Consolidated Regional Analysis of the UNGASS Reports Presented by 17 Latin American Countries in 2010

Transcription

1 Consolidated Regional Analysis of the UNGASS Reports Presented by 17 Latin American Countries in 2010 Joint United Nations Programme on HIV/AIDS Regional Support Team for Latin America June 2011

2 Authors: this document was prepared by Arachu Castro with contributions from HTCG and LACASSO General Coordination: Marjolein Jacobs Technical Review: Monica Alonso Omar Sued Claudia Velasquez Patricia Bracamonte Patricia Rivera Gabriela de la Iglesia Marjolein Jacobs Paloma Cuchi Andrea Boccardi Victoria Bendaud Hege Wagan Alicia Sánchez César Núñez Luisa Frescura Karen Stanecki David Pettigrove Verónica Pereyra Analysis of Indicator 1: Victoria Bendaud Translation: Rolando Ng Translation edition: Marjolein Jacobs and Victoria bendaud 2

3 Index Preface... 5 Executive Summary... 7 Acknowledgments Abbreviations and Acronyms Introduction UNGASS Indicators 17 The process of preparing the UNGASS reports 18 Tools to model the HIV epidemic and the spending on AIDS 19 Training in Monitoring and Evaluation.19 Harmonization of the HIV component in population surveys.20 Critical paths for preparation of the UNGASS reports.20 Participation of institutional and social sectors..20 UNGASS country reports 20 The HIV epidemic in Latin America Achievements and challenges in the response to HIV Commitments regarding blood safety (Indicator 3) 33 Commitments regarding access to antiretroviral therapy (Indicators 4, 6, 7 and 24) 34 Commitments regarding prevention of mother to child transmission of HIV (Indicators 5 and 25) 43 Commitments regarding support and education in boys, girls and adolescents affected by HIV and regarding information about HIV prevention in schools (Indicators 10, 11 and 12) 50 Commitments regarding prevention of sexual transmission of HIV in adolescent and adult populations (Indicators 13, 15, 16 and 17) 52 Commitments regarding HIV prevention in male and female sex workers (Indicators 8a, 9a, 14a and 18) 57 Commitments regarding HIV prevention in men who have sex with men (Indicators 8b, 9b, 14b and 19) 60 Commitments on HIV prevention in persons who use injecting drugs (Indicators 8c, 9c, 14c, 20 and 21) 66 National Commitment Commitments regarding financing of national AIDS responses (Indicator 1) 69 Commitments regarding national policy (Indicator 2) 78 Conclusions and recommendations for programs and public policies Appendix 1: Report presented by the Latin American and Caribbean Horizontal Technical Cooperation Group in HIV/AIDS Analysis of the strategic response by means of a review of National Strategic Plans (NSP) and UNGASS 2010 reports in thirteen Latin American Countries 88 Analysis of basic juridical, legal and political aspects of the NSP..88 Analysis of the drafting, monitoring and evaluation of the NSP 90 General characterization of the vision, mission, and general and specific goals of the NSPs.90 A descriptive characterization of the epidemic in NSP 91 Characterization of the prevention programs in NSP..92 Progress perceived in the implementation of HIV prevention programs as per UNGASS 2010 reports..92 Problems pending resolution in the efforts made to implement HIV prevention programs in Characterization of the treatment programs..92 3

4 Progress perceived in the implementation of the treatment, care and support services related to HIV Problems to be resolved in the implementation of treatment, care and support services related to HIV Analysis of indicators that are not measured in the UNGASS reports for Latin America HIV screening and counseling services 93 HIV Expenditures 95 Conclusions 99 Recommendations 100 Appendix 2: Quality and participation of civil society organizations in the process of drafting the UNGASS 2010 Reports for Latin America: An analysis of the experience in nine countries Inserting civil society into the development of a national response to HIV and AIDS 106 Constructing the 2010 Country Report 107 Participation of the actors..109 Civil Society s contribution..109 Final considerations 111 Differences and similarities between 2008 and Establishment of new alliances 111 Feedback from civil society organizations 111 Training of the organizations for UNGASS monitoring 112 Gaps and deficiencies with regard to coordination with civil society 112 Recommendations 113 References Index of graphs Index of tables

