all patients with HIV infection are entered into care, the projected demand for these laboratory services would quickly exceed capacity of the existing system; The existing hospital laboratory system, which serves both hospital-based services and community polyclinics, lacks a computerized lab information system that is linked to patient records. All data entry into charts is manual, delaying receipt of patient results. The existing system for storage and distribution of ARV medications is inadequate to safely store larger quantities of drug in a secure manner. An integrated information system to permit central monitoring and tracking, distribution, and consumption of ARVs across all pharmacy/dispensary sites will be required as increasing numbers of patients are placed on therapy. A monitoring and evaluation framework for the response to the epidemic is not yet in place. The Commonwealth of The Bahamas had to address these limitations and challenges in its NASP. 34

53 SECTION 2 THE STRATEGIC PLAN FOR SCALING UP HIV/AIDS CARE AND TREATMENT IN THE BAHAMAS Model of Care for the Strategic Plan In recognition of the importance of responding to the HIV/AIDS epidemic and the achievements and challenges observed in the National AIDS Programme over the period 1985 to 2002, the Government of The Bahamas committed through its Strategic Plan 2003 to 2005, to extend and improve the quality of life for all PLWHA and to prevent the transmission of the HIV virus. Special focus was given in this plan on providing comprehensive HIV/AIDS care at the community level. The model of comprehensive HIV/AIDS care to be adopted over the life of the plan is presented in Table 14 below. Table 14: Profile of Comprehensive HIV/AIDS Care -Voluntary counselling and testing for HIV infection -Prevention of HIV transmission including sexual, parenteral, and mother to child transmission -Comprehensive clinical management: 1. Counselling and support therapy 2. Staging using CD4 and viral load criteria 3. Antiretroviral treatment using HHS-published guidelines (CD4 < 350 or viral load > 30,000) with adherence support 4. Clinical and laboratory monitoring 5. Prophylaxis against opportunistic infections (OIs) 6. Diagnosis and treatment of HIV-related conditions including OIs and neoplasm 7. Inpatient care 8. Palliative care 9. Referral to appropriate level of care -Nutrition and nutrition services -Patient and family education -Social support and referral to appropriate services -Surveillance and contact tracing -Advocacy -Patient support groups Source: Ministry of Health,

54 2.2 Core Principles of the Strategic Plan The delivery of such comprehensive care was to be guided by a set of core principles and values throughout the implementation of the plan. Table 15 below, lists the set of principles and values. Table 15: Guiding Core Principles and Values in the Implementation of the Plan Principles and Values 1. Respect: for human rights and individual dignity. 2. Accessibility and Availability: appropriate care provided at the local level. 3. Equity: care provided to all PLWHA regardless of gender, age, race, ethnicity, sexual identity, income, place of residence, or immigration status. 4. Coordination and Integration: across the continuum of providers and levels of care. 5. Community Participation: meaningful involvement in decision-making of affected individuals and families, alliances, partnerships, and mobilization of private and public sectors. 6. Empowerment: meaningful involvement of clients in the clinical management process; encouragement of individual responsibility for self-management and adherence. 7. Evidence-based: interventions based on explicit, proven guidelines and qualitative and quantitative information resources. 8. Quality Care: satisfied clients receive care provided in an efficient and effective manner. 9. Information: best practices and knowledge documented, disseminated, and shared. Source: Ministry of Health, Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas

55 2.3 Goals of the Strategic Plan The Strategic Plan articulated three (3) goals: Goal 1 Goal 2 Goal 3 Extend and improve the quality of life for all PLWHA in The Bahamas Prevent the transmission of HIV in The Bahamas Develop a National HIV/AIDS Resource Center to serve The Bahamas and the region. The targets, objectives and key activities of the plan are shown in the Tables 16 to 18. Table 16: Targets, Objectives and Key Activities for Goal 1 of the Plan Goal 1: Extend and Improve the Quality of Life for all PLWHA in The Bahamas Targets Objectives Key Activities Decrease mortality rate due to the HIV disease by 23 percent by December 2005 Decrease hospitalizations for HIV disease and related conditions by 50 percent by December 2005 Provide integrated care as per defined protocols to 100 percent of PLWHA accessing the public health system by December To provide specialty and tertiary care at the clinics in the Princess Margaret Hospital and the Rand Memorial Hospital to patients referred from the primary health care clinics 1.2 To integrate primary care for HIV in community clinics Continue to provide ongoing services Hire staff and train as appropriate to serve increased patient load Refer stable patients to primary care clinics Hire polyclinic staff and train in management of HIV Conduct a public awareness campaign around availability of care at polyclinics and the benefits of care Ensure essential infrastructure is in place Source: Ministry of Health, To make comprehensive HIV laboratory services available 1.4 To assign the procurement and distribution of HIV/AIDS medications including antiretroviral drugs to The Bahamas Department of Public Health Continue to contract for specialty HIV laboratory services from the Hospital for Sick Children, Toronto Continue to provide routine lab services at PMH Lab Refurbish physical space to house equipment for specialized HIV tests Purchase and install necessary equipment and supplies Hire and train necessary personnel Implement lab information system that ensures capture of data from labs at PMH, community clinics, and that cross-references to medical records Negotiate best possible prices for ARV drugs Prepare secured space to store drugs centrally and at polyclinic level Implement procedures for tracking 37

56 Table 17: Targets, Objectives and Key Activities for Goal 2 of the Plan Goal 2 : Prevent the Transmission of HIV in The Bahamas Targets Objectives Key Activities To reduce the HIV/transmission rate among partners and children of patients in care by 20 percent, based on current data available from the contact tracing program. 2.1 To educate infected and affected individuals, their families, and the community through comprehensive HIV prevention services 2.2 To educate the public and promote condom use by an HI/AIDS awareness campaign Hire staff and train new and existing staff at all levels Document protocol for prevention counselling Provide comprehensive HIV prevention services Continue school, other youth focused, church, business programs, and media campaigns targeting prevention messages and the de-stigmatisation of HIV/AIDS Distribute condoms. Source: Ministry of Health, Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas Table 18: Targets, Objectives and Key Activities for Goal 3 of the Plan Goal 3 : Develop a National HIV/AIDS Resource Center to Serve The Bahamas and The Region Targets Objectives Key Activities To organize the National HIV/AIDS Center in 2003 with initial effort focusing on The Bahamas To expand the services of the Center to the region n 2004, with a primary target to train at least 100 providers from other Caribbean countries by December To expand the national capacity of The Bahamas to respond to the HIV/AIDS epidemic 3.2 To make available to other nations of the Region, the HIV/AIDS resource needs for quality, best practice, training and other activities Hire and train professional and support staff Refurbish each of the three floors of Curry House to accommodate the physical plant needs of the national center Purchase equipment and supplies Establish program operations in Curry House as space and staff are available Co-ordinate training and technical assistance activities for the region Conduct special projects of national and regional significance. Source: Ministry of Health, Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas

57 2.4 Annual Targets of the Strategic Plan The plan projected annual targets for the number of PLWHA, the number receiving care, and the number receiving ARV therapy as shown in Table 19. Table 19: Annual Targets for Care and Treatment to PLWHA in The Bahamas Indicator Number of PLWHA in 6,000 6,255 6,546 6,864 The Bahamas Number of PLWHA receiving HIV 1,200 2,560 4,469 5,276 care Number of PLWHA to receive ARV therapies 467 1,660 2,669 3,243 Source: Ministry of Health, A breakdown of these targets according MTCT Interventions, Infants and Children, and Adults is presented in Table 20. Table 20: Patient Targets for Care and Treatment to PLWHA in The Bahamas by Category PLWHA Cohort Category of Patient MTCT Interventions HIV-exposed babies MTCT Interventions Pregnant women Infants and Children HIV-positive infants Infants and Children Children Adults PLWHA receiving ARVs 381 1,545 2,545 3,243 Adults PLWHA receiving care other than ARVs NA 900 1,800 1,905 Total of Lines ,560 4,469 5,276 Source: Ministry of Health,

58 According to the Ministry of Health (2002), meeting these targets required that: 1) By 2005, all patients requiring ARV treatment would receive it; 2) Personnel at PMH and RMH outpatient clinics would be increased; 3) Staff would be hired to deliver care and bolster general primary health services at four (4) polyclinics; 4) Hospitalization would be reduced by 50% at the end of 2005; 5) Investments would be made in current facilities to accommodate an expanded laboratory capacity; 6) Renovations would be effected to the building that housed the National HIV/AIDS Centre; 7) Funding would be provided for additional staff in prevention and education and expanded public awareness campaigns; 8) Resources would be made available for building capacity in-country for providing training and technical assistance to providers in the region; 9) The research agenda for the support of the plan would be funded; 10) Resources would be provided for establishing a standardized surveillance system; 11) Resources will be provided for establishing a monitoring and evaluation programme; 12) Resources would be provided for increases in programme support staff. 2.5 Cost and Funding of the Strategic Plan The cost of implementing the plan was estimated to be US$23,142,186 as shown in Table 21 below. Inpatient care and medications were the top two expenses accounting for 35% and 20% respectively of this amount. Table 21: Budget for the Plan Expense Category Total Medications $1,040,073 $1,652,564 $2,030,432 $4,723,069 Outpatients primary and specialty medical care $1,218,105 $1,093,585 $1,111,585 $3,423,275 Inpatient medical care $3,282,525 $2,904,822 $1,969,515 $8,156,862 Laboratory services $1,200,170 $1,039,250 $1,044,120 $3,283,540 Equipment and capital improvements $493,680 $22,480 $14,680 $530,840 Prevention and education $303,000 $200,000 $200,000 $703,000 Training and technical assistance $188,400 $183,400 $183,400 $555,200 Research $142,800 $142,800 $142,800 $428,400 Surveillance $55,000 $45,000 $45,000 $145,000 Monitoring and Evaluation $105,000 $57,000 $57,000 $219,000 Program support $358,000 $308,000 $308,000 $974,000 Total Expenses $8,386,753 $7,648,901 $7,106,532 $23,142,186 Source: Ministry of Health,

59 The Bahamas Government committed to supporting 75 percent of the $23 million budget. The Clinton Foundation committed to stimulating support funding from donors in the United States, and the Bahamian business community, such as Kerner International, for an additional $1.8 million or 8 percent. 2.6 Achievements & Challenges of the Strategic Plan Implementation of the Plan was initially hampered by the lack of financial resources to support the process, but a portion of the required funding was secured to support key activities, in particular, the training of laboratory staff and organizational development. Notwithstanding the ongoing challenges of funding and human resource capacity constraints, some progress was made vis-à-vis the goals of the plan. These are detailed below The HIV Epidemic Figure 10 shows that as of December 31, 2005, The Bahamas had a cumulative total of 10,479 reported cases of HIV infections. The number of living cases totaled 6,853, a mere 11 cases short of the target of 6,864 set out in the strategic plan. Of the 6,853 living individuals, 1,631 are living with an AIDS diagnosis, while the remaining 5,222 have not yet progressed to AIDS (Ministry of Health, 2006). Figure 10: Cumulative Number of Reported HIV Infections with Status as of December 31st, Percent (%) AIDS Cases Non-Cases Alive Dead Total Number Total Infected Source: Gomez,

60 Young adults between the ages of 25 and 44 years accounted for 7,661 or 73 percent of all reported HIV infections at the end of 2005 (HIV/AIDS Centre, 2006). The overall male to female ratio was approximately 1.2 to 1 (see Figure 11). The Ministry of Health, (2006) noted that the younger age groups showed smaller ratios and in some instances a reversal of.this pattern. The corresponding ratios for HIV cases that do not progress to AIDS and for all AIDS cases were 1 to 1 and 1.5 to 1 respectively as displayed in Figure 11 below. Figure 11: Cumulative Number of Reported HIV Infections by Sex as of December 31st, 2005 Number Source: Gomez, AIDS Cases Non-Cases Total Infected Male Female Total The number of new non-aids HIV infections decreased by 22 percent to 256 in 2004 from 330 in The National HIV/AIDS Centre launched a mass media campaign Know Your Status in 2005 to encourage Bahamians to know their HIV status. This campaign resulted in additional persons accessing HIV tests and an increase in the number of new non-aids HIV infections for 2005 to 303 as shown in Figure 12 below. Overall, the number of new non- AIDS HIV infections decreased by 8 percent over the period of the strategic plan. Adolescents and young adults account for the fastest growing cohort of new infections (HIV/AIDS Centre, 2006). 42

