REVIEW OF HIV SURVEILLANCE ACTIVITIES IN LATIN AMERICA AND THE CARIBBEAN Surveillance of key affected populations

TXEMA GARCÍA CALLEJA W O R L D H E A LT H O R G A N I Z AT I O N REVIEW PREPARED BY: JERRY O.JACOBSON

OBJECTIVES OF THE REVIEW To assess surveillance systems in LAC by: 1.Identifying types of surveillance activities and kinds of information available to inform understanding of the epidemic 2. Identifying whether plans and sufficient resources are in place for future surveillance in key affected populations

METHODS Data gathered July-Oct, 2012 on 33 countries Desk review:  2010 and 2012 country GARP reports  Available materials cited in those reports

Country survey received from 29/33 countries for information unavailable in GARP:  PAHO and UNAIDS focal points  Surveillance partners, UVG/Tephinet/CDC

Themes based on WHO surveillance evaluation guidelines

THEMES FOR KAP’S 1. The review examined MSM, FSW, DU/IDU and male-tofemale Trans 2. Availability of selected bio-behavioral indicators: •

HIV prevalence & incidence, condom use, HIV testing, exposure to prevention

3. Ability to construct time trends 4. Size estimates 5. Planning and resources for future surveillance rounds

Recent data on MSM available. Except: - VEN, some OECS

Sources of HIV and/or behavioral estimates in KAP's in past 5 years MSM

FSW

DU/IDU

Trans women

Mesoamerica

FSW: - Less availability, especially in Andean & Carib. Trans: - Data from MSM subsamples in CA - Trans-specific studies in Andean - No data in Carib. Multiple sources for MSM, FSW, trans available, particularly in Mesoamerica. DU/IDU: Very limited*

Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community study (IBBSS/BSS)

Facility-based

IBBSS/BSS & facility-based

None

Sources of bio-behavioral indicators for MSM in past 5 years r

ea r

pr e po su re to

n

Mesoamerica

Some studies have estimated HIV testing in past year but not lifetime testing. Some studies have not measured coverage of HIV prevention.

Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community study (IBBSS/BSS)

Facility-based

IBBSS/BSS & facility-based

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Recent HIV prevalence widely available: gaps mainly in Carib.

Ex

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Indicators available for MSM

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Sources of bio-behavioral indicators for FSW in past 5 years

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Larger gaps in other subregions. Prevalence available in:

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Recent data on most indicators available in Mesoamerica.

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Indicators available for FSW

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Mesoamerica Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries

2 of 5 Andean countries 3 of 5 S. Cone 7 of 16 Caribbean Data on lifetime testing and prevention coverage are less available, as in MSM.

Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community study (IBBSS/BSS)

Facility-based

IBBSS/BSS & facility-based

None

Sources of bio-behavioral indicators for Trans women in past 5 years ea r H

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Less recent data available overall.

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Indicators available for Trans

Mesoamerica

Principally from Mesoamerica, Andean and Paraguay High HIV prevalences detected (~30%) Older studies in Argentina with similar findings

Incidence available only in Peru (Lima)

Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community study (IBBSS/BSS)

Facility-based

IBBSS/BSS & facility-based

None

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Sources of bio-behavioral indicators for DU/IDU in past 5 years ea r ti

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HIV prevalences in 2% to 8% range

H

IV

Recent studies in 8 countries.

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Indicators available for DU/IDU

Mesoamerica Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries

IDU in COL Others have tracked DU (crack/cocaine or a combination) Perceived as “irrelevant” to the epidemic in many countries (according to GARP reports).

Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community study (IBBSS/BSS)

Facility-based

IBBSS/BSS & facility-based

None

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ABILITY TO CONSTRUCT TIME TRENDS IN KAP’S

• Tracking trends over time is a principal aim of all surveillance systems.