5 Preface This Consolidated Regional Analysis of the UNGASS Reports Presented by 17 Latin American Countries in 2010 is the first regional analysis of UNGASS reports produced by the UNAIDS Regional Support Team for Latin America. The analysis provides strategic information for national and regional responses regarding progress being made by Latin American countries and the region. Noting achievements and challenges will help decision makers define the actions to be taken on matters of similar interest and concern, with the objective to reach Universal Access to HIV prevention, treatment, care and support as well as the Millennium Development Goals. Since it will be one of the background documents for the Regional Consultation on Universal Access in Latin America (Mexico City, March 1 and 2, 2011), this report will contribute to the analysis and the recommendations that will be presented at the UNGASS High Level Meeting (New York, June 2011), during which it is expected that the UN member states will renew their commitments to the HIV response. This report represents more than just a compendium of statistics. It aims at reflecting the efforts, concerns, joys and commitments of everyone involved: individuals as well as groups; community groups and public institutions; and academic, private, local and international organizations all of which, over the past thirty years, have struggled to obtain the right to a healthy and dignified life for people living with HIV. Likewise, it introduces a few of the many activists in the efforts against HIV in Latin America; it is essential to bear in mind the efforts of these men, women, and youths who live with HIV, who love life, and who, day by day, renew their commitment to achieving Universal Access. Dr. Cesar Antonio Núñez Regional Director Joint United Nations Programme on HIV/AIDS UNAIDS Latin America 5

6 Jaime s passion is his family. Together, they enjoy going to the mountains or to the ocean, or just driving around without a set destination. Jaime is also passionate about reading and adores the novels of Gabriel García Márquez. A fanatic of bands like AC/DC, he also enjoys listening to classic rock and heavy metal. Jaime is 46 years old and has been living with HIV for 13 years. When he received his diagnosis, he was married, had two daughters, and was working as an agricultural engineer at a company. He immediately lost his job, suffered a financial crisis, separated from his wife, and had to start all over again. Jaime says that he is alive today thanks to the care provided by his sister and recognizes that he had to make huge efforts to overcome his most difficult moments. On this road, he realized that many other people were in the same situation and so his efforts turned into a collective effort. Today, in addition to being the founding president of the National Association of HIV-Positive Persons of El Salvador, Jaime has been appointed the first Chief of the recently created Human Rights and HIV Department of the Office of the Attorney for the Defense of Human Rights of El Salvador. In the family aspect, the situation has also improved considerably: his eldest daughter made him a grandfather in May of this year. Due to the difficult bouts with illness that he has had throughout the years, this is a joy that he had not expected to experience. At present, Jaime fell in love again and had another daughter. Today he feels fulfilled and in the prime of life. His work as an HIV/AIDS activist is another one of his passions, and he dedicates most of his day to these endeavors. Jaime has goals and projects and is not afraid of death, even though he admits that living with HIV is not always easy. 6

7 Executive Summary HIV Prevalence The prevalence of HIV in the adult population of Latin America is estimated at 0.4%, but in the groups that are more exposed to HIV (trans population, men who have sex with men, male and female sex workers, and people who inject drugs) for whom there is data, prevalence is considerably higher. Up to 34% of the trans population is reported to be living with HIV. Among men who have sex with men, HIV prevalence can be as high as 20,3%, and is above 5% in all the countries of the region. Among sex workers, HIV prevalence in Latin American countries can be as high as 4,9% reported by Brazil, but for male sex workers HIV prevalence in the countries that report data can reach 22,8%. In persons who inject drugs, HIV prevalence is higher than 5%. Blood safety Twelve of the sixteen Latin American countries that report data offer 100% systematic screening of blood donations following quality assurance criteria. One country did not report data and in Peru, Guatemala, Bolivia and Honduras less than 100% of the blood donated is analyzed to detect HIV with quality assurance criteria; the percentages reported in these four countries vary between 50 and 90%. Access to antiretroviral therapy According to demographic surveys, in Latin America the percentage of men and women between 15 and 49 years of age who responded that they took an HIV test in the past 12 months and are aware of their serological status continues to be low, with values between 4% and 30%. The percentage is higher among women (ranging between 1% and 66%) than among men (ranging between 1% and 39%). In women as well as in men, individuals 20 years or older are the ones who admit most to having taken an HIV test during the past 12 months and knowing the results. Antiretroviral therapy (ART) coverage based on WHO 2010 guidelines show a large variability in Latin America. If one were to take as a denominator the estimated number of persons with advanced HIV infection who need antiretroviral therapy according to the WHO 2010 guidelines, the regional average is 51% (45 61%), above the average coverage of all the regions with middle and low income countries, which was estimated at 36% in If one considers persons with advanced HIV infection who need to receive ART according to the information provided by health services, the percentage is above 70% in half of the countries of Latin America (9 out of 17 countries). The large difference that exists in the percentage of persons receiving treatment between the estimated population and the population reported by health services could be linked to the estimation methods, the low percentage of people living with HIV who have taken the test and know the result, and barriers to access HIV treatment services. More than 80% of the Latin American child and adult population continue on treatment 12 months after initiating ART. In the countries that report data, the difference in the percentage of retention on ART between men and women is small. The percentage of retention on ART in these countries is not related to estimated treatment coverage since retention is high regardless of coverage, which suggests that the obstacles to obtaining 7