61 Figure 12: New Non-AIDS HIV Infections by Sex and Reported Year, Number Male Female Total Male Female Total Source: Gomez, Figure 13 highlights the strong correlation (0.99) between the number of reported new HIV infections and the number of new non-aids HIV infections by year for the period 1989 to Given such a correlation, the number of new HIV infections for the period covered by the strategic plan is expected to show an overall decline. This decline can be attributed to the strategies taken by the Government of The Bahamas beginning early in the epidemic, and that continue to form the backbone of the response to HIV/AIDS, including blood screening, surveillance and partner notification, and behaviour change communication and public awareness campaigns (HIV/AIDS Centre, 2006). 43

62 Figure 13- Reported New HIV Infections and New Non-AIDS HIV Infections by Year Reported New HIV Infections and New Non-AIDS HIV Infections by Year Source: Ministry of Health, 2006; CAREC, Total New HIV Non-AIDS HIV The age group years accounts for 71 percent of the cumulative non-aids HIV infections. While the overall male to female ratio for non-aids HIV infections is 1.2:1 (Figure 14). Comparative ratios for the age groups years and 60+ years are higher at 2.0:1 and 1.9:1 respectively, and the female to male ratio is higher for the younger age group years. According to HIV/AIDS Centre (2006), the younger age at which females contract HIV may be due to their earlier sexual activity, a higher male-to-female transmission efficiency or the preference of older men for younger women. The last factor is perceived to be the most likely reason. 44

63 Figure 14: Cumulative Number of Non-AIDS HIV Infections by Age and Sex as of December 31st, Number Male Female Total Source: Gomez, < Unk The number of HIV infections among women of childbearing age diminished over the period as previously shown in Figure 5. Surveillance of HIV in antenatal women has confirmed a further drop in prevalence from 3.1 percent to 2.9 percent between 2002 and 2004 as highlighted in Figure 17. Concern exists however for the level of unprotected sex among teenagers as evidenced by the number of teenage pregnancies, per annum or 12 percent of the country s annual pregnancies. Among patients receiving care for STIs, Figure 15 shows that the percent testing positive for HIV decreased from 4.8% to 4.1% between 2002 and Infection rates among persons admitted to the prison decreased from 3.4% to 2.5% from 2002 to Sentinel surveillance activities continue among these target populations, and among those in treatment for substance abuse (Gomez, 2006). 45

64 Figure 15: 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 New cases of AIDS increased from 335 in 2002 to 347 in 2003 and declined to 248 in The slight increases in new AIDS cases in 2002 and 2003 (as shown in Figure 16 below) are likely to be the result of both the improved diagnostic capacity to identify AIDS cases through laboratory testing with the addition of CD4 testing in 2001, ART, and the improved treatment of opportunistic infections (Gomez, 2006). Over the period covered by the strategic plan, the male to female ratio for the number of new AIDS cases was 1.4: 1. 46

65 Figure 16: New Cases of AIDS, By Sex and Year August 1985 to December 31st, Number Male Female Source: Gomez, The number of AIDS deaths declined by 44 percent from 162 in 2002 to 91 in 2005 as shown in Figure 17 below. Mortality rates among AIDS cases declined from approximately 50 percent in the period 2002 to approximately 37 percent in This level of improvement exceeds the target set in the strategic plan. The declining trend observed in the percentage of all registered deaths due to AIDS, namely from 18.4% to 11.8% between 1996 and 2003, is expected to continue through the period covered by this strategic plan given the improved ability to enter individuals in care, as well as diagnose and treat opportunistic infections, and the increased affordability and availability of antiretroviral therapy (ART) from the year AIDS became the leading cause of death in the age group years by 2005 (Gomez, 2006). 47

66 Figure 17: Current Status of Reported AIDS Cases as of December 31 st, Number Alive Dead Source: Gomez, While the overall male to female ratio for the alive AIDS cases is 1.4: 1, the ratio is higher for the age groups 5 9 years, years, and 50+ years as shown in Figure 18. The female to male ratio is higher for the age group years. Figure 18: AIDS Cases Alive by Age Group and Sex as at December 31 st, AIDS Cases Alive By Age Group and Sex December 31st Male Female 50 0 < Unknown Source: Infectious Diseases Division, PMH and Department of Public Health, January

67 2.6.3 Treatment and Care Overall, 1,880 PLWHA were receiving ARV therapy in 2005, an increase from 1,278 at the end of The breakdown in terms of children, antenatal and adults is shown in Figure 19. Comparative targets for the period of the Strategic Plan are shown in Figure 20. The number of PLWHA on ARV therapy in 2005 represents 58% the target proposed in the Plan. Figure 19: Cumulative Number of HIV-Infected Clients receiving Antiretroviral Therapy to December 31, Number Children Antenatals Adults Total Source: Ministry of Health, Figure 20: PLWHA Receiving ARV Therapy, PLWHA Receiving ARV Therapy Actual Target Actual Target Source: Ministry of Health,

68 At the start of the strategic plan, The Bahamas faced a major challenge with the cost of ARV medications. However, the effective lobby of the Clinton Foundation led to an agreement in 2003 that drastically reduced the costs of essential HIV/AIDS medication. Clinton Foundation Member Purchasers are now able to purchase generic drugs from WHO and MCC pre-qualified suppliers at prices that are approximately 50% less than current market rates (Ministry of Health, 2006) Voluntary Counselling and Testing (VCT) Training in voluntary counselling for officers of the uniformed services in The Bahamas was conducted in 2003 by UWIHARP under the aegis of the CHART Initiative. The CHART Initiative for the training of health care providers, social service workers and volunteers was formally launched in The Bahamas by the National HIV/AIDS Centre with two workshops in February - March In particular, VCT, PMTCT and nutrition training were initiated under the CHART Initiative for public health nurses, social workers and volunteers throughout The Bahamas. The training also included modules which focused on stigma and discrimination. Training of public health primary physicians in HIV/AIDS prevention, treatment, care and support protocols and guidelines, including referral to appropriate support services was also conducted under the CHART Initiative. Gomez (2006) reported that over 80 care providers (inclusive of public health and private physicians) had been trained on VCT by the end of the period covered by the strategic plan, in preparation for the decentralization of comprehensive care. Other providers were trained as VCT Trainers in order to more effectively expand capacity. Monitoring by the social services and labour sectors revealed that the pattern of movement of immigrants in The Bahamas follows the pattern of hotel construction in the Family Islands. Accordingly, VCT training for care providers on the Family Islands has been pegged to the pattern of hotel construction Prevention of Mother-To-Child Transmission (PMTCT) The number of antenatal patients testing positive for HIV in the period averaged 104 per year. Overall, 2 percent of antenatal patients are HIV-positive; the corresponding overall rate for The Bahamas is 3 per cent (HIV/AIDS Centre, 2006). The number of HIVinfected antenatal patients who did not receive ART therapy under the PMTCT Programme ranged from 18 in 2003 to 30 in Table 22 below, gives a breakdown of these cases. Notwithstanding, the Ministry of Health (2006) reports that no children were born HIV positive to HIV-infected mothers who accessed antenatal care in 2003 and Vertical transmission rates were effectively decreased to less than 1 percent in According to HIV/AIDS Centre (2006), the strategies adopted for the sustained reduction of the vertical transmission rates from HIV-positive mothers to their children included: 1. the provision of ARV to all HIV positive pregnant women by the second trimester of pregnancy with monitoring of adherence; 50

69 2. counselling aimed at prevention of repeated pregnancies; 3. the promulgation of protocols for addressing the needs of children of HIV-positive mothers; and 4. initial focus on the growing problem of orphans. Table 22: Summary of Antenatal Clients Accessing PMTCT Care Client Status * Total antenatal clients testing HIV positive HIV-infected antenatal clients receiving PMTCT ART Total HIV-infected antenatal clients not treated Antenatal HIV result negative Positive N/A postpartum No antenatal care Not located (antenatally)/not referred N/A Refused N/A Delivered prior to treatment N/A Miscarried/Aborted/Intrauterine death prior to treatment N/A * Full analysis for 2005 not yet completed. Source: HIV/AIDS Centre, Gomez, Contact Tracing and Partner Notification The communications skills of the public health nurses and other trained staff in counselling, contact tracing, and maintaining client confidentiality constituted an important asset to the NAP during the period covered by the strategic plan. The compassionate professionalism of the medical staff in the HIV/AIDS clinics earned patients confidence and trust while patient s privacy was assigned the highest priority during the period covered by the strategic plan (Gomez, 2006) TB Control Programme A significant decrease in TB Prevalence was recorded in 2005 after modest increases over the period Gomez (2006) attributes this decrease to improved clinical management and the delivery of DOTS therapy. Co-infection of TB and HIV continues to decline. Approximately 38% of individuals infected with TB are also HIV-positive at end of Clients on both TB and ARV medications receive DOT follow-up to ensure compliance with both classes of medication. 51

70 2.6.8 Hospitalisation In recent years, improvements in early diagnosis and treatment of opportunistic infections, appropriate prophylaxis, and aggressive efforts by the TB Control Programme have all contributed to a decrease in utilization of inpatient beds by patients with HIV/AIDS. The number of inpatient hospitalizations for HIV-related conditions among children has decreased dramatically, with only an occasional child admitted for management of drug regimens or an older child developing a first opportunistic infection before their HIV status is recognized. Today, care for children with HIV is almost entirely provided through the outpatient clinic setting (Gomez, 2006) Post-Exposure Prophylaxis All victims of sexual assault during the period covered by the strategic plan were provided with post-exposure prophylaxis (PEP). A PEP protocol is in place for needle-stick injuries and other high-risk injuries Research The Bahamas commenced participation in an open Label Phase three study of ABT- 378/Ritonavir of HIV-infected children. Eighteen (18) children were enrolled in this study by the end of the period covered by the strategic plan. Other areas of research identified in Gomez (2006) included Protocol 247, Penpact 1 (Penta9/Pactg390), Tipranavir , and ATN Human Rights Issues At the end of the period covered by the strategic plan, efforts were ongoing with respect to policy development and enacting legislation, promoting human rights and nondiscrimination, and the follow-up with unions and Human Resource Managers on the decisions taken at the August 2000 National Consultation on HIV/AIDS in the workplace. Drafting of legislation on HIV/AIDS in the workplace was significantly advanced. Several FBOs and Women s Groups have been empowered through education for the reduction of stigma and discrimination. The Ministry of Education has adopted specific policies over this period to protect HIVinfected children from discrimination and to protect their confidentiality as it relates to play and sport, namely, the participation of an HIV/AIDS infected student/athlete in sports and other recreational activity has not to date, presented sufficiently clear indications that such practices expose others to the infection; 52

71 the HIV/AIDS infected student/athlete has a right to confidentiality and thus his/her medical condition in this instance need not be placed on general medical records in the school. The Ministry of Education initiated the drafting of legislation over this period to address requirements for treatment, management and education of all persons affected and infected with HIV/AIDS (including students and teachers), and the provision of systematic and consistent information and educational materials on HIV/AIDS to students and school personnel (National HIV/AIDS Centre, 2006) Prevention and Education The National AIDS Education Programme, which draws on the expertise of volunteers and persons in NGOs, was successful in making the Bahamian public aware of the threat of HIV/AIDS to persons in The Bahamas as well as in other countries of the region. Structured island outreach workshops were conducted in the Family Islands on an ongoing basis. The Community Nurse in charge of the major clinics serves as a focal point with the assistance of the School Family Life Educators. Prevention efforts were maximized during cultural festivals such as regattas with the involvement of local Government teams. Several interventions were effected to reduce the spread of HIV/AIDS in the following vulnerable populations, namely: Young People Specialty programmes for adolescents e.g. the FOY initiative Sexually active persons Non Sexually Active Persons School children FOY s I am Special Programme, the Health and Family Life School Programme for grades 6 8, Annual World AIDS Day School Competition Commercial Sex Workers (CSW) Men who have sex with men (MSM) Institutionalized populations The Creole-speaking population Uniformed organizations Hotel staff Teenagers and adults who offer sex in return for designer clothes and footwear, and loan payments. National HIV/AIDS Centre (2006) records that the work of the FOY and YAPL among the youth was expanded and the media continued its role in HIV prevention education. Several FBOs and Women s Groups were empowered through education for HIV prevention. YAPL accommodated an intake of 75 young people annually for the four-week training as ambassadors. Trained ambassadors were organized into teams of eight and assigned to work with schools or youth who are HIV-positive. 53

