HIV/AIDS in Latin America and the Caribbean

More than 2 million people are now living with HIV in Latin America and the Caribbean, including the estimated 250,000 that contracted HIV in the past year. At least 120,000 people died of AIDS in the same period - the highest regional death toll after sub-Saharan Africa and Asia.

Diverse epidemics

HIV is well-entrenched in this region, with national HIV prevalence at least 1% in 12 countries, all of them in the Caribbean Basin. The most recent national estimates showed HIV prevalence among pregnant women reaching or exceeding 2% in six of them: the Bahamas, Belize, the Dominican Republic, Guyana, Haiti, and Trinidad and Tobago. In contrast, most of the other countries of the region have highly concentrated epidemics, notably in South America where Brazil (with by far the largest overall population in the entire region) is home to the vast majority of people living with HIV in the region.

Distinctive epidemiological patterns are being observed in the region. All the main modes of transmission coexist in most countries amid significant levels of risky behaviour - such as early sexual debut, unprotected sex with multiple partners and the use of unclean drug-injecting equipment.

The Caribbean

In the Caribbean, heterosexual transmission predominates (and, in many cases, is associated with commercial sex), although Haiti’s persistently serious epidemic is now well-established in the wider population. One notable exception is Puerto Rico, where injecting drug use appears to be the main driver of the epidemic.

Two of the region’s most serious epidemics are on Hispaniola Island - in Haiti and the Dominican Republic. Stricken with the lowest health and other development indicators in the entire region, Haitians’ woes are being aggravated dramatically by the AIDS epidemic, which is claiming an estimated 30,000 lives a year and has left some 200,000 children orphaned by AIDS. Haiti’s national HIV prevalence levels have remained at 5-6% since the late 1980s. The factors contributing to this apparent levelling off of national HIV prevalence are unclear, although it must be noted that sentinel surveillance has shown that HIV prevalence levels vary dramatically (from as high as 13% in the north-west to 2-3% in the south along the border with the Dominican Republic).

Further east, in the Dominican Republic, prevention efforts in recent years appear to have stabilized HIV prevalence among 15-24-year-olds in the capital of Santo Domingo. Having climbed to 3% in 1995, HIV prevalence among pregnant women in that age group in the capital has fallen to less than 1%. Increased condom use and fewer sexual partners appear to have been factors. However, the situation appears different in some other cities, where HIV prevalence as high as 12% has been measured among female sex workers, pointing to the need to expand and sustain prevention efforts. In addition, little is known about HIV patterns among men who have sex with men - a potentially important facet of the country’s epidemic.

Latin America

In the bulk of the South American countries, HIV is being transmitted chiefly through injecting drug use and sex between men (with subsequent heterosexual transmission to other sexual partners), while in Central America most HIV infections appear to be occurring through sexual transmission (both heterosexual and between men).

In Central America, national HIV prevalence is around 1% in Guatemala, Honduras and Panama. New data from an international study on HIV prevalence show that HIV prevalence in sex workers varies significantly - from less than 1% in Nicaragua to over 10% in Honduras. HIV prevalence among men who have sex with men was found to be uniformly high in several Central American countries - ranging from 9% in Nicaragua to 18% in El Salvador.

In Colombia and Peru, HIV spread is most marked among men who have sex with men. HIV prevalence of 18% was recently reported in this population group in Bogotá, while another survey in the same city found very low consistent condom use in this group. Highlighted is the considerable potential for HIV transmission from men who have sex with men to their female partners, and children. Studies from Peru are bearing out this concern. HIV prevalence of 22% has been measured in the city of Lima among men who have sex with men (up from 18% in 1998), where 1 in 10 men surveyed said they had sex with other men.

Although Brazil’s epidemic has spread from the major urban centres to smaller municipalities across most of the country, median HIV prevalence of pregnant women attending antenatal clinics has remained below 1%, with little variation over the past five years. At least in part, this is a testament to the prevention programmes mounted since the 1990s, including efforts to extend coverage of harm reduction and other prevention programmes among vulnerable groups (and, in addition, an active and successful programme to treat persons with HIV).

However, Brazil cannot rest on its laurels. HIV prevalence rates of 3-6% have been measured in Rio Grande do Sul among women who enjoy only rare access to the public health system. This has raised fears that serious epidemics might be under way but undetected in some disenfranchised communities.