8 access to treatment are greater to initiate treatment than to continue it. This relatively high retention rate strengthens the idea that greater effort is being made to follow up on the persons who are receiving treatment than to draw in people living with HIV who are unaware of their diagnosis. With regard to the handling of HIV tuberculosis co infection, only in Costa Rica, Argentina, Mexico, Nicaragua and Peru more than 70% receive treatment for the two infections. Prevention of mother to child transmission of HIV During the period, the majority of Latin American countries experienced an increase of HIV screening in pregnant women (11 of the 15 countries that reported data). Five countries of the region reported that in 2009 more than 80% of pregnant women took an HIV test (Ecuador, Peru, Uruguay, Argentina and Panama), which represents an increase compared to 2008, year in which only two countries (Argentina and Costa Rica) reported at least such a percentage. Five countries reported that between 50% and 80% of pregnant women had an HIV test in 2009, while in five other countries (Guatemala, Bolivia, Mexico, Colombia and Paraguay) less than 50% of pregnant women had an HIV test in No data was reported for Venezuela. In six countries of Latin America (Nicaragua, Chile, Uruguay, Argentina, Ecuador and Costa Rica) antiretroviral therapy is offered to 80% or more of pregnant women diagnosed with HIV who go to health care centers. In Venezuela, Guatemala, Mexico, Bolivia, Honduras, Colombia and Paraguay, less than 50% of pregnant women diagnosed with HIV who go to health care centers receive antiretroviral therapy. The regional average is estimated at 53% (37 81%), which is equal to the global average for low and middleincome countries. No country reported data disaggregated by the type of antiretroviral therapy regimen provided to pregnant women. In Latin America, care and follow up of newborns exposed to HIV is limited. In this population group, only six countries (Nicaragua, Panama, Ecuador, Argentina, Brazil and Paraguay) reported ART coverage above 50%. With regard to prevention of opportunistic infections through the use of cotrimoxazol, of the eight countries that reported data, only in Argentina and Nicaragua cotrimoxazol is administered to more than 50%. Of the 7 countries that reported data regarding virological tests, only in Nicaragua these tests are performed on more than 50% of the newborns exposed to HIV. In Latin America the percentage of mother to child transmission is very high since the majority of countries have a transmission rate way above the 2% or less that could be achieved if the 2010 WHO recommendations were applied. However, the measurement instruments and methods used to calculate mother to child transmission of HIV still vary greatly from one country to another. According to the method used to calculate the indicator using statistical estimates or based on epidemiological surveillance data the transmission rate can vary within the same country. What the indicator shows is that, in Latin America, when pregnant women with HIV receive timely diagnosis and treatment to reduce the risk of mother to child transmission, the transmission rate can be reduced to less than 2%. Support and schooling of boys, girls and adolescents affected by HIV and information about HIV prevention in schools 8