72 Support Data from Samaritan Ministry revealed that by the end of 2005, this Ministry had trained over 250 lay counselors; of these were assigned to provide personalized support to PLWHA and their families. Commissioned lay counselors met weekly to review progress of the PLWHA in their care and to solve problems as they arise. In addition to sustaining its mission of moving the PLWHA from dependence to independence and later to providing assistance to other PLWHA, Samaritan Ministry played an advocacy role relative to the role of the Churches in the response to HIV/AIDS. To this end, presentations were made to FBOs at conferences in the Dominican Republic in 2004 and Guyana in Samaritan Ministry also provided training in the support and care of PLWHA to the League of Mercy, an arm of the Salvation Army. Orphans became an increasing challenge for the National AIDS Program over the period of the strategic plan. The AIDS Foundation initiated an outreach to this sub population The National HIV/AIDS Centre The role of the Centre was expanded and restructured in 2003 so as to bring all prevention, treatment, care, and support activities for HIV/AIDS under one umbrella. A significant feature of the restructuring is the HIV/AIDS Centre Resource Committee, a multi-sectoral team of persons drawn from the community that collaborates with stakeholders on behalf of the HIV/AIDS Centre. The Committee meets monthly to review strategic plans, programme activities and outcomes, and to collaborate on joint initiatives. Members of the committee assisted in disseminating information to schools and youth groups, conducted workshops and presentations for CBOs and FBOs, provided walk-in counselling and expanded the PLWHA support group. They also networked with a range of organizations including The Bahamas Family Planning Association, The AIDS Foundation and The Bahamas Barbers & Cosmetologist Association (HIV/AIDS Centre, 2006). The Centre also assimilated the Three Ones Principles into its National HIV/AIDS Programme during the period The Three Ones Principles were approved at the 13 th Annual Conference on AIDS & STIs in Africa in September 2003 and subsequently adopted by the Government of The Bahamas (Gomez, 2006). Consistent with the third goal of the strategic plan, the Centre received additional human resources for the National HIV/AIDS Programme in the areas of pharmacy, laboratory, social work and counselling resources, funded in part through the Clinton Foundation networks. According to the Ministry of Health (2006), other achievements for the Centre, and by extension the National HIV/AIDS Programme, over the period were: The development of draft HIV/AIDS protocols and guidelines from regional guidelines and adapted for The Bahamian context; The strengthening of laboratory service capacity to include viral load and CD4 testing in-country; 54

73 The initiation of VCT, PMTCT and nutrition training under the CHART Initiative to public health nurses, social workers and volunteers throughout The Bahamas. Modules focusing on stigma and discrimination were included in this training; The initiation of a national Know Your Status public awareness campaign to encourage Bahamians to get tested; Training of public health primary physicians in HIV/AIDS prevention, treatment, care and support protocols and guidelines, including referral to appropriate support services under the CHART Initiative. The Bahamas has recognized that the experience of its response to HIV/AIDS over the past two decades positions the National HIV/AIDS Centre to cooperate with NAPs in other countries in the development of HIV/AIDS prevention and control interventions. The Centre initiated technical cooperation to Turks and Caicos, St. Kitts, Belize and Antigua during the period covered by the strategic plan, providing expertise and medications, when required (Gomez, 2006). It is evident that significant progress was made in terms of achieving the target linked to the third goal of the Plan Challenges at the end of the Strategic Plan Over the period , progress was made with respect to meeting the three goals of the Plan namely: To extend comprehensive care to all persons living with HIV/AIDS by 2005; To prevent the transmission of HIV in The Bahamas To establish a National HIV/AIDS Resource Centre to serve The Bahamas and the region. This is evidenced by the partial achievement of the five targets that link to these goals. However, several challenges contribute to the gap between achievement and targets. Sustainable funding remains a key challenge, even though the funding timeframe for the 2003 to 2005 scaling-up initiative has ended. While the Government is striving to maintain its current commitments to the National HIV/AIDS Programme, and new private sector and non-governmental donors are in the process of committing new funds, the strategy for achieving the goals and objectives of the NASP will require additional funds sustained over the longer term. A key ongoing challenge to the NAP is the continued exclusion of The Bahamas from funding by international donors on account of its GDP. Another major challenge remains the acceleration of the decentralisation and integration of comprehensive care to the community level. The Ministry of Health (2006) emphasizes that decentralisation and integration accelerate access to comprehensive care by: 1. overcoming resistance to accessing care caused by centralization within specialty clinics that are specifically identified with HIV/AIDS care; 2. increasing capacity to provide HIV/AIDS care across the primary level of care, thereby reducing barriers caused by human resource and infrastructure constraints; 3. reducing geographical barriers to accessing services by providing geographically disposed service capacity. 55

74 However, Ministry of Health (2006) also warns that decentralization and integration of services present challenges which need to be addressed in the scaling-up strategy, including: i ensuring adequate infrastructure and human resources to provide services that meet standards of care; ii ensuring quality control and monitoring to ensure adherence to guidelines and protocols; iii ensuring confidentiality throughout the expanded system; ensuring that services are provided in a non-stigmatised, non-judgemental and nondiscriminatory environment. HIV/AIDS Centre (2006) identified immediate challenges in terms of the needs to accelerate HIV/AIDS prevention in the following areas: Outreach to PLWHA; Outreach to the large and growing Creole-speaking community; Outreach to MSM and bisexual populations; Outreach to sexually active young people in and out of school; Support for parents; Outreach to the CSW population and persons who are not generally considered as CSW but who regularly have sex in return for car payments, loan payments etc.; Prevention of repeat pregnancy for HIV-positive mothers with one child; Structured, sustained outreach to the smaller Evangelical, Pentecostal and Independent Churches; Outreach to drug addicts especially victims of alcohol abuse; Outreach utilizing the sporting community; Work with men who patronize bars by utilizing bartenders; Website development. Although the National HIV/AIDS Programme has always incorporated monitoring and evaluation as a key component and has been driven by an evidence-based approach, The Bahamas, like other low and middle income countries still faces a challenge in this area. In particular, The Bahamas lacks a comprehensive monitoring and evaluation framework. Data collected from various sources and methodologies are not well-integrated into a single set of core indicators. Like many countries, The Bahamas must respond to requests from international multilateral organizations and donors using different and sometimes conflicting sets of indicators. The HIV/AIDS Centre requires additional expertise to develop a comprehensive monitoring and evaluation framework that is based on a single set of core indicators, harmonized with international organizations and donors (Gomez, 2006). The programme is also challenged by the absence of information systems. Most surveillance and other data are manually collected and summarized. This is a highly time-consuming process for an already overworked staff. Raw and indicator data are maintained in multiple data stores, including spreadsheets and databases. These manual collection processes and disparate storage systems mean that data is often months or even years out of date and information is not readily available when required for reporting or evaluation purposes (Gomez, 2006). 56

75 In the area of stigma and discrimination, The Bahamas recognizes the importance of protecting individuals from discrimination through public policy, education, legislation and advocacy. While the country does have strong legislative and policy protection against discrimination in many sectors, there are still gaps, such as protections based on sexual orientation or preference. Societal stigma and fear of discrimination of HIV/AIDS continue to pose a challenge at the end of the period as they prevent people at risk of infection and those already infected from seeking services. Fear of stigma, retribution and further discrimination also prevent many PLWHA from pursuing redress to discriminatory actions, even when protected by law or policy (Gomez, 2006). The Government of The Bahamas views the development of the Roadmap to Scaling Up Towards Universal Access to HIV Prevention, Treatment, Care and Support Services (February 2006) as a catalyst for the renewal and update of the strategic plan to 2010, and has included an updated NASP as a key action toward universal access. It is critical that this roadmap addresses the challenges mentioned above. While work plans and budgets were developed and approved, milestones often could not be achieved by target dates because of human resource, funding and infrastructure constraints. 57

76 SECTION 3 TOWARDS UNIVERSAL ACCESS TO HIV/AIDS PREVENTION, TREATMENT, CARE AND SUPPORT SERVICES 2006 TO Background In the nearly five years since UN Member States made the Declaration of Commitment on HIV/AIDS at the 2001 Special Session of the UN General Assembly, the global AIDS response has shown steady growth, placing the goal of moving towards universal access to HIV prevention, treatment, care and support services within reach by As the 2010 benchmark approaches, UNAIDS has been facilitating a multi-partner effort, driven by the countries themselves, to scale up towards universal access. The process aims to identify solutions to the key obstacles that are blocking universal access to prevention, treatment, care and support services, and to develop nationally agreed, targeted plans or roadmaps for building significantly more comprehensive AIDS programmes by According to The Ministry of Health, the process thus builds on a continuum of efforts to better help countries as they scale up their AIDS responses in a sustainable manner, integrated with wider developmental efforts. The critical elements of this process are: It occurs within and builds upon existing processes at all levels; Countries drive the process, supported by international and bilateral institutions and donors, in line with the Three Ones principles and the recommendations of the Global Task Team; It covers the scale-up of a comprehensive and integrated AIDS response, including prevention, treatment, care and support; It focuses on finding practical solutions to the main obstacles to scaling-up, building on decisions already made; The participation of a wide range of stakeholders especially civil society and PLWHA is critical to its elaboration and success; It encourages countries to set their own roadmaps including midpoint targets and milestones in order to advance toward universal access and to achieve the MDG on HIV/AIDS. The Government of The Bahamas viewed this roadmap process and its outcome as an opportunity to review the progress of existing initiatives and strategies, and as a foundation for the renewal of the National HIV/AIDS Strategic Plan The Bahamas Roadmap to Scaling Up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support Services is the result of the execution of the above process in The Bahamas. It was led by the National HIV/AIDS Centre with technical and financial support from the UNAIDS Office, and included a detailed review of strategic plans to 2005, 58

77 and consultations with key stakeholders to identify accomplishments to-date, status of key initiatives and strategic plans, key barriers, and future actions and milestones. 3.2 The Resource Profile of the National HIV/AIDS Centre It is instructive to record the resource profile of the National HIV/AIDS Centre as its sets about the implementation of this Roadmap. The Centre has six units, each with its own coordinator and staff, and reporting to the Managing Director. Table 23 below provides a summary of the units in terms of their service delivery areas and staffing levels. Table 23: Areas of Responsibility and Staffing by Unit for the HIV/AIDS Centre Unit of HIV /AIDS Centre Areas of Responsibility Staff The treatment, Care and Support Unit Pediatric Clinic Antenatal Clinic Adult clinic PMTCT Programme VCT Programme Pre & post-test counselling Partner notification Contact tracing Defaulter tracing DOT home visits Social support Group support counselling Adolescent peer counselling Liaison and coordination with Government and non- Government support services Epidemiological and compliance surveillance Coordination with the National Health Information Unit ARV dispensing Compliance monitoring Patient counselling Monitoring and reporting adverse events Inventory management and ordering 1 Nursing Officer 1 Pharmacist 1 Registered Nurse 2 Graduate Nurses 1 Social Worker 1 Trained Clinical Nurse 2 Health Aides/Phlebotomists 1 Community Worker 1 Filing Assistant 59

78 Table 23 (Cont d) Areas of Responsibility and Staffing by Unit for the HIV/AIDS Centre Unit of HIV /AIDS Centre Areas of Responsibility Staff HIV Specialty Laboratory Collating all laboratory data for HIV clients Monitoring and charting laboratory analyses Viral load testing CD4 testing (beginning Feb. 2006) Quality assurance HIV resistance testing and research (beginning July 2006) Prevention Education Unit Focus on Youth Unit Research Unit Training (CHART) Unit Source: National HIV/AIDS Centre, Develop, coordinate and deliver prevention education, outreach and communication Outreach (including condom distribution) Coordination and delivery of the FOY Programme Evaluation of youth prevention education programmes Youth Ambassadors for Positive Living Programme Oversee and coordinate research and clinical trials Ethical Review Coordinate and deliver CHART and other training initiatives 1 Lab Manager 1 Senior Lab Technologist 1 Lab Technologist 1 Clerk 1 Nursing Officer 1 Trainee Social Worker/HIV Educator 1 Educator/ Counsellor 1 Office Assistant 1 Senior Clerk 1 Education Display Person 1 Coordinator 2 Nursing Officers 1 Senior Nursing Officer 60

79 3.3 Definition of Universal Access The Roadmap is based on a working definition of universal access developed as part of The Bahamas Process, i.e.: Sustainable high quality prevention, treatment, care and support services are accessible by all residents of The Bahamas living with, or affected by, HIV/AIDS regardless of legal status or ability to pay. This definition includes the following dimensions that guided the design of the Roadmap: Availability (quality service delivery points available, sustained availability); Accessibility (distance, time); Affordability (monetary and other costs, opportunity costs); Acceptability (gender, ethnicity, language) Perceived needs (perception of a disease or health risk, belief that the intervention will make a difference); Quality of care (diagnosis ability, choice of interventions, adherence). 3.4 Goals and Targets within the Roadmap The Bahamas Roadmap has identified two goals for universal access over the period , namely: 1. Extend and improve the quality of life for all residents of The Bahamas living with, or affected by, HIV/AIDS. 2. Prevent the transmission of HIV in The Bahamas. The related key targets for universal access over the period of the Roadmap are as follows: The rate of new HIV infections in The Bahamas is reduced by 50%; 90% of all HIV-infected residents of The Bahamas are accessing the prevention, treatment, care and support services required to extend and improve their quality of life; 100% of eligible HIV-infected residents of The Bahamas are receiving antiretroviral therapy; Knowledge, behaviour and attitude studies show a reduction in the fear of stigma and discrimination among persons living with, and affected by, HIV/AIDS, and reducing in stigmatizing and discriminatory attitudes among the general population. 61

