HIV epidemic in the Caribbean Gonneke Hermanides, MD Izzy Gerstenbluth, MD epidemiologist
Epi (upon) - demos (people) An epidemic occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is "expected, based on recent experience. The Plague of Athens,430-427 BC
A concise history of the HIV epidemic 1981: Emergence of AIDS epidemic in gay men East and West Coast US 1983/84: Discovery of the causative agent: HIV Nobel prize for medicine 2008 goes to AIDS pioneers and cancer researcher L. Montagnier, F. Barre-Sinoussi, professor Harald Many theories about it s origin: Hunter theory - Contaminated Needle theory Oral Polio Vaccine theory - Colonialism theory Conspiracy theory First plasma: Demographic Republic Congo 1959 Origin of HIV: 1884-1929 ¹ (1) Worobey et al. Nature, 2008: 455: p. 661-664
Global HIV epidemic, 1990 2007¹ Number of people living with HIV (millions) 40 % HIV prevalence, adult (15 49) 4.0 30 3.0 20 2.0 10 1.0 0 1990 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 06 2007 0 Number of people living with HIV % HIV prevalence, adult (15 49) http://data.unaids.org/pub/globalreport/2008
Rapid spread of the epidemic? 1. Men having sex with men 2. Poverty 3. Traveling 4. Other 0% 0% 0% 0% A. Men having sex wi.. B. Poverty C. Traveling (goed) D. Other
Highest HIV prevalence in the 1. Haiti region? (14-49) 2. Dominican Republic 3. Jamaica 4. St. Maarten 0% 0% 0% 0% Haiti Dominican Repu... Jamaica St. Maarten
Selected Estimated Adult HIV Prevalences (15-49) Cuba <0.1-0.2 0.2 % Canada 0.2-0.60.6 % Mexico 0.2-0.50.5 % Colombia 0.4-0.80.8 % USA 0.4-1.0 % Brazil 0.5-0.80.8 % Barbados 0.8-1.7 % D.R. 0.9-1.2 % Curaçaoao 1.0-1.71.7 % Trin. & Tobago 1.0-2.1 % Jamaica 1.1-2.1 % Neth. Antilles 1.3-2.1 % Suriname 1.5-4.3 % Haiti 1.9-2.5 % Bahamas 1.9-4.2 % St. Maarten 2.1-3.5 % UNAIDS Global report 2008, data for 2007
Estimate HIV Prevalence Netherlands Antilles by the end 2007/ beginning 2008. Island Registered PLWHA Estimated prevalence HIV Estimated prevalence HIV in 15-49 yrs Curaçao ± 300 0.62 1.05 % 1.03 1.72 % Bonaire 16 0.41 0.69 % * Sint Maarten 177 1.41 2.34 % 2.09 3.48 % Sint Eustatius 5 0.55 0.91 % * Saba 9 1.84 3.07 % * Neth. Ant. ± 500 0.76 1.27 % 1.25 2.09 % *Due to small or unknown numbers not calculated. ** Range prevalence calculated using multiplication factors 3 and 5 for PLWHA. Epidemiology & Research Unit; Medical and Public Health Service Curaçao. *preliminary data for 2008 Gerstenbluth & Lourents, April 2009
HIV prevalence in NL? 1. 0.001% 2. 0.01% 3. 0.1% 4. 1% 0% 0% 0% 0% 0.00% 0.01% 0.1% 1%
10% 1% 0.1%
SXM: Newly diagnosed PLWH per year? 1. 10-30 2. 30-90 3. 90-200 4. >200 0% 0% 0% 0% 10-30 30-90 90-200 >200
Incidence HIV + per 1000 population 2000-2008* 2008* Netherlands Antilles, Curaçao and Sint Maarten *preliminary data for 2008 Gerstenbluth & Lourents, April 2009
Limited data Laboratory based surveillance Confirmation testing Time of transmission unknown
Incidence of known HIV infections by year Netherlands Antilles 1985-2008* 120 100 80 * 60 40 20 46 54 80 78 113 80 71 79 59 67 79 88 84 82 89 65 110 96 102 92 106 83 114 0 9 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 *2008 Bon 1, SXM 23 Cur 90 *preliminary data for 2008 Gerstenbluth & Lourents, April 2009
Neth. Ant Curaçao St. Maarten Linear (Neth. Ant) Linear (Curaçao) Linear (St. Maarten) 1,4 1,2 1 0,8 0,6 0,4 0,2 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 Neth. Ant Curaçao St. Maarten Linear (Neth. Ant) Linear (Curaçao) Linear (St. Maarten) 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Known HIV-infected Netherlands Antilles per agegroup; Netherlands Antilles 1985 2008* 1400 1200 1224 1000 800 600 400 200 0 425 178 49 7 8 35 <1 1-4 5-14 15-24 25-44 45-64 65+ *preliminary data for 2008 Gerstenbluth & Lourents, April 2009
SXM: What behavior is leading the epidemic? 1. Men having Sex with Men (MSM) 2. Prostitutes 3. Answer A +B 4. None of the above 0% 0% 0% 0% Men having Sex... Prostitutes Answer A +B None of the ab...
Heterosexual Heterosexual MSM
A= Abstinence B= Be Faithfull C= Condom use
Last 25 year: Biomedical approach Behavioral changes Structural changes
Casus: What prevention intervention would you recommend a 28 year old single women? What would you recommend to a teenage boy of 15 years old? What kind of prevention intervention would you recommend to a man of 57 years old, in different concurrent relationships?
Effect of prevention interventions + - Sex workers, high Regular, concurrent Condom risk groups partners HIV testing HIV positive HIV negative Treatment STI's (6RCTs) Abstinence Multiple partners Male circumcision Microbicides Vaccines 1 Young people Great imact Men and women 2 (no effect on HIV), 2 (HSV) discouraging Most infection occur during 20's Not effective Not effective Reassessing HIV prevention, Potts et al. Science vol 320, 9 may 2008,
Recently: Infrastructure & Strategics
Highly Active HIV Prevention
Organization - Co-ordination - Collaboration Quality - Reporting - Efficacy
St Maarten
SXM: What kind of HIV 1. Low rate epidemic epidemic? 2. Concentrated epidemic 3. Generalized epidemic 4. Unknown 0% 0% 0% 0% Low rate epide... Concentrated e... Generalized ep... Unknown
Concluding: Epidemiology of SXM (1) Number of PLWH is relatively high HIV incidence unknown, but still growing No detailed data Certain risk behavior Sero-prevalence of HIV in certain subpopulations Data on STDs
Concluding: Epidemiology of SXM (2) Highly Active HIV prevention Community involvement (RED Campaign & AIDS Foundation) Leadership (Public health, RED campaign) Data on populations or behavior most at risk Through ACT RED, GO TEST