9 There is scarce data regarding the percentage of orphaned and vulnerable boys and girls whose households receive basic and free external support for care of the boy or girl, or of school attendance of orphaned and non orphaned children between 10 and 14 years of age. Only five Latin American countries (Costa Rica, Venezuela, El Salvador, Uruguay and Nicaragua) provided at least 30 hours of education regarding HIV in more than 80% of public and private schools during the most recent school year. Six countries (Bolivia, Chile, Colombia, Panama, Paraguay and Peru) did not report any data. Prevention of sexual transmission of HIV In the majority of countries with available data (7 out of 11 countries), less than 50% of the population of men and women between 15 and 24 years of age know how to prevent sexual transmission of HIV and reject major misconceptions about HIV transmission. In all age groups, condom use during the most recent sexual encounter among persons who reported having sex with more than one partner over the past 12 months tended to be higher among men than among women. In the countries that reported data, men start having sexual relations earlier than 15 years of age more frequently than women. The percentage of young men and women between 15 and 24 who report having had their first sexual encounter before the age of 15 ranges from 4% in Mexico to 35% in Brazil. Sexual relations among persons between 15 and 49 years of age with more than one partner in the past 12 months was more frequent in men than in women and among persons between 20 and 24 years of age than in persons younger or older than this age group. HIV prevention among most exposed groups The majority of Latin American countries report more data regarding HIV prevention among female sex workers than among male sex workers. In the majority of countries that report data (7 out of 10 countries), more than 50% of female sex workers have taken an HIV test and know the result. According to the studies carried out, the percentage of female sex workers who have had access to prevention programs ranges from 21% to 93%. The percentage of female sex workers who know how to prevent sexual transmission of HIV and reject major misconceptions regarding HIV transmission is below 50% in seven of the eight countries that provided data (Guatemala, Honduras, Bolivia, Colombia, Peru, Brazil and Paraguay), except for Panama, where it is 92%. In practically all countries, condom use by female sex workers is surprisingly higher than the percentage of female sex workers who have been reached by prevention programs and to the number who know how to prevent the sexual transmission of HIV and reject major misconceptions about HIV transmission. The use of a condom with the most recent client is higher than 65% in the 10 countries that reported data for female sex workers (El Salvador, Guatemala, Honduras, Mexico, Panama, Bolivia, Colombia, Ecuador, Argentina and Brazil) and higher than 75% in three (Guatemala, Honduras and Uruguay) of the five countries that report data for male sex workers. Latin America has made considerable efforts to characterize the epidemic in men who have sex with men. Of the groups most exposed to HIV, the population of men who have sex with men is the one that has been studied the most in Latin America. Several 9

10 countries actually reported data for the four indicators for the first time in 2009, which could indicate a greater emphasis being placed on the need to have strategic information on one of the population groups most exposed to HIV. In more than half of the countries that reported data, more than 50% of men who have sex with men and who have undergone an HIV test know the results, have been reached by prevention programs, know how to prevent HIV transmission and reject the main erroneous ideas about HIV transmission. The use of condoms is almost equal to or above 50% in all of the countries that report data (a range of 47% to 86%). In view of the fact that in Latin America HIV transmission is predominantly sexual, the majority of countries do not report data for the indicators related to injecting drug use since they consider them irrelevant to their HIV epidemic. Nevertheless, in the four countries for which some data exists, a limited percentage of people who use injecting drugs took an HIV test and know the results (range 13% to 32%), are not reached by prevention programs (range 20% to 40%), do not know how to prevent HIV transmission and do not reject major misconceptions about HIV transmission (range 30% to 32%), and usually do not use a condom (average of 46%). Nevertheless, of the four countries that reported data, an average of 66% report having used sterile injecting equipment the last time they injected drugs. Financing of national AIDS responses The availability of economic resources in the countries is dissimilar and with very large variations among them. According to NASA reports, there is greater availability of resources in South America than in Central America. Funds are mainly directed to treatment and to a lesser degree for prevention. Although access to treatment is one of the most significant achievements of the region, it is necessary to find sustainable financing mechanisms with increasing commitment from governments to contribute that will allow a reduction of the degree of dependence on external cooperation. In the majority of Latin American countries there is an upward trend in total investment for the response to the epidemic between 2007 and On average, 95% of the total investment in AIDS in the region was financed by domestic sources (public and private) and an average of 79.5% was financed by public sources. Nevertheless, sustainability of the response over the medium and long terms might be at risk due to the fact that, in general, public investment has shown a downward trend which increases the percentage of investment financed by private sources, while international investment remained stable at 4.5% of total investment in HIV and AIDS. Private expenses include social security administered by profit seeking private institutions, profit seeking institutions and household expenditures. In 2008, 47.6% of investment from international sources came from the Global Fund. Between 2007 and 2009 the main spending category was care and treatment, followed by prevention. In 2008, investment in care and treatment corresponded to an average of 49% of investment. Investment in prevention was an average of 27.9% in the countries in the region. In 2007, almost the total of investment in care and treatment of AIDS came from public sources, while between 2007 and 2009 the percentage of public investment decreased and private investment increased. International investment remained stable between 2007 and In 2009, financing of prevention by public 10