80 3.5 Major Challenges faced and Actions needed to achieve the Goals and Targets of the Roadmap Table 24 below summarizes the challenges currently faced by The Bahamas in scaling-up towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support Services and provides recommended solutions 7 which must be implemented over the period of the Roadmap. Table 24: Major Challenges Faced and Actions Needed to Achieve the Goals and Targets of the Roadmap Challenges Societal stigma and fear of discrimination of HIV/AIDS prevents people at risk of infection and those already infected from seeking services. Actions Provide services throughout the primary care level in settings that are not specifically associated with HIV/AIDS care; Target behavioural change communications and public awareness campaigns to change attitudes among service providers and the general population that reduce stigma and discrimination; Ensure appropriate anti-discriminations policies and laws are in place, and ensure existing policies and laws are enforced; Conduct education and public awareness campaigns to encourage people to know their status, and on the importance of seeking treatment if HIV-infected; The outpatient clinics at PMH and RMH lack capacity to provide all required services to all HIV-infected individuals. Empower PLWHA to advocate for change on their own behalf, and provide legal and other services to help them seek redress for discriminatory actions. Decentralise comprehensive HIV/AIDS prevention, treatment, care and support services to the primary care level to distribute demand across the system; Increase HIV/AIDS prevention, treatment and care capacity through training providers at the primary care level; Reduce HIV transmission through prevention programs such as PMTCT and behavioural change communications. 7 Specific actions and milestone are addressed in further detail in The Bahamas Roadmap to Scaling Up Towards Universal Access to HIV Prevention, Treatment Care and Support Services 2006 to 2010, February

81 Table 24 (Cont d): Major Challenges Faced and Actions Needed to Achieve the Goals and Targets of the Roadmap Challenges There is a shortage of trained professionals with expertise in HIV/AIDS prevention, treatment, care and support services to meet the needs of the expanding number of patients accessing services which is exacerbated by the ineffective deployment of existing human resources. The level of social support interventions, nutrition services, mental health services and oral health care is compromised due to inadequate numbers of personnel to provide these services in the clinic setting and through home visits in the community. Community clinics are at physical capacity for all patient categories, even without treating HIV/AIDS patients. Medical records are not yet computerized in The Bahamas, and there is no common patient identification system in place linking community clinics, hospital settings, and ancillary services. This makes it difficult to monitor quality of care, especially in a decentralised model. Information required to support prevention, treatment and care services is not readily available and, manual processes and duplication of tasks consume valuable human resources. There is no integrated information system to permit central monitoring and tracking, distribution and consumption of ARVs across all pharmacy/dispensary sites. The existing hospital laboratory system, which serves both hospital-based services and community polyclinics, lacks a computerized lab information system that is linked with patient records. All data entry into charts is manual, delaying receipt of patient results. Actions Provide HIV/AIDS training to health care providers and other service providers throughout the primary care level. Implement a comprehensive human resources management plan that appropriately targets resources to identified needs and gaps, and includes strategies for recruitment and retention. Liaise with National programs aimed at developing human resource capacity to ensure that the appropriate competencies required for HIV/AIDS prevention, treatment, care and support services, including planning and management capacity, are addressed. Implement a comprehensive human resources management plan that appropriately targets resources to identified needs and gaps, and includes strategies for recruitment and retention. Increase HIV/AIDS support capacity through partnerships with volunteer, community and faith-based organizations, and through international support for technical assistance. Identify infrastructure requirements and develop a plan and budget to upgrade facilities, including communication and transportation systems. Implement a Public Health Information System, including a unique client identifier with appropriate protections for confidentiality. Implement a Pharmacy Information System. Implement a Laboratory Information System integrated with the Public Health Information System. 63

82 Table 24 (Cont d): Major Challenges Faced and Actions Needed to Achieve the Goals and Targets of the Roadmap Challenges There is inadequate funding available to fully scale-up human resource capacity and infrastructure to support universal access to comprehensive HIV/AIDS care as required. The Bahamas is generally excluded from international donors and funds because of its GDP. Sustained funding to support the current capacity of service delivery is not guaranteed. Source: National HIV/AIDS Centre, Actions Develop roles and expertise to focus on accessing both domestic and international sources of funding; Work with Government officials and international donors to remove barriers to funding; Work with private sector and international organizations to secure access to low-cost technologies, such as laboratory equipment and supplies. The Roadmap details a list of milestones for each of the actions listed above. These milestones are to be accomplished over the 2006 to period. 3.6 Critical Success Factors for Sustained National Response to HIV/AIDS There are some critical factors that are necessary for the continuance of a sustained and successful response to HIV/AIDS in the Bahamas. These factors cover a relatively wide range of policy and operational areas and are detailed below. 1. Strong Political Commitment and Leadership The Government of The Bahamas, through its Ministry of Health, demonstrated this commitment from as far back as 1985, two years after the first case of AIDS was reported in the country. The commitment can be seen in the personal commitment of the Minister of Health, the Permanent Secretary, the Chief Medical Officer and the National HIV/AIDS Programme Director in initial discussions with national and international partners, and in programme planning and implementation. Without this senior level collaboration, the integrated planning and programme execution required for the successful implementation of the country s strategic plans and initiatives would not have been possible. 2. Dedicated, Competent and Caring Program Management of the National Response The HIV/AIDS response in The Bahamas was initially coordinated by the National AIDS Programme, later by the National HIV/AIDS Secretariat, and currently by the National HIV/AIDS Centre. Notwithstanding its designation, the coordinating agency of the response in The Bahamas has been dedicated to coordinated, comprehensive, compassionate community based, family-centered care and support of persons living with HIV/AIDS, as well as their families and significant 8 Specific actions and milestones are addressed in further detail in The Bahamas Roadmap to Scaling Up Towards Universal Access to HIV Prevention, Treatment Care and Support Services 2006 to 2010, February

83 others. In addition, this coordinating agency has led initiatives aimed at engaging the entire population of The Bahamas in prevention and advocacy against stigma and discrimination. 3. Public, Private and Civil Sector Support - Collaboration among health agencies and departments, the Ministries of Education, Youth, Sports, Social Services, Tourism, and Culture, the hotels, labour unions, the National Insurance Board, The Bahamas Family Planning Association, and private sector companies like the Imperial Life Insurance Company has been a hallmark of the NAP in The Bahamas. 4. A Committed Network of Non-Governmental Support Agencies Under the direction of the National HIV/AIDS Centre and the Ministry of Health, a group of NGO s, including the AIDS Foundation of The Bahamas, The Bahamas Red Cross, Bahamas Barbers & Cosmetologists, The Bahamas Network for Positive Living, Samaritan Ministry, the Salvation Army, and other community and faith-based organizations continue to work together as a coherent network to provide expertise, funding, and human resource capacity to the strategic planning efforts, as well as directly providing support services to PLWHA. 5. A Public Health Policy and Extensive Public Health Infrastructure The Bahamas possesses extensive and well planned health care infrastructure providing both preventative and primary health services through a system of public hospitals and community clinics. Its national health policy guarantees universal access to essential health and social services to all residents of the Commonwealth of The Bahamas. The existence of the infrastructure allowed for a much more rapid scale-up process and provided a highly functional context for strategic planning, programme management and delivery of health services. Further, the capacity for surveillance, public health outreach and prevention education was already well established when the AIDS epidemic emerged in The Bahamas, and these approaches formed the backbone of the country s response from the very beginning, providing a strong foundation for scaling-up of comprehensive care and treatment. 6. Well Designed and Continuous National HIV/AIDS Strategic Plans The Bahamas developed and implemented strategic plans covering the periods and Currently, the country s response is guided by a Roadmap to Scaling Up Universal Access to HIV/AIDS Prevention, Treatment, Care and Support Services Adequate Funding for the Implementation of National HIV/AIDS Strategic Plans Such funding must provide for the resources needed to facilitate the achievement of milestones within the strategic plan. In the implementation of the strategic plan, The Bahamas failed to meet its milestones for decentralisation of comprehensive treatment and care due to the lack of funding. 8. Adequate Manpower Resources The implementation of each strategic plan required the delivery of services of a full range of medical, nursing, ancillary, and support services. These services must be adequately resourced by teams of infectious diseases specialists, pediatricians, medical house officers, infection control nurse 65

84 practitioners with advanced training in HIV, public health nurses, social workers, nutritionists, community volunteers, and pharmacists. The adequacy must be characterized in both quantity and competencies. All resource persons engaged in the NAP must live the value system 9 spelt out in the Strategic Plan and be developed to bring the cutting edge of treatment, care, support, prevention and advocacy to the NAP. 9. Adequate Infrastructure for the NAP Distinct from the Public Health Infrastructure HIV/AIDS is more than a health problem for countries; it is a development problem. The Bahamas, like any other country, must ensure that adequate infrastructure is in place for the provision of treatment, care, support, prevention and advocacy services to the defined standards. Infrastructure is also required to support ongoing research in all priority areas of the national response. 10. Networking with Regional and International Agencies and Research Institutions The GDP of The Bahamas disqualifies the country from the funding provided by international donor agencies. Against these circumstances, the on going national HIV/AIDS response in The Bahamas has benefited from significant contributions made by regional and international agencies, research institutions, and pharmaceutical companies in the areas of research, training, technical cooperation and support. Examples are CARICOM, CFNI, UWIHARP, CCC, CAREC, CCNAPC, The Clinton Foundation, UNAIDS, PAHO, WHO, CDC, NASTAD, Pangaea Global AIDS Foundation, Abbott International Laboratories, Med-Pharm, Toronto s Hospital for Sick Children, The Institute of Human Virology University of Maryland, and Wayne State University. The networking and the research has allowed the country to stay on the cutting edge of HIV/AIDS treatment and care. 11. Availability and Accessibility to Cost-Effective ARV Therapy The addition of ARV therapy to the treatment protocols in the National AIDS Programme in The Bahamas has resulted in a better standard of life for those PLWHA who practice adherence. Furthermore, the lobby efforts of the Clinton Foundation resulted in a significant reduction in the purchase price of the ARV medications to The Bahamas. It is this reduced price that facilitated the increase in the number of eligible PLWHA receiving ARV therapy at the end of The Operational Model for the Delivery of Treatment, Care and Support to PLWHA In The Bahamas, treatment services for HIV/AIDS patients are organized around a seamless One Stop Shop delivery model. In this model, HIV/AIDS treatment services for antenatal HIV-positive women, adults and children patients are provided at one Infectious Diseases Clinic staffed by a multi-disciplinary team of providers. 13. A Holistic Monitoring and Evaluation Framework and a Fully Resourced Monitoring and Evaluation Unit - This factor is critical to The Bahamas HIV/AIDS Response having the capacity and capability to evaluate performance against targets 9 In particular, the values of confidentiality, caring, and service that is non-stigmatised, non-judgemental and non-discriminatory. 66

85 and goals of successive NASPs. The monitoring function will cater to the ongoing need for quality control in the NAP. 14. A Clear Appreciation of the Potential Role of the Tourism Sector in the Spread of HIV/AIDS - The adoption of an explicit HIV/AIDS tourism policy regarding the dominant role of tourism in the country s economy. 3.7 Lessons Learnt An examination of the experience of The Bahamas shows that there are several lessons that can be learned and applied for continued success and refinement of the response strategies. These include: Strong political leadership and commitment are essential to the success of national programs aimed at scaling-up comprehensive HIV/AIDS care. An operational HIV/AIDS Programme and a Strategic Plan with multi-sectoral participation and support are critical for the sustained scaling-up of HIV/AIDS treatment, care, support, prevention and advocacy. The support of a network of Non-Governmental Support Agencies is critical to the outreach of the national response to HIV/AIDS. Maintain and upgrade Public Health Policy and Public Health Infrastructure since these provide the backbone of country s scaling-up initiatives to treatment, care and support. The experience gained by the NAP in delivering existing services within the menu of comprehensive care of HIV/AIDS is valuable in terms of providing baselines for scaling-up to universal access to comprehensive care of PLWHA. Specially focused initiatives are required for managing the contribution of the crack cocaine epidemic to the HIV epidemic. Support the direction of the National HIV/AIDS Programme by a properly structured research agenda that focuses on treatment, care, prevention and advocacy issues. PLWHA need Family support; Treatment support; Church support; Workplace support; and Community support. PLWHA must be empowered and left to make the appropriate decisions with respect to their adherence to treatment. The success of the PMTCT Programme confirms that among HIV/AIDS care providers there must be a will to care; a will to take action; and a capacity for hard work. 67