• The review examined the availability of at least 2 recent “comparable” time points • Typically 3 time points are desired for constructing a trend

HIV prevalence trends (≥ 2 time points)

Ability to construct recent time trends for HIV prevalence in KAP’s MSM

FSW

DU/IDU

Mesoamerica

MSM: 5 countries

FSW: 5 countries DU/IDU: 2 countries Large gaps in all subregions. Some trends only possible using facilitybased data: - MSM in MEX - FSW in MEX, GUA - DU in MEX

Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community studies (IBBSS)

Facility-based

IBBSS & facility-based

None

Behavioral trends (≥ 2 time points)

Ability to construct recent time trends for risk behavior in KAP's MSM

FSW

DU/IDU

Mesoamerica

MSM: 9 countries FSW: 11 countries DU/IDU: 2 countries

Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil

Greater availability in Mesoamerica and Caribbean for MSM and FSW, largely due to BSS studies (e.g., TRaC).

Argentina Brazil Chile Paraguay Uruguay The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. K itts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Community studies (IBBSS/BSS)

Facility-based

IBBSS/BSS & facility-based

None

SIZE ESTIMATES

• Examined availability in past 3 years (2009-2012) • WHO/UNAIDS guidelines suggest updating every 2 years

MSM: 15 countries

Population size estimates in KAP's within the past 3 years

FSW: 12 countries

MSM

FSW

M/C Map M/C M/C

M/C Map M/C M/C

Map M/C M/C HH Net

M/C Map

HH HH M/C M/C

HH HH Map M/C

HH

HH

M/C

M/C

Wis Del Map

Map Map

DU/IDU

Trans

Mesoamerica

DU/IDU: 4 countries

Trans: 3 countries

Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries

Few mapping estimates (the method most useful to inform prevention) Range of methods used impedes ability to conduct cross-country comparisons. Many countries must use international estimates to apply estimation/projection models.

Bolivia Colombia Ecuador Peru Venezuela

Map M/C HH

Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay

ARQ HH

The Caribbean Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. Kitts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago

M/C

Map

PLANNING AND RESOURCES FOR SURVEILLANCE IN KAP’S •

Examined whether plans are currently in place for at least 1 future round of HIV prevalence studies and/or size estimates in MSM and FSW

•

And whether sufficient resources are currently allocated

• The minimum possible measure: does not reflect longterm sustainability

Planning and resources for a future HIV prevalence estimate Most countries do not have plans and sufficient resources in place.

Plans less common for FSW.

Planning for future HIV bio-behavioral surveillance in KAP's MSM

FSW

Mesoamerica Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil Argentina Brazil Chile Paraguay Uruguay The Caribbean

No data on several countries: MSM: 6 / 33 FSW: 6 / 33

Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. K itts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Plan in place Plan in place and sufficient resources allocated

No plan in place

Planning and resources for a future size estimate

Fewer countries have plans and resources in place for size estimates.

Planning for future population size estimates in KAP's MSM

FSW

Mesoamerica Mexico Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone & Brazil

Plans less common for FSW.

Argentina Brazil Chile Paraguay Uruguay The Caribbean

No data on several countries: MSM: 6 / 33 FSW: 7 / 33

Antigua & Barbuda Bahamas Barbados Belize Cuba Dominica Dom. Republic Grenada Guyana Haiti Jamaica St. K itts & Nevis St. V incent & Gren. St. Lucia Suriname Trinidad & Tobago Plan in place Plan in place and sufficient resources allocated

No plan in place

KEY FINDINGS: KAP’S Strengths

• Recent bio-behavioral data on MSM throughout LAC • Recent bio-behavioral data on FSW available, with exception of Andean sub-region • Recent studies in trans have revealed a higher risk group. • A small number of studies in DU have documented high prevalences beyond the IDU subgroup. • Time trends for MSM and FSW available in a small number of countries • Size estimates available for MSM and FSW in all sub-regions

KEY FINDINGS: KAP’S Areas for improvement

Limited recent data on FSW in Andean, trans in Caribbean Very limited ability to produce time trends: a need to focus on consistency in methods over time and sustainability. Current situation in DU/IDU largely unknown, no hard data to justify exclusion from surveillance efforts Several countries without size estimates, particularly in DU and trans; limited consistency in methods across countries Regular planning processes and resource allocation for KAP’s a challenge: Sustainability? Impact on ability to construct trends?

Special thanks to

• PAHO sub-regional offices and focal points • UNAIDS LA and Caribbean regional offices • UNAIDS Peru • Universidad del Valle de Guatemala • Tephinet • CDC