11 sources was situated at 53% of the total investment in prevention, and it was reported that 36% of investment in prevention came from private sources. Only three countries, Colombia, Peru and Venezuela, reported investments disaggregated by prevention sub categories for the three years from 2007 to One can notice an increase in the total investment in prevention aimed at populations of men who have sex with men and female sex workers, which corresponds to a maximum of 3.1% of total spending on prevention in Colombia and Venezuela, while in Peru 14.2% is for prevention in men who have sex with men and 22.8% for prevention in female sex workers. Strengthening health care and health information systems In order to respond to HIV, it is necessary to strengthen health systems and to integrate HIV care into primary healthcare services. This will promote improved coordination of healthcare to people living with HIV and increased effectiveness of resources invested in healthcare. It is necessary to strengthen the availability of timely strategic information on HIV in Latin America to contribute to the development of public policies that correspond to the epidemiological profile of HIV. Priority health information topics required to enhance the impact of public policies include: continually carrying out studies to estimate and project the prevalence of HIV in the population groups most exposed to HIV; to carefully obtain and analyze information to respond to the dynamics of the epidemic in each key community; to estimate the size of key populations in each country; to strengthen systematic epidemiological surveillance; develop modes of transmission exercises; and improve data systems to construct indicators on prevention, treatment coverage and retention, treatment of HIV TB co infection, follow up of boys and girls exposed to HIV, and on the monitoring of prevention interventions. One of the challenges is ensuring that this information is gathered homogenously and consistently so that valid data analysis can be performed. Articulation between the governments and civil society organizations Strengthening a single multi sector authority will help to increase active and effective participation by civil society organizations in planning, budgeting, monitoring and evaluation processes in Latin America. It is essential for civil society organizations to be technically and politically prepared to carry out activities involving monitoring of public policies, social control and political incidence. The existence in the region of civil society organizations with vast knowledge in the area of HIV that carry out activities to monitor UNGASS goals is recognized. This experience must be expanded to more civil society groups in all countries. Likewise, it is essential that technical staff of the National AIDS Programmes gain greater familiarity with UNGASS goals and that this knowledge be passed on to the persons responsible for AIDS policies in municipalities. It is recommendable to generate spaces for the review of policies and norms that will allow the development of prevention and control activities, taking into account respect for human rights and promoting a reduction of stigma and discrimination, as well as establish political and technical spaces to monitor compliance with policies and norms. Strengthening spaces for the exchange of information and analysis will favor horizontal cooperation between countries. 11

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13 Acknowledgments Data analysis and drafting of the report was carried out by Arachu Castro, who worked in collaboration with several UNAIDS staff members: Marjolein Jacobs, Claudia Velasquez, Andrea Boccardi, Victoria Bendaud, Patricia Bracamonte, Patricia Rivera and Gabriela de la Iglesia. Hege Wagan, Mary Ann Seday, Alicia Sánchez, César Núñez, Luisa Frescura, Karen Stanecki, Paloma Cuchí and Peter Ghys contributed to the review of the report. The Pan American Health Organization (PAHO) also contributed comments. Deborah Rugg and Eva Kiwango were in charge of leading UNGASS training in the region. PAHO, UNICEF and CDC collaborated in the process that led to the drafting of the UNGASS country reports. We would like to thank the Spanish Agency for International Development Cooperation for its financing of an extra budgetary project through which it became possible to support several aspects and processes related to the drafting of the UNGASS country reports. We likewise express recognition to the Passion for Life Campaign of IMLAS and, in particular, to Nicolás Anguita from Photonomada and to Leandro Cahn from Fundación Huésped. We give thanks for the testimonies of the people living with HIV, who strongly remind us of the meaning of our daily work. Finally, we would like to express our most sincere thank you to all of the national AIDS programs and civil society organizations that contributed their effort and enthusiasm, particularly the Latin American and Caribbean Horizontal Technical Cooperation Group in HIV/AIDS and the Latin American and Caribbean Council of AIDS Service Organizations. 13

14 The Lord is a passion in Jucimara s life. Her faith is what gives her the strength to go on, to overcome difficulties, and to triumph over obstacles. She knows a lot of people who abandoned their HIV treatment believing that their faith in God would be enough to face up to HIV. However, Mara clarifies that HIV has won all barriers: religious, racial, social classes. And that faith in the Lord and care of our bodies through medical treatments must go hand-in-hand. Jucimara is 34 years old and has been living with HIV for the past 16 years. She got married when she was 18 and, three months later, her husband discovered that he was living with HIV. A year and a half later he passed away due to AIDS. Mara never imagined that she could be at risk of contracting HIV. That is why she affirms that any one of us is vulnerable to HIV. After being without a partner for 7 years, Mara met the man who is her husband today: a man who does not live with HIV. When she told him that she was living with HIV he responded: Not because I have discovered that a rose has thorns am I going to stop admiring its beauty or its fragrance. 14