86 There is significant advantage to be gained by the dual appointment of Director of the Infectious Diseases Clinics and Director of the HIV/AIDS Outpatients Clinics. 3.8 Recommended Practice Arising from The Bahamas Experience Based on the lessons learnt and the experiences gained from implementing the HIV/AIDS response programmes, there are several practices that are recommended for application, namely: 1. Embrace the practices embodied in the Three One Principles. 2. Understand the links between HIV and STI on the one hand, and between HIV and drug use on the other hand in your country. Locate the STI Clinic and the Substance Abuse Clinic in close proximity to the HIV/AIDS Clinic. 3. Organise treatment services for HIV/AIDS patients into a seamless One Stop Shop. In The Bahamas, HIV/AIDS treatment services for antenatal HIV-positive women, adults and children are provided at one Infectious Diseases Clinic staffed by a multidisciplinary team of providers i.e. infectious diseases specialist, pediatrician, medical house officers, infection control nurse practitioners with advanced training in HIV, public health nurses, social workers, nutritionists, community volunteers from the Samaritan Ministries, and pharmacists. This full range of medical, nursing, ancillary, and support services allows for the delivery of a holistic, seamless patient care to PLWHA to be concentrated in one place. 4. Providers of treatment and care for HIV/AIDS patients must be committed able to multi-task, must show respect for patients, maintain client confidentiality, and be good team players. Experience has shown that the combination of commitment, multi-tasking, respect, confidentiality and teamwork among providers creates a welcoming environment for the PLWHA and results in a good sense of self among the infected. 5. Provide quality pharmaceutical care. In The Bahamas, HIV/AIDS patients are benefiting from one-on-one counselling on medication prescribed, client confidentiality, and individual passports that keep track of their CD4 count, viral load, and medication prescribed. The passport is to be presented to health care providers whenever care and treatment are being accessed. Providers of pharmaceutical care must also demonstrate charisma. 6. Ensure that protocols are designed, implemented, monitored and updated for all aspects of treatment and care to HIV/AIDS patients, e.g. staging, blood tests, VCT, prophylaxis for OIs; ARV therapy, treatment of TB, and nutrition. 7. Ensure that contact tracing and partner notification are executed in a manner that maintains client confidentiality, makes the facilitator as anonymous as possible, and explores all available options for making contact. Generally these include going to 68

87 the home, going to the place of work, calling on the phone, or leaving a discrete note under the door. Facilitators must be flexible in terms of the choice of location for the first meeting with the contact. 8. Follow-up on patients who missed clinic appointments. Trigger defaulter tracing after two (2) defaults. 9. Make the health of the baby the main focus of the HIV-infected pregnant mother, her husband or consort and the counsellor during pre & post test counselling of HIVpositive antenatal women. 10. Persons who facilitate advocacy and prevention and education initiatives targeted at the youth must demonstrate in their lives that they walk the talk. 11. Adopt the Samaritan Ministry as a model of collaborative faith based ministry that focuses on care and support for, as well as stigma and discrimination, on behalf of PLWHA and the affected community. 12. Adopt DOTS as a critical strategy in the fight for adherence to treatment by PLWHA. 13. Health & family education must be designed so as to be age appropriate. 14. Ensure that all doctors assigned to HIV/AIDS clinic are aware of the side effects of all medications listed in the treatment protocols for HIV/AIDS, TB, STIs. 15. Facilitators involved in HIV/AIDS prevention and education of youth should adopt the approach that has been effective for the YAPL in The Bahamas, namely: Get their attention; Listen to what they are saying; Provide information on the myths; Engage them in role play on issues related to past situations and situations that they are about to encounter; Provide options good ones & not so good ones; Leave youths to make the decision; Do not impose the decision. 16. Integrate DOTs, PMTCT & VCT training in the curriculum of the country s Nursing Schools. 17. In addition to providing VCT training to private physicians through CHART, National AIDS Programs must provide for direct access to the National AIDS Director by private physicians so trained. Where appropriate, the CHART Team can facilitate referrals and queries from private physicians. 18. In implementing the CHART initiative in country, target supervisory providers; train them as VCT preceptors; have them subsequently release their subordinate staff for VCT training; and ensure that they mentor subordinate staff. 69

88 VOLUME 2 A COMPARATIVE ANALYSIS OF HIV/AIDS IN BRAZIL AND UGANDA

89 SECTION 4 A COMPARATIVE ANALYSIS OF HIV/AIDS RESPONSE AND LESSONS LEARNT: BRAZIL, UGANDA AND THE BAHAMAS 4.1 Brazil Brief Demographic Background Brazil is the largest and most populous country in South America; it has a land of area 8.5 million square kilometres. This continental federal republic is composed of twenty-five states and has an estimated population of 188,078, National Response The first clinical AIDS was identified in Brazil in Similar to many countries, the Ministry of Health led the Government s response to HIV/AIDS. In 1985 the Ministry of Health established the National STD/ AIDS Programme (PN-DST/AIDS). The programme s original focus was disseminating information about HIV and AIDS to vulnerable populations in particular men who have sex with men who were the first HIV infected, epidemiological surveillance and the provision of medical assistance. In 1986 the National AIDS Control Programme was expanded to include sexually transmitted infections under its purview. The National AIDS Control Committee was formed in 1987 to be the focal point for the multisectoral approach to the epidemic; the committee comprised civil society representatives and representatives of the scientific community. (UCSF, 2004) The early response was characterised by mass media campaigns on all available media: television radio networks, outdoors, and bus doors. The first media campaigns focused on the provision of objective information on high risk behaviours for the contraction of HIV. In 1988 the Ministry of Health began the distribution of drugs for opportunistic infections in and comprehensive blood screening becomes compulsory at all blood banks. At the same time the Ministry of Health developed ethical guidelines for the management of HIV/AIDS to which all physicians were required to adhere. As treatment for HIV evolved the Government began offering AZT in 1991 through its public distribution channels (UCSF, 2004). In 1992 the National STD/AIDS Programme became multisectoral in nature. It expanded to include linkages with civil society, other governmental areas and international institutions for technical cooperation. The programme embarked on the piloting and implementing of 10 Available on the internet at the CIA website: 11 Available on the internet at the Avert website 71

90 prevention and treatment programmes during the period aided by a US$160 million loan from the World Bank (AIDS-I). These programmes consisted of: condom distribution both at the government level and at the level of NGOs; building a network of VCT (voluntary counselling and testing) centres; interventions to promote behaviour change among high-risk groups; and strengthening the safety of the blood supply (UCSF, 2004). The World Bank in 1992 estimated that, given the trends in the epidemic by the year 2000 Brazil would have approximately 1.2 million people living with HIV. However, in 2006 by UNAIDS estimates it was found that there were 620,000 persons living with HIV/AIDS in Brazil. Further, since 2000 the HIV adult prevalence rate has stabilised at 0.5%. These results are indicative of the country s comprehensive prevention and treatment initiatives. In December 1996, by the order of federal law 9313, universal free ARV access became the right of all those infected and the ARV Support Committee was created. This committee has complete independence from the Ministry of Health and is charged with the formulation of guidelines and recommendations along with revisions to the same when necessary. The Programme made use of funding from AIDS-II, a second World Bank loan of US$165 million ( ), to strengthen its existing proven effective prevention services (condom provision and VCT) by increasing the access to condoms and increasing the number of VCT sites. The loan also helped finance the strengthening laboratory services for clinical monitoring, activities surrounding measuring drug adherence and resistance and necessary training activities for clinical staff with aim of providing better quality service to those infected (UCSF, 2002). The Brazilian response to the epidemic coincided with a period of democratization and rejuvenation of civil society. This climate fostered a strong NGO presence and a state-led recognition of human rights and entitlements. It should be noted that the state s early response was greatly influenced by a strong civil society lobby which along with increasing cases of infection mandated an effective state intervention. This state-led intervention which emerged from this climate was one which linked its response to HIV to the question of human rights Treatment and Care The structure of the programme is not limited to distribution but consists of an intricate system of 362 accredited hospitals, 148 specialised care services, 69 day hospitals and 52 home therapeutic care projects. (Levi and Vitóra, 2002) Brazil s strategy in addressing the issue of treatment involved identifying locations where medicines could be distributed to those in need, developing a system to track distribution of medicines and correct usage as well as the establishment of a laboratory network for clinical monitoring. Between 1997 and 1998 the National STD/AIDS Programme implemented a system which registers ARV distribution known as the Computerized System for the Control of Drug 72

91 Logistics (Sistema de Controle Logístico de Medicamentos, SICLOM). This system aids in stock management and helps to ensure that ARV prescriptions are in harmony the national treatment guidelines. ARVs are distributed through AIDS Drugs Dispensing Units (ADDU) which are located at public hospitals or health centres. In 2003 there were 474 sites throughout Brazil. (Levi and Vitóra, 2002) As a result of this there is domestic production of 7 of the 18 ARVs available in Brazil, also to aid in cost reduction the Ministry of Health invested in Brazilian owned drug manufacturing companies. (Levi and Vitóra, 2002) Additionally, a network of laboratories was created in 1997 by the Ministry of Health in this same year System for Control of Laboratory Exams (Sistema de Controle de Exames Laboratoriais, SISCEL) was established to gather data from the labs fro transference online to PN-DST/AIDS and as at 2001, there were 78 laboratories equipped to perform CD4/CD8 testing, and 66 laboratories were equipped to perform viral load quantification. This network is backed up by an external quality control programme. (Levi and Vitóra, 2002) As at 2002, 14 labs were capable of performing resistance genotyping services, however for cost containment purposes these services are only available to patients failing an ARV regimen, rather than before starting their first (UCSF, 2004). Brazil provides care services to PLWHAs through outpatient services, day hospitals, home therapeutic care services, public hospitals and STD care centres. The efficacy of Brazil s treatment and care programme has been borne out by the fact that between 1996 and 2002, mortality from AIDS was reduced by 50 percent, and AIDS-related hospitalizations fell by 70 percent. (Okie 2006, 1977) Voluntary Counselling and Testing In 1988 a network of free voluntary counselling and testing centres was established with these centres being introduced in the cities of Rio de Janeiro, São Paulo and Porto Alegre. This network has expanded into other areas over the years Prevention While Brazil has been a pioneer particularly in the aggressive promotion of condoms in its media campaigns, the key prevention strategies identified were: the promotion of testing, promotion and education on condom use, the provision of disposable syringes, increasing the availability and provision of incentives for pre-natal testing and prevention of STDs. The Prevention campaigns have addressed both the entire population and at risk groups. The National Programme in partnership with NGOs, also often implements activities such as condom promotion and free distribution targeted at low-income segments of the population and individuals who engage in high-risk behaviour such as commercial sex workers (CSWS), men who have sex with men (MSM), transvestites, adolescents, and drug users. There are 73

92 also interventions for marginalized groups such as street children, indigenous populations, prison inmates, low-income women and adolescents. The Government s proactive approach has at times been at odds with conservative views particularly with regard to its work with CSWs and its needle exchange programme. However recent surveys have shown that this proactive non-conservative approach has borne fruit, it was found in 2005, that condom usage among Brazilians 16 to 65yrs of age was 35% as opposed to 24% in Additionally, in 2001, 74% of commercial sex workers reported consistent use of condoms and the prevalence for this group remained at a sustained 6% according to a 2005 report. (Okie 2006, 1977) Further, it was found that 76% of IDUs reported no sharing of needles or syringes. As a result, cases of AIDS acquired through drug injection have fallen, in fact in 2003, IDUs accounted for only 10 percent of newly reported cases, as compared with 28 percent in 1993 (New England Journal of Medicine, 2006). The PN-DST/AIDS has also engaged in prevention activities in schools with the establishment of a teacher-training program on sexuality, STD/AIDS, and drug abuse. The programmed aimed to prepare teachers in public schools to engage in sex education and activities for the prevention of STDs and drug use. Teacher training manuals and materials geared towards students were produced by a team of multidisciplinary specialists. The state s proactive approach to the epidemic with its special interventions for high risk groups, coupled with its open approach to sex and sexuality through condom promotion and information campaigns against discrimination, has been put forward as one of the main contributing factors in Brazil s success thus far NGO Response In 1983 civil society took an early lead with informational campaigns carried out by gay support groups in major cities in Brazil. In 1985 the first Brazilian HIV/AIDS NGO Support Group for AIDS Prevention (GAPA) was set up. Since that time various NGOs addressing HIV/AIDS have been set up by diverse groups: from religious organisations to sex workers to transvestites and feminists. In fact it was estimated that 1,681 projects were financed between 1988 and 2000 involving 686 civil society organisations (UCSF, 2004). The role of NGOs has evolved over the course of the epidemic, moving from the role of lobbying the public sector on the areas of blood safety and rights of HIV positive persons, to working in partnership with the Government as part of the national response with NGO representation on the National AIDS Commission and the National Health Council FBOs Brazil presents an interesting picture given that it has the largest Roman Catholic population worldwide whilst the state-led prevention response consists mainly of condom promotion, education about condom use and condom distribution. The role of the Catholic Church in 74

