The HIV/AIDS epidemic in Latin America and the Caribbean poses serious developmental challenges for the region and is currently affecting more than one million people. The number of individuals newly infected each year is estimated to be between 100,000 and 420,000, and nearly 80,000 people die of AIDS-related illnesses each year.
Worldwide, the Caribbean is second only to sub-Saharan Africa in terms of HIV infection rates. Haiti — the poorest country in the region — also has the highest prevalence at more than 3.5 percent. The countries most affected by the epidemic include Suriname, Guyana, Belize and the Dominican Republic. The scale of the epidemic and the effect of these high infection rates on small island nations in particular pose a serious and destabilizing threat to the economies of these countries.
In the Caribbean, the epidemic is concentrated mainly among socially marginalized populations, with sexual transmission being the primary means of infection. The exception is Bermuda, where a significant number of new cases are attributed to injecting drug use, with a rate of infection of 3.3 percent. The stages of the epidemic vary from nation to nation. Unequal socio- economic development, poor health care and high population mobility are among the factors helping to drive the spread of HIV in the Caribbean. A common cultural trend also contributing to the epidemic is for younger women to have sexual relationships with older, HIV-infected men. On some islands, the HIV rate among girls aged 15 to 16 years is up to five times that of boys in the same age group.
In Central America, Honduras is the country hardest hit by the epidemic, reporting 60 percent of the region’s cases, even though it only represents 17 percent of the population (Belize, which has similar or higher incidence rates, is considered part of the Caribbean rather than Central America). As in several Caribbean islands, sex tourism is a growing trend contributing to the epidemic in Central American countries such as Costa Rica.
The HIV/AIDS epidemic in South America tends to be characterized by a low national prevalence with particularly high incidence rates among vulnerable populations. In some cities in Brazil, for example, up to 60 percent of injecting drug users have tested positive for HIV, while in Argentina the numbers can be as high as 50 percent. Across the region, men who have sex with men also show high prevalence rates. Targeted efforts financed through Global Fund grants are implementing prevention and behavior change communication campaigns to educate vulnerable populations, reduce stigma and improve respect of human rights of people living with HIV and include such initiatives as campaigns to demystify condom use.
The TB burden in the Americas is concentrated in ten countries in Latin America: Haiti, the Dominican Republic, Mexico, Honduras, Ecuador, Bolivia, Brazil, Nicaragua and Peru. The combined estimated number of cases in these countries in 2005 was more than 220,000, of which men constituted 58 percent. The impact of HIV and multidrug resistance on TB control has been enormous. The prevalence of TB/HIV co-infection is generalized in Haiti, Guyana, Honduras and Panama. Multidrug-resistant TB is highest in the Dominican Republic with 6 percent, Ecuador with 5 percent and Guatemala and Peru with 3 percent.1
Treatment drop-out rates contribute to the high prevalence of multidrug-resistant TB in the Americas. But community-based programs have been effective in increasing treatment adherence even in poor settings, as has been demonstrated by a number of studies carried out in the region.
DOTS — the internationally recommended strategy for treating TB — is at the heart of international programs led by the Stop TB Partnership to control the epidemic, and efforts are underway in the region to increase DOTS access in rural and remote areas and among vulnerable populations.
Several of the Global Fund’s TB grants focus on increas- ing detection rates for new smear-positive cases and increaing success rates for treatment as well as DOTS- Plus for multidrug-resistant TB. Global Fund-financed strategies include decentralization of health care services via the creation or strengthening of diagnosis and treatment services in regional and isolated communities.
Currently, Global Fund grants support TB programs in Bolivia, Brazil, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay and Peru.
In Latin America, approximately 40 percent of the population lives in at-risk areas for malaria transmission. Plasmodium vivax (P. vivax), the least deadly strain, is the one most commonly found in Latin America, although there are high incidence rates and prevalence of the more deadly Plasmodium falciparum (P. falciparum) in rainforest regions. Malaria transmission is a public health problem in the eight South American countries that share the Amazon rainforest: Bolivia, Brazil, Colombia, Ecuador, Guyana, Peru, Suriname and Venezuela (along with French Guiana, which is a department of France). Malaria is also present in Central America, including Mexico and the island of Hispaniola, where Haiti and the Dominican Republic are located. In the Dominican Republic, a serious epidemic was contained with the help of the Global Fund, which also supports the Haitian government in implementing strategies to fight malaria.
One of the countries with a high incidence of P. falciparum is Colombia. Treatment and prevention in malaria-endemic zones have been hampered by violence in the region. In 1996, a malaria epidemic was declared in Ecuador with 11,000 cases; five years later, the number of cases had increased by a factor of nine to a record 106,000. Malaria cases have since diminished through concerted government efforts. In Peru, malaria threatens about 2.5 million people that live in at-risk areas, while in Brazil and Suriname high population movement across borders resulted in an epidemic in 2003.
Several countries employ insecticide-treated bed nets as part of their national malaria control strategy. The Global Fund is supporting efforts to widen net distribution to encompass poor and vulnerable popula- tions living in remote areas. These efforts have met with some success, especially in countries such as Suri- name, where native populations have contributed to the design and treatment of the bed nets.
Vector control by indoor residual spraying and larviciding in focal areas form part of the national malaria control strategy in most countries. Additional strategies include the integration of the national program with local health services to promote community participation in malaria control.
Drug resistance of P. falciparum to chloroquine has been documented in 80 percent of cases, while resistance to several other drugs has also been documented or suspected in 20 percent of cases. In South America, Bolivia, Colombia, Ecuador, Guyana, Peru, Suriname and Venezuela are changing national drug policies and now use artemisinin-based combination therapy (ACT) for the treatment of falciparum malaria.