15 Abbreviations and Acronyms ART ASAP CRIS CSO EPP GCTH HIV IDU M&E MDGs MoT MSM NASA NCPI PMTCT SW TB UNGASS Antiretroviral therapy AIDS Strategic Action Planning Country Response Information System Civil society organizations Estimation and Projection Package Latin American and Caribbean Horizontal Technical Cooperation Group in HIV/AIDS and STIs Human immunodeficiency virus Injecting drug user Monitoring and evaluation Millennium Development Goals Modes of transmission Men who have sex with men National AIDS Spending Assessment National Composite Policy Index Prevention of Mother to Child Transmission Male or Female Sex Workers Tuberculosis United Nations General Assembly Special Session on HIV/AIDS 15

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17 Introduction In June 2001, the 189 Member States of the United Nations adopted the Declaration of Commitment on HIV/AIDS [1] during the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). This declaration contains commitments linked to a timetable established to generate measurable actions and concrete progress in the response to HIV. In 2006, Member States made a commitment, in the Political Declaration on HIV/AIDS [2], to take extraordinary steps to advance toward universal access to HIV prevention, treatment, care and support by 2010 and to strengthen the response to Millennium Development Goal 6 (MDG 6). The reporting system of UNGASS indicators helps to monitor progress of commitments acquired since 2001: having halted and started to reduce the spread of HIV by 2015, and achieving universal access to treatment for HIV infection for those who need it by UNGASS Indicators In order to monitor progress towards commitments acquired, since 2001 four cycles of reports have been developed (2003, 2005, 2008 and 2010). As a result of collaboration between national governments, UNAIDS, and other partners, for the first round of 2003 a group of core indicators to monitor the UNGASS Declaration of Commitment were developed. Since then, the indicators are reviewed after completion of each report cycle and, if necessary, they are updated based on an analysis of the performance of each indicator, recommendations from various partners, and programmatic developments [3]. One of the main updates to the indicators focuses on the importance of obtaining and reporting data disaggregated by sex and age in order to monitor equity in access to various interventions and an adequate focus toward specific populations [3]. The disaggregation of data allows for improved monitoring of resources and the programmatic response to the needs of each population, leading to greater success in the response to HIV. The core indicators facilitate evaluation of the efficiency of the response at national and regional levels and allow to monitor progress in order to establish and achieve universal access goals. These indicators are divided into three categories: [3]: 1. Commitment and action (indicators 1 through 11): these indicators are focused on financing and on policies and strategies to guarantee blood safety; provide treatment to people living with HIV and to people with co infection of HIV and tuberculosis; prevent mother to child transmission of HIV; provide HIV testing to the adult population, including groups most exposed to HIV, and guarantee that individuals become aware of the result and are reached by prevention programs; provide services to households with orphaned and vulnerable boys and girls; and ensure HIV education coverage at schools. This category includes the National Composite Policy Index (NCPI), which includes information on legal, political, plan and program aspects related to issues of gender, employment, stigma and discrimination, prevention, care and support, human rights, participation of civil society organizations (CSO) and monitoring and evaluation. 2. Knowledge and behavior (indicators 12 to 21): these indicators measure school attendance of orphans; knowledge about the modes of transmission of HIV 17