93 Brazilian HIV prevention programs can be best described as complicated. Officially, condom use is condemned by the church, but individual priests have at times supported condom use as appurtenant HIV prevention, (often with Governmental backing, inclusive of use of federal funds to produce informational material). Where Official Church condemnations of such efforts have occurred, the Government has been dismissive of it given that it sees the Church as an important potential partner in HIV prevention and care (UCSF, 2004). 4.2 Lessons Learnt The Brazilian response in the main was characterised by: early response by a strong civil society; a bold proactive state with an open approach to sex and sexuality; supportive and complementary links between the state and civil society; a balance between prevention and treatment initiatives; and an organised approach to treatment initiatives. NGOs in Brazil played a vital role in the country s response being the first responders to the epidemic. The vibrant nature of Brazilian NGOs allowed for the creation of a strong lobby for at risk at marginalised groups and due to their grass-roots nature, it allowed for effective partnering with the state in prevention activities later on. The presence of well-know public figures who were HIV positive and who were founders of NGOs dealing with HIV/AIDS, also provided a human face to epidemic and fostered a spirit of brotherhood. Further, NGOs have been able to reach the three groups with the highest infection rates as identified by the PN-DST/AIDS (MSM, IDUs and CSW) and make available prevention and care services. The Ministry of Health in the early stages of the epidemic identified its big three high risk groups (CSWs, MSM, IDUs) and took the necessary steps to prevent infection in this group through condom promotion and needle exchange programmes. The State went on to take decisive action with regard to these groups, liaising with NGOs where necessary. When HIV began to spread to the rest of the population, strong pro-condom messages were sent while at the same time, appropriate messages were still being sent this high risk group. Further, in its response, the State did not look at prevention and treatment as isolated strategies but as part of a continuum, which allowed for a balanced approach to the epidemic. This approach attempted to contain the epidemic by reducing the amount of new infections through condom promotion while at the same time seeking to maintain the health and prolong the life of those infected as part of their rights as Brazilians. The Brazilian experience in containing the epidemic also highlights the importance of early rigorous sustained prevention strategies. The experience shows that these actions tend to keep the pool of those infected in check, thereby reducing the burden on the health system in 75

94 the future and allowing for more manageable administration and delivery of treatment and care services later on. Finally, Brazil s treatment response did not consist of the ad hoc provision of generic medication but involved a system for distribution, a network of labs for clinical monitoring and an information system to tie everything together into one coherent whole. 4.3 Uganda Brief Demographic Background Uganda, officially the Republic of Uganda is a country in Eastern Africa. It is bordered in the east by Kenya, Sudan in the north, Tanzania and Rwanda in the south and the Democratic Republic of Congo to the west. It is estimated to have a population size of million 16, which would have been higher if not for the extreme mortality of AIDS. As such, healthy life expectancy in Uganda is only around 50 years. At the end of 2005, UNAIDS estimates that 6.7 percent of adults were living with the HIV virus National Response Uganda, considered one of the world s earliest and best success stories in overcoming HIV, has experienced dramatic declines in prevalence and evidently incidence during the 1990s. According to estimates the number of new infections peaked in the late 1980 s, and then fell sharply until the mid 1990s. This decline is largely due to the unique response of Ugandans to this epidemic, which has evolved from a stereotypical concept of witchcraft and stigmatization to a proactive commitment and a patriotic battle against this deadly disease. The path which has led to the decline in incidence and prevalence in Uganda is complex and not yet completely understood. However, it is apparent that there were some key elements which contributed to the decline namely: high level political commitment, decentralized planning, a multi-sectoral response, community based participation and behaviour change. In 1986, Uganda s new head of state, President Yoweri Museveni responded to the emerging epidemic with unparallel openness. He appealed to Ugandans of all walks of life to view avoidance of contact with HIV as their patriotic duty. In that same year the National AIDS Control Program (ACP) was established, the ACP launched an extremely effective public media campaign which attacked the problem from the grass roots level. This early high level political commitment fostered a multi sectoral response; prioritizing HIV/AIDS and enlisting a cross range of national participants in the war against the devastating disease known locally as slim. The Ministry of Defence established an AIDS control programme in 1987 with subsequent initiates being post-test clubs created in 1990 and the creation of a Network of PLWHA in The Ministry also joined forces with the MoH mobile health clinics both for military personnel and adjacent populations, as well as awareness raising activities. 12 Available on the internet at the Avert website 76

95 In 1992, the Government adopted the Multisectoral Approach to the Control of AIDS, approach which resulted in the formulation and adoption of the National AIDS policy. To complement this approach, the Uganda AIDS Commission (UAC) was established in that same year in the Office of the President and given the responsibility to coordinate the activities of the various partners, coordinate and monitor the national AIDS Strategy and mobilize resources. In 1994, the ACP became the STD /AIDS Control Programme and has since trained a multitude of organizations and individuals consisting of PLWHA also as counsellors, educators and other type of specialists. As of 2001, at least 700 agencies both Governmental and non-governmental were working on HIV/AIDS related activities in the country. President Museveni s political openness to discuss the causes of HIV infection seems to have been a significant factor behind the changes in people s behaviour which allowed prevalence level to decline. Evidence has suggested that Uganda s successful decline in prevalence and incidence is due to the positive response to the ABC approach. The Government responded swiftly, emphasizing simple messages: 1. Increased abstinence; abstaining from sex until marriage and delaying sexual activity by youths. 2. Increased faithfulness to one s spouse, which was hard in a culture which accepted extra marital affairs. 3. The use of condoms, especially among casual partners. The key message was Zero Grazing which instructed people to avoid casual sex. The most significant determinant to the decline in HIV incidence appeared to be faithfulness or partner reduction behaviours by Ugandan men and women, whose reported casual sex encounters declined by well over 50 percent in World Health Organization surveys conducted in 1989 and Treatment and Care The Ministry of Health established the National Committee on Access to ARV Therapy in This was followed by the establishment of the Drug Access Initiative in 1998, which aimed to lobby for reduced drug prices along with providing support for the setting up of the required infrastructure for drug administration. In October 2000, the Joint Clinical Research Centre, an initiative of the MoH the MoD and Makerere University began importing generic ARVs. In the main, care for PLWHAs consists mainly of Home Based Care (HBC). This may be accounted for in part by prevailing conditions of few health care facilities, access barriers to the very ill and the preference to die in one s own bed. This service is provided by mainly FBOs. There is no overt State policy or involvement in Home Based Care and the cost of HBC is financed in the main by external donors. 77

96 4.3.4 Voluntary Counselling and Testing The first African Voluntary Counselling and Testing AIDS Information Centre (AIC) service was launched in Uganda in (USAID 2002) By 1993, AIC was active in four major urban areas as more and more people became interested in knowing their sero-status. AIC pioneered providing same day results using rapid HIV tests, as well as the concept of Post Test Clubs to provide long-term support for behaviour change to anyone who has been tested, regardless of sero-status. Uganda was fairly unique in Africa in the emphasis it placed on VCT, at a time when the Global Program on AIDS and other international organizations were not yet recommending it as a prevention strategy. (USAID 2002) Prevention The Uganda prevention response has in the main focused on behaviour change communication. In the area of blood safety in the late 1980s, the Blood Transfusion Service was upgraded with the ability to screen all blood received. In 1999 the first AIDS vaccine trial in Africa began in Uganda. While in the 1990s there was some initial resistance to promotion of condom use by the President and some religious leaders, by the mid 1990s this opposition had dissipated. In some parts of the country condom use by commercial sex workers has been reported at close to 100 percent and among people reporting a non-regular partner in the past 12 months, 59 percent of men and 38 percent of women reported using a condom with their last non-regular partner. (USAID 2002) It has been postulated in some quarters that the increased level of condom use in the past decade coupled with behaviour change is responsible for the country s success NGOs In 1987, the AIDS Support Organization (TASO) was formed and over the past twenty years has had a strong activist role against stigma and discrimination while breaking new ground in the field of care of PLWHAs through a community-based approach. In Uganda, faith based organizations and non-governmental organizations exert enormous power in the communities. They are at the root of the country s successful combination of ABC strategies. Very early in the epidemic they were mobilized and united to wage war against this disease. Together they were able to target different population groups, empowering them with information which eroded myths, stereotypical thinking and stigmatization. They provided counselling specific to the need of the group for instance; persons who were not sexually active were encouraged to continue abstinence while individuals sexually active were encouraged to use the options of secondary abstinence, zero grazing and consistent, condom usage to reduce their risk of infection. A considerable effort was made to discuss sexually taboo topics honestly and openly to ensure the breaking down of the stigma associated with AIDS. In 2002, awareness was rated at 99.7 percent and knowledge at 78 percent of the general population. (Uganda AIDS Commission Secretariat 2002) This was mainly due to the impact of citizens employing their patriotic duty to support the endeavour. 78

97 Real individuals stepping up and disclosing their status has also been a major factor in the response. Philly Lutaaya; a popular Europe based Ugandan musician announced in 1989 he was HIV positive. Through his music and educational tours he changed the public s perception of the disease whilst motivating others to confront the disease. There have also been other figures like a Major in the Ugandan army and a Protestant minister who both spoke openly about their status and the use of condoms with present spouses to avoid infection. The Behaviour Change Communication (BCC) approach used in Uganda was largely of a low tech word of mouth, community based nature which was fitting to the community based culture of the country. BCC interventions reached not only the general population, but also key target groups including female sex workers and their clients, soldiers, fishermen, longdistance drivers, traders, bar girls, police, and students, without creating a highly stigmatizing climate. Since 1989, teachers have been trained to integrate HIV education and sexual behaviour change messages into curricula. (USAID 2002) FBOs In 1989, a national AIDS education workshop funded by Uganda's NACP and WHO was held by the Islamic Medical Association of Uganda (IMAU). Over 300 Islamic medical practitioners were in attendance. The workshop included a declaration of support from the highest level of Uganda s Muslim community. As a result of the workshop IMAU piloted AIDS education workshops for Muslim religious leaders in various areas. This project was selected as a Best Practices Case Study by UNAIDS. Traditional Healers and Modern Practitioners Together Against AIDS (THETA), launched the Resource Center for Traditional Medicine and AIDS in The Center allows for national, regional and global information exchange and networking. Also, it has issued a newsletter and published videos, training kits and booklets. The Church has also played a role in the AIDS fight in Uganda. The Protestant Church of Uganda executed a workshop for bishops and other religious leaders in 1991, and subsequent to that carried out an AIDS education project in various districts. In the area of care, the Catholic Church and mission hospitals blazed the trail by creating AIDS mobile home care projects and programs targeted at AIDS widows and orphans Lessons Learnt The communication strategies employed should be culturally sensitive. In Uganda, it was realized that to successfully implement meaningful behaviour change they needed to attack the problem at the grass roots level. They relied on non electronic mass communication which led to creative and culturally appropriate interventions which changed behaviour patterns despite extreme levels of household poverty. 79

98 A multifaceted approach should be utilized, as the disease cannot be handled by a sector in isolation. Each sector should employ its strength in a particular mandate, avoiding duplicity and encouraging partnership. The role of faith based organizations, non Governmental agencies and PLWHAs should not be overlooked, as they are in direct contact with communities and can exert enormous influence in a country. It was noted in the Ugandan experience that the people were motivated by their leaders examples to fight against AIDS. Direct interventions to high risk groups were employed in Uganda particularly with regard to marginalised groups such as women and girls. Thus, a specific effort was made to empower women and girls targeting youth in and out of schools. Since at least 1989, HIV education and sexual behaviour was woven into the school curricula. Youth friendly approaches promoted messages such as abstinence, partner reduction and use of condoms. 80

99 4.4 Conclusion A comparison of the experience of the Bahamas, Brazil and Uganda in the fight against HIV/AIDS, shows that though they are diverse in terms of resources available, history, population size and culture, there are common threads which contributed to the success of their national response. These common elements are listed under the headings below according to priority. Strong political leadership In all three cases the State was the lead actor in the response and there was political ownership of the national response at the highest level. In Uganda and Brazil particularly, the national response consisted of early multisectoral involvement which was coordinated into one coherent coordinated response. Appropriate BCC strategies Bahamas, Brazil and Uganda experienced their success in terms of prevention of new infections due to effective communication strategies. In all three cases, simple, culturally appropriate messages were used via the appropriate media. For example, in the case of Uganda given the dispersion of rural villages, word of mouth was found to be the most effective so face-to face communication was used. On the other hand, in The Bahamas and Brazil given the more urban nature of these countries mass media messages were used. Strong civil society presence All three countries experienced strong NGO response in the areas of prevention, treatment and care. In the Ugandan case, NGOs have the primary responsibility for the provision of care. The experience also showed that particularly in Brazil, the potential for well organised NGOs to be viable State partners in the national response as well as to exert strong lobbying power in campaigning for the rights of PLWHAs. In the cases of both Uganda and Brazil there were generally recognisable and popular faces of PLWHAs at the forefront of the fight against the epidemic with whom the general population could readily identify. This helped to reduce discrimination and made the fight against the epidemic resonate with the general public. Comprehensive integrated treatment and care systems Brazil and The Bahamas have seen a fall in AIDS related deaths through a comprehensive integrated care and treatment programme. This decline was facilitated by the establishment of appropriate infrastructure for the execution of treatment and care services along with policy guidelines developed to regulate this system. Targeted intervention to high risk/vulnerable groups In all three cases there were direct and targeted interventions to vulnerable and high risk groups, whether these interventions were focused on girls and women as was the case in Uganda, or CSWs, transvestites and IDUs in Brazil. 81

100 Legislation supporting the rights of PLWHAs Both Brazil and The Bahamas have legislation protecting the rights of PLWHAs. However, The Bahamas has no legislative protection based on sexual orientation and preference. In the Brazil situation, it may be that more comprehensive legislation accounted for the openness and tenacity of PLWHA groups. Monitoring and Evaluation In the area of monitoring and evaluation it should be noted that Brazil is in the lead with its computerised system of indicators MONITORAIDS, which is useful in tracking the epidemic and measuring success and failures. Finally, it should be said that looking at both the challenges faced and the success achieved by all three countries there is a common important lesson learnt: the need for a sustained response supported by a strong multisectoral approach guided by a comprehensive national strategic plan. Once the course of action to fight the epidemic has been adopted and results are being seen, even when the epidemic evolves and new high risk groups emerge or some other on the ground conditions change, it is important to have inbuilt flexibility. This will allow for the incorporation of variability into the response, while at the same time staying the course with regard to what has worked and continues to work. To summarise, the following lessons can be extrapolated to the wider Caribbean: A sustained response supported by a comprehensive national strategic plan is vital. Simple, clear culturally appropriate messages using the correct type of media for maximum impact are essential. There must be a strong network of civil society organisations to partner with the state and to reach at risk groups that the state response cannot. Direct interventions to high risk groups are a necessary part of the response even when such interventions may be controversial. Legislation to support the rights of PLWHAs is essential. Effective Monitoring and Evaluation Systems need to be developed and maintained. Proper infrastructure for administration of ARVs is important. The execution of an integrated and comprehensive treatment and care system is vital There needs to be a face to the epidemic. 82

101 REFERENCES AIDS Policy Research Center University of California San Francisco Country Aids Policy Analysis Project HIV/AIDS in Brazil. August Avert website. HIV/AIDS in Brazil. Avert website. HIV/AIDS in Uganda. CAREC. (2004). Status and Trend Analysis of the Caribbean HIV/AIDS Epidemic Caribbean Epidemiology Centre, Port of Spain. Gomez, P. Dr. (2003.) A Caribbean Success Story. Nineteen Years of National Struggle Against the HIV/AIDS Epidemic: National HIV/AIDS Program, The Bahamas Gomez, P. Dr. (2006.) Overview of the AIDS Epidemic in The Bahamas,. Ministry of Health, The Bahamas. HEU. EU (2006) A Socio-Economic Profile - Draft Report - Evaluation Study of The Bahamas HIV/AIDS Programme, Health Economics Unit, U.W.I. St. Augustine, Trinidad. HIV/AIDS Centre Centre.(2006). HIV) HIV/AIDS. Ministry of Health, The Commonwealth of The Bahamas. Isabela Cabral Felix de sousa, Fundacao Oswaldo Cruz Conceptual and Practical Approaches to HIV/AIDS: the Brazilian Experience. Current Issues in Comparative Education. Levi, Guido Carlos, Vitóra, Marco Antonio A. Fighting against AIDS: the Brazilian experience. AIDS 16: Low Beer Daniel and Stoneburner Rand. (2004). Behavior and communication change in reducing HIV: Is Uganda unique? Centre for AIDS Development Research and Evaluation (CADRE). Ministry of Health The Commonwealth of The Bahamas HIV/AIDS Programme A Model For Success. Ministry of Health, The Bahamas. Ministry of Health Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas Ministry of Health, The Bahamas. Ministry of Health The Good News An Overview of Scaling-Up Achievements, Lessons Learned and Best Practices. Ministry of Health, The Bahamas. 83

102 National HIV/AIDS Centre The Commonwealth of The Bahamas Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS) Country Report. National HIV/AIDS Centre, Ministry of Health, The Bahamas. National HIV/AIDS Centre The Bahamas Roadmap to Scaling Up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support Services 2006 to National HIV/AIDS Centre, Ministry of Health, The Bahamas. Okie, Susan Fighting HIV- lessons from Brazil. The New England Journal of Medicine. 354: May UCSF Country AIDS Policy Analysis Project, HIV /AIDS in Brazil, University of California San Francisco. UCSF UCSF Country AIDS Policy Analysis Project, HIV /AIDS in Uganda, University of California San Francisco. Uganda AIDS Commission Secretariat HIV/AIDS in Uganda: The epidemic and the response. UNAIDS Uganda HIV and AIDS - related Discrimination, Stigmatization and Denial. US Agency for International Development What Happened in Uganda? Declining HIV Prevalence, Behavior Change and the National Response. 84

103 APPENDICES MILESTONES IN THE HIV RESPONSE BAHAMAS, BRAZIL AND UGANDA 85

104 APPENDIX 1 Milestones in the HIV/AIDS Response in The Bahamas 1984 First clinical case of AIDS reported in the Commonwealth of The Bahamas 1984 National AIDS Programme was commissioned Surveillance of HIV/AIDS began with the advent of the ELISA test National AIDS Secretariat established to advise the Ministry of Health on policy issues and mobilized different sectors of the society in the fight against HIV/AIDS 1988 The Samaritan Ministry Initiative is launched 1988 Legislation amended to make HIV infection a notifiable disease A Vertical Transmission Study conducted AIDS Foundation was launched AIDS became the leading cause of death PMTCT Programme was commissioned Education Act revised to entitle all 5 16 year olds to free education and include provisions for children regardless of HIV status The number of AIDS cases peaked Focus on Youth Programme initiated to develop comprehensive life skills within the Ministry of Education s Health and Family Education curriculum National AIDS Strategic Plan (NASP) developed and integrated into the National Health Service Strategic Plan CD4 Testing is implemented Employment Act enacted to protect employees or persons applying for employment from discrimination based on their HIV status. Under this legislation, an employee or applicant cannot be required to submit to an HIV test. 86

105 2000 Triple ARV combination therapy introduced in the protocol for the treatment of all pregnant women and children The National AIDS Strategic Plan (NASP) was updated into The Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas with support from the Clinton Foundation and other international partners The mandate of the National HIV/AIDS Secretariat was enhanced and renamed the National HIV/AIDS Centre and charged with responsibility for national oversight, planning, training, coordination and evaluation for the national response in The Bahamas The Government of The Bahamas negotiated a lower cost of ARV with suppliers after an effective lobby by the Clinton Foundation The Government also committed to providing ART to all eligible persons The country achieved the milestone of no children born with the HIV virus to HIV-infected mothers in the PMTCT Programme The country signed on to the Three Ones Principles approved at the 13 th Annual Conference on AIDS & STIs in Africa September A significant decrease in TB prevalence was recorded after modest increases over the period The country achieved the milestone of 60% of all eligible HIV infected persons (i.e adults, 127 children and 337 antenatal clients) receiving ART Roadmap to Scaling Up Towards Universal Access to HIV Prevention, Treatment, Care and Support Services launched as a precursor to The Strategic Plan for Scaling Up HIV/AIDS Treatment, Care and Support in The Bahamas

106 APPENDIX 11 Milestones in the HIV/AIDS Response in Brazil 1982 Brazil s first AIDS case was reported 1985 Guidelines for The National AIDS Control Programme along with an organizational structure for its management are established by the Ministry of Health through Ordinance# The first Brazilian HIV/AIDS NGO AIDS Prevention and Support Group (GAPA) is set up 1986 Compulsory screening for HIV at all blood banks in São Paulo comes into effect 1986 The Brazilian Interdisciplinary AIDS Association is founded by Herbert de Souza popular figure (former political exile) 1987 The National AIDS Control Committee of Brazil is formed comprised of representatives from the scientific community and organised civil society is established The first case of mother to child transmission is recorded 1988 HIV screening tests become compulsory at all blood banks through Brazil 1988 Medicines for OIs are distributed through the public health system 1988 Lawsuits are filed against the state to force government to provide medication to PLWHAs given that under the 1988 constitution it was declared that the provision of healthcare was a right of all and a duty of the state 1988 Ethical guidelines for the management of HIV/AIDS are developed 1989 Grupo Pela Vidda (GPV)(for the Valorisation, Integration and Dignity of People with AIDS) a non-governmental, not for profit, community based organization is formed to provide support services to PLWHAs is founded by Herbert Eustaquio de Carvalho 1991 The Government announces that AZT will be provided free of charge to all who need it 1991 Project Hope (Projecto Esperanca) is legally constituted in 1991 with the goal of improving the quality of life of PLWHAs. 88

107 1992 The NACP is reorganized with more emphasis on linkages between Government and NGOs 1992 The first sentinel studies are conducted needle exchange programmes were implemented for injecting drug users (IDUs) 1996 The Minister of Health makes a statement that the Government will provide ARVs to all PLWHAs free of charge 1996 Law 9313 is signed which guarantee free universal distribution of antiretrovirals including protease inhibitors through the public health system 1997 The Ministry of Health sets up a network of public laboratories.to provide free CD4 and viral load testing 1997 System for control of Laboratory Exams is established to gather data from public labs and send the information online to the PNDST/AIDS in Brasilia needle exchange programmes are implemented, with 1,500,000 syringes exchanged The mother to child transmission rate falls 3% with the implementation of zidovudine treatment regimes to mother and child and recommendations against breastfeeding Two million female condoms are distributed by the Government 2001 Brazil manufactures locally 8 of the 12 drugs in the national ARV cocktail The first campaign by the Ministry of Health addressing acceptance of male homosexuality was aired on Brazilian TV stations An AIDS prevention campaign targeted toward sex professionals is launched with the heroine of the campaign Maria without shame or Shameless Maria. The slogan of the campaign is: You need have no shame girl. You have a profession and it was aimed at increasing the self esteem and encouraging sex workers to take an active interest in their health 2003 Government distributes an estimated 400 million free condoms A Study is executed out using 322 outpatient services in Brazil, comprising 87,000 patients, finds that the adherence rate for ART is75% 13 Due to public outcry the film was suspended by the National Advertisement Board but in the main it was found that the message of the film was understood by the majority of the population 89

108 2003 The Be in the Know campaign is promoted at one of the largest fashion shows in the nation s capital, with models wearing t-shirts promoting the campaign and the need to get tested The first prevention campaign directed at transvestites was launched 2005 The Government refuses US$40 million funding for its programme given that it would have to make a statement against commercial sex work (which is not illegal in Brazil) which could have implications for its national programme since CSWs programmes are an integrated part of its national HIV response. 90

109 APPENDIX 111 Milestones in the HIV/AIDS Response in Uganda 1982 The first AIDS (slim disease) case was diagnosed Seventeen additional cases of AIDS were reported Slim disease was confirmed as AIDS President Yoweri Museveni reacted to the burgeoning HIV crisis with a hands-on approach embarking on a national face to face tour insisting that Ugandans adopt the ABC approach as their patriotic duty The first National AIDS Control Programme (NACP) is established. The programme s initial approach was grounded in blood safety and public education. The public education component consisted in the main of an aggressive grass roots targeted media campaign TASO a community organisation is formed by volunteers who were all personally affected by HIV/AIDS. The organisation led the way in its use of a community based approach to the care of PLWHAs 1988 The first national survey is conducted and the average HIV prevalence rate is found to be 9% The first AIDS Information Centre is established in Kampala. The centre was set up to provide voluntary counselling and testing services An AIDS education project in rural Muslim communities was conducted by the Islamic Medical Association of Uganda. This approach developed into a wider initiative to train religious leaders and lay community workers and was later selected as a Best Practice by the UNAIDS 1992 Establishment of the Uganda AIDS Commission to coordinate the multisectoral approach to HIV/AIDS Individual AIDS control programmes are set up in different Government ministries such as: Agriculture, Internal Affairs, Justice 1994 The Sexual Transmitted Infections Project is financed through a US$50 million World Bank loan and the pooling of additional Government and donor funding of US$25 million Uganda confirmed initial indications of declining trends in HIV prevalence. 91