18 among youth and most exposed populations; and the beginning of sexual activity and the number of sexual partners, as well as use of condoms and sterile injecting equipment. 3. Impact (indicators 22 to 25): these indicators measure the prevalence of HIV among youth and most exposed populations; coverage of antiretroviral treatment (ART) one year after it was initiated; and the percentage of exposed newborns. The process of developing UNGASS reports The process of developing UNGASS reports in Latin America has helped to strengthen the countries information systems, their technical resources for monitoring and evaluation (M&E) and strategic alliances between the government, CSO, people living with HIV, the academic sector and international organizations. By improving the coordination, harmonization and functioning of information systems, UNGASS progress reports are an indispensable tool to guide public policies toward an evidence based response to HIV. UNAIDS has developed information programs to help countries map the HIV epidemic and determine the number of people living with HIV (including the number of pregnant women), the number of new infections, deaths due to AIDS, and prevention and treatment needs. Based on this data, countries can project their needs for healthcare services and laboratory networks, human resources, diagnostic equipment and medicines. Every two years, UNAIDS carries out regional technical training with the epidemiological teams of each country who update the estimates based on the most recent surveillance and program data and make projections regarding future consequences of the epidemic. Following the regional training, the teams from each country share the results of these estimates and projections with other national organizations to improve the models before sending them to UNAIDS. The more the models are based on systematic epidemiological surveillance data, the greater their quality and the accuracy of their estimates and projections. In Latin America, where the HIV epidemic is of a prevalence equal to or lower than 1% and is concentrated in certain vulnerable population groups in which prevalence is of at least 5%, the epidemic is modeled based on: 1. The combination of epidemic curves in the various population groups in which HIV exposure is greater, and in the rest of the population. For each group, data is required regarding the size of the population, epidemiological surveillance and its evolution, and estimates of the number of persons in each group that are receiving ART. 2. Program data on the number of persons receiving ART and pregnant women who are receiving antiretrovirals to prevent mother to child transmission (MTCT). 3. Other demographic and epidemiological data. The country teams can send their data to UNAIDS through the on line reporting tool for UNGASS. The use of this tool requires only an Internet connection. This system facilitates data entry and management of the data submission process, as well as sharing the data with the various participating institutions. 18

19 Tools to model the HIV epidemic and AIDS spending In Latin America, three information programs are used to model the HIV epidemic at national level. The Estimations and Projections Package (EPP) is used to generate the epidemic curve, which is then imported into Spectrum to estimate the impact of HIV in the country. If a country with a concentrated or low prevalence epidemic has limited information, Workbook is used to generate an estimate of the current HIV prevalence in each population group most exposed to HIV for a specific year and this is repeated for several years. For each of these groups (by default the program includes men who have sex with men (MSM), injecting drug users (IDU) and sex workers (SW) and their clients, but it can be expanded to include other groups) it is necessary to know the maximum and minimum estimates of population size and HIV prevalence. Prevalence estimates generated by Workbook are entered into EPP to generate an epidemic curve. Three tools are proposed to measure AIDS spending: 1) the National AIDS Spending Assessment (NASA) allows one to obtain information on spending beyond the health sector, in order to broadly reflect a multi sector and comprehensive national response including financing sources, expenditure categories, beneficiary populations, production factors, financial agents and service providers; 2) national health accounts analyze the sub accounts for AIDS in the health sector, and therefore it is possible that they might not reflect the spending related to the national response to HIV made by other sectors; and 3) resource flow surveys. The results obtained after using the selected tool are entered into the National Financing Matrix, which is submitted as part of the UNGASS country progress report. Monitoring and Evaluation Training In 2009 and 2010, UNAIDS held training workshops on M&E, estimates and development of UNGASS reports with the participation of representatives from the 17 countries of Latin America [4]. These workshops were held in collaboration with cosponsor agencies such as UNDP, UNICEF, PAHO and UNESCO, as well as other bilateral and multilateral partners such as the Program for Strengthening the Central American Response to HIV/AIDS of the U.S. Agency for International Development (USAID/PASCA) and the Global AIDS Program of the U.S. Centers for Disease Control and Prevention (CDC GAP). In 2009, UNAIDS facilitated the creation of a sub regional M&E network for Central America with the participation of Mexico, Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica and Panama [4]. As a result, in these countries there are HIV M&E focal points appointed by the national authorities. These focal points promote the development of national working groups to strengthen the national M&E systems. Developing human resources trained in M&E in the region continues to pose a challenge for Latin America. However, in general there is evidence of a positive trend at country level as well as among cooperation agencies in provision of support to this area. In 15 of the 17 Latin American countries national and international consultants were hired to support M&E activities. Their tasks include gathering data, drafting UNGASS reports, supporting epidemiological estimates, NASA exercises and other special studies. 19