110 1997 A study is conducted on the use of antiretroviral drugs and the prevention of mother to child transmission A decline in the prevalence rat to 9.7 percent was noted among pregnant women Arising out of the need for lower price antiretrovirals the Drug Access Initiative is formed to lobby for reduced drugs and to create the necessary infrastructure to facilitate ARV access 1999 A new programme of voluntary door-to-door HIV testing using rapid tests was initiated by the Ministry of Health Uganda's Poverty Eradication Action Plan expands to incorporate HIV issues Uganda s AIDS prevention and treatment programmes get a boost of US$47.5 million from the World Bank over the next five years A report is released by the National Guidance and Empowerment Network, which states that Uganda's HIV prevalence was actually 17% which is more than four times the official rate. Critics have stated that the study s results are flawed but assented that the HIV problem in Uganda may still be much worse than official statistics indicate The United States is accused of promoting the shift of Uganda s HIV policy away from condom promotion to an abstinence only approach. There is a reported severe shortage of condoms in Uganda Experts believe that Uganda s prevalence rate may be rising once again 92

111 APPENDIX 1V Comparative Table of the Milestones in the HIV/AIDS Response Bahamas, Brazil and Uganda Year Bahamas Brazil Uganda 1982 Brazil s first AIDS case was reported The first AIDS ( slim disease ) case is diagnosed There are seventeen more reported cases of slim disease First clinical case of Aids reported in the Commonwealth of The Bahamas. Slim disease was confirmed as AIDS. National AIDS programme was commissioned 1985 Surveillance of HIV/AIDS began with the advent of the ELISA test Guidelines for the National AIDS Control Programme along with an organizational structure for its management are established by the Ministry of Health through ordinance #236 The first Brazilian HIV/AIDS NGO AIDS Prevention and Support Group (GAPA) is set up Compulsory screening for HIV at all blood banks in Sao Paolo comes into effect, The Brazilian Interdisciplinary AIDS association is founded by Herbt de Souza a popular figure ( former political exile) President Yoweri Museveni reacted to the burgeoning HIV crisis with a handson approach embarking on a national face to face tour insisting that Ugandans adopt the ABC approach as their patriotic duty. The first National AIDS Control Programme (NACP) is established. The programme s initial approach was grounded in blood safety and public education. The public education 93

112 Year Bahamas Brazil Uganda component consisted in the main of an aggressive grassroots targeted media campaign The National AIDS Control Committee of Brazil is formed comprised of representatives from the scientific community and organised civil society is established National AIDS Secretariat established to advise the Ministry of Health on policy issues and mobilize different sectors of the society in the fight against HIV/AIDS. The first case of mother to child transmission is recorded. HIV screening tests become compulsory at blood banks through Brazil. Medicines for OIs are distributed through the public health system. TASO a community organization is formed by volunteers who were all personally affected by HIV/AIDS. The organisation led the way in its use of a community based approach to PLWHAs. The first national survey is conducted and the average HIV prevalence rate is found to be 9%. The Samaritan Ministry Initiative is launched. Legislation amended to make HIV infection a notifiable disease. Legislation amended to make HIV infection a notifiable disease Lawsuits are filed against the state to force government to provide medication to PLWHAs given that under the 1988 constitution it was declared that the provision of healthcare was a right of all and a duty of the state. Ethical guidelines for the management of the HIV/AIDS are developed Grupo Pela Vippa (GPA) (for the Valoriuzation, Integration and Dignity of People with AIDS a non governmental, not for profit, community based organization is formed to provide support services to 94

113 Year Bahamas Brazil Uganda PLWHAs is founded by Herbert Eustaquio de Carvalho The first AIDS Information centre is established in Kampala. The Centre was formed to provide voluntary counselling and testing services The government announces that AZT will be provided free of charge to all who need it. An AIDS education project in rural Muslim communities was conducted by the Islamic Medical Association of Uganda. This approach developed into wider initiative to train religious leaders and lay community leaders and was later selected as a best practice by the UNAIDS. Project Hope (Projecto Esperanca) is legally constituted in 1991 with the goal of improving the quality of life with PLWHAs st Vertical Transmission Study conducted. AIDS Foundation was launched AIDS became the leading cause of death. The number of newly reported HIV infections peaked. The NACP is reorganized with more emphasis on linkages between government and NGOs. The first sentinel studies are conducted During the period ( ) 12 needle exchange programmes were implemented for injecting drug users (IDUs) Establishment of the Uganda AIDS Commission to coordinate the multisectoral approach to HIV/AIDS. Individual AIDS control programmes are set up in different government ministries such as: Agriculture, Internal Affairs and Justice The Sexual Transmitted Infections 95

114 Year Bahamas Brazil Uganda Project is financed through a US $50 million World Bank Loan and the pooling of additional government and donor funding of US $25 million PMTCT Programme was commissioned. Uganda confirmed initial indications of declining trends in HIV prevalence Education Act was revised to entitle all 5 The Minister of Health makes a statement 16 year olds to free education and include that the government will provide ARVs to provisions for children regardless of HIV all PLWHAs free of charge. status. Law 9313 is signed which guarantee free universal distribution of antiretrovirals including protease inhibitors through the public health system The number of AIDS cases peaked. The Ministry of Health sets up a network of public laboratories to provide CD4 and viral load testing. A study is conducted on the use of antiretroviral drugs and the prevention of mother to child transmission. System for control of Laboratory Exams is established to gather data from public labs and send the information online to PNDST/ AIDS in Brasilia Focus on Youth Programme initiated to develop comprehensive life skills within the Ministry of Education s Health and Family Education curriculum. AIDS Project I garnered $90 million in domestic funds and a $160 million loan from the World Bank over the period. 12 needle exchange programmes were implemented for injecting drug users A decline in the prevalence rate to 9.7 percent was noted among pregnant women Arising out of the need for lower price antiretrovirals the Drug Access Initiative is formed to lobby for reduced 96

115 Year Bahamas Brazil Uganda (IDUs) over the period drugs and to create the necessary 1999 A new programme of door- to- door HIV testing using rapid tests was initiated by the Ministry of Health National AIDS Strategic Plan (NASP) developed and integrated into the National Health Service Strategic Plan. CD 4 testing is implemented Uganda s Poverty Eradication Action Plan expands to incorporate HIV issues. Employment Act enacted to protect employees or persons applying for employment from discrimination based on their HIV status. Under this legislation, an employee or applicant cannot be required to submit to an HIV test. Triple ARV combination therapy introduced in the protocol for the treatment of all pregnant women and children. 40 needle exchange programmes are implemented with 1, 500, 000 syringes exchanged. The mother to child rate falls to 3% with the implementation of zidovudine treatment regimes to mother and child and recommendations against breastfeeding. 97

116 Year Bahamas Brazil Uganda 2001 The National AIDS Strategic Plan (NASP) was updated into The Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas with support from the Clinton Foundation and other international partners. Over the period two million female condoms are distributed by the Government. Brazil manufactures 8 of the 12 drugs in the national ARV cocktail. Uganda s AIDS prevention and treatment programmes get a boost of US $47.5 million from the World Bank over the next five years. The mandate of the National HIV/AIDS Secretariat was enhanced and renamed the National HIV/AIDS Centre and charged with responsibility for national oversight, planning, training, coordination and evaluation for the national response in The Bahamas The Government of The Bahamas negotiated a lower cost of ARV with suppliers after an effective lobby by the Clinton Foundation. The Government also committed to providing ART to all eligible persons The country achieved the milestone of no children born with the HIV infection to HIV- The first campaign by the Ministry of Health addressing acceptance of male homosexuality was aired on Brazilian TV stations. 9 An AIDS prevention campaign targeted toward sex professionals is launched with the heroine of the campaign Maria without shame or Shameless Maria. The slogan of the campaign is: You need have no shame girl. You have a profession and it was aimed at increasing the self esteem and encouraging sex workers to take an active interest in their health. Government distributed nearly 400 million free condoms. 98

117 Year Bahamas Brazil Uganda infected mothers in the PMTCT Programme. UWIHARP facilitated a CHART Workshop To Be in the Know campaign is promoted at one of the largest fashion shows in the held for Uniformed Officers in The nation s capital, with models wearing t Bahamas shirts promoting the campaign and the need to get tested The country signed on to the Three Ones Principles approved at the 13 th Annual Conference on AIDS & STIs in Africa September A study is executed out using 322 outpatient services in Brazil, comprising 87, 000 patients finds that the adherence rate for Art is 75% 2005 A significant decrease in TB Prevalence was recorded after modest increases over the period The country achieved the milestone of 60% of all eligible HIV infected persons (i.e adults, 127 children and 337 antenatal clients) receiving ART Roadmap to Scaling Up Towards Universal Access to HIV Prevention, Treatment, Care and Support Services launched as a precursor to The Strategic Plan for Scaling Up HIV/AIDS Treatment, Care and Support in The Bahamas The first prevention campaign directed at transvestites was launched. The government refuses US $ 40 million funding for its programme given that it would have to make a statement against commercial sex work (which is not illegal in Brazil) which could have implications for its national programmes since CSWs programmes are an integrated part of its national HIV response. A report is released by the National Guidance and Empowerment Network which states that Uganda s HIV Prevalence was actually 17% which is more than four times the official rate. Critics have stated that the study results are flawed but assented that the HIV problem in Uganda may still be much worse than the figures indicate. The United States is accused of promoting the shift of Uganda s HIV policy away from condom promotion to an abstinence only approach. There is a reported severe shortage of condoms in Uganda. Experts believe that Uganda s prevalence rate may be rising once again. 9 Due to public outcry the film was suspended by the National Advertisement Board but in the main it was found that the message of the film was understood by the majority of the population 99

118 REFERENCES AIDS Policy Research Center University of California San Francisco Country Aids Policy Analysis Project HIV/AIDS in Brazil. August Avert website. HIV/AIDS in Brazil. Avert website. HIV/AIDS in Uganda. CAREC. (2004). Status and Trend Analysis of the Caribbean HIV/AIDS Epidemic Caribbean Epidemiology Centre, Port of Spain. Gomez, P. Dr. (2003.) A Caribbean Success Story. Nineteen Years of National Struggle Against the HIV/AIDS Epidemic: National HIV/AIDS Program, The Bahamas Gomez, P. Dr. (2006.) Overview of the AIDS Epidemic in The Bahamas,. Ministry of Health, The Bahamas. HEU. EU (2006) A Socio-Economic Profile - Draft Report - Evaluation Study of The Bahamas HIV/AIDS Programme, Health Economics Unit, U.W.I. St. Augustine, Trinidad. HIV/AIDS Centre Centre.(2006). HIV) HIV/AIDS. Ministry of Health, The Commonwealth of The Bahamas. Isabela Cabral Felix de sousa, Fundacao Oswaldo Cruz Conceptual and Practical Approaches to HIV/AIDS: the Brazilian Experience. Current Issues in Comparative Education. Levi, Guido Carlos, Vitóra, Marco Antonio A. Fighting against AIDS: the Brazilian experience. AIDS 16: Low Beer Daniel and Stoneburner Rand. (2004). Behavior and communication change in reducing HIV: Is Uganda unique? Centre for AIDS Development Research and Evaluation (CADRE). Ministry of Health The Commonwealth of The Bahamas HIV/AIDS Programme A Model For Success. Ministry of Health, The Bahamas. Ministry of Health Strategic Plan for Scaling Up HIV/AIDS Care and Treatment in The Bahamas Ministry of Health, The Bahamas. Ministry of Health The Good News An Overview of Scaling-Up Achievements, Lessons Learned and Best Practices. Ministry of Health, The Bahamas. 100

119 National HIV/AIDS Centre The Commonwealth of The Bahamas Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS) Country Report. National HIV/AIDS Centre, Ministry of Health, The Bahamas. National HIV/AIDS Centre The Bahamas Roadmap to Scaling Up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support Services 2006 to National HIV/AIDS Centre, Ministry of Health, The Bahamas. Okie, Susan Fighting HIV- lessons from Brazil. The New England Journal of Medicine. 354: May UCSF Country AIDS Policy Analysis Project, HIV /AIDS in Brazil, University of California San Francisco. UCSF UCSF Country AIDS Policy Analysis Project, HIV /AIDS in Uganda, University of California San Francisco. Uganda AIDS Commission Secretariat HIV/AIDS in Uganda: The epidemic and the response. UNAIDS Uganda HIV and AIDS - related Discrimination, Stigmatization and Denial. US Agency for International Development What Happened in Uganda? Declining HIV Prevalence, Behavior Change and the National Response. 101