20 Harmonization of the HIV component in population surveys Population surveys are a valuable source of information for UNGASS indicators, since one third of UNGASS indicators are based on these results. In Central America, these surveys began incorporating questions regarding HIV as recognition grew regarding the progress of the epidemic in the region. During 2007, in coordination with key counterparts, USAID and CDC established a strategic alliance for the purpose of harmonizing the HIV component in population surveys. Four national and one sub regional consultation workshops were held in Honduras, Nicaragua, El Salvador and Guatemala. The result was the publication in 2008 of the Guide for the Standardization of HIV/AIDS/STI Variables in Demographic Surveys. Workflows for development of UNGASS reports In 2009, with the active participation of civil society organizations, the 17 countries of the region drew up workflows for development of UNGASS reports. A workflow is a planning tool that consists of a detailed timetable of activities, with responsibilities defined for each activity [4]. Participation of institutional and social sectors So that each country can take ownership of M&E processes and institutionalize them in their national response, it is necessary to increase the participation of multi sector public institutions (health, economy, education and justice ministries and the ombudsman s office), CSOs, people living with HIV, the academic sector and bilateral and international organizations, and these alliances should be led by the government of each country. Harmonization of the monitoring processes conducted from different viewpoints will help bring to the UNGASS reports a more complete vision of national reality. UNGASS country reports The first time that all 17 Latin American countries presented their UNGASS reports was in This effort included Venezuela, which prepared an UNGASS report for the very first time. In the UNGASS 2010 reports for Latin America there is a large variability in the number of indicators reported by each country. Table 1 shows the list of indicators that are analyzed in this report (even though the table does not include the NCPI, a partial analysis is provided further on). Table 1: List of UNGASS Indicators 1 Domestic and international AIDS spending by categories and financing sources 2 National Composite Policy Index (NCPI) 3 Percentage of donated blood screened for HIV in a quality assured manner 4 Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy 4a: in b: in Percentage of HIV positive pregnant women who receive antirretroviral therapy to reduce the risk of mother to child transmission 20

21 5a: in b: in Percentage of estimated cases of HIV positive incident TB cases that received treatment for TBand HIV 7 Percentage of men and women aged who received an HIV test in the last 12 months and who know the result 8 Percentage of most at risk populations that have received an HIV test in the last 12 months and who know the result 8a: female and male sex workers 8b: men who have sex with men 8c: persons who use drugs intravenously 9 Percentage of most at risk populations reached by HIV prevention programs 9a: female and male sex workers 9b: men who have sex with men 9c: persons who inject drugs 10 Percentage of orphans and vulnerable children whose household received free basic external support in caring for the child 11 Percentage of schools that provide life skills based HIV education within the last academic year 12 Current school attendance among orphans and among non orphans aged 10 and Percentage of young men and women aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 14 Percentage of most at risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 14a: female and male sex workers 14b: men who have sex with men 14c: persons who use drugs intravenously 15 Percentage of young men and women who have had sexual intercourse before the age of Percentage of adults aged who have had sexual intercourse with more than one partner in the last 12 months 17 Percentage of adults aged who had more than one partner in the last 12 months who report the use of a condom during their last sexual encounter 18 Percentage of female and male sex workers reporting the use of a condom with their most recent client 19 Percentage of men reporting the use of a condom the last time they had anal sex with a male partner 20 Percentage of injecting drug users who reported using sterile injecting equipment the last time they injected 21 Percentage of injecting drug users who report the use of a condom at last sexual intercourse 22 Percentage of young men and women aged who are HIV infected 23 Percentage of most at risk populations who are HIV infected 24 Percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy 25 Percentage of infants born to HIV infected mothers who are infected An analysis of the integrity with which the indicators are reported reveals the diversity between countries (see Table 2). With regard to indicators 4, 5, 6, 16, 17 and 24, some countries also reported the data disaggregated by sex or age group, for more than a year or with different denominators (for indicators 4 and 5, the denominator of the reported data refers to either the estimated population living with HIV or to the population 21

22 that seeks healthcare services). If one takes into account 24 core indicators without including the disaggregated indicators, it will be noted that, on average, of the 17 countries of Latin America, 55 percent report on the commitment and action indicators, 24 percent report on the knowledge and behavior indicators, and 50 percent report on the impact indicators. Of the indicators that are reported, UNAIDS values their consistency [5] according to the extent to which they follow the criteria established in the UNAIDS guidelines [3], which allows comparison of the data between countries and over the years. Table 3 presents the consistency of the indicators by country. On average, if one takes the 22 core indicators into account, of the 17 countries of Latin America 63 percent of the commitment and action indicators, 38 percent of the knowledge and behavior indicators, and 71 percent of the impact indicators are reported consistently. The indicators that are reported the least are those related to orphaned boys and girls (numbers 10 and 12) and to persons who inject drugs (numbers 8c, 9c, 14c, 20 and 21). Sometimes the countries do not report these indicators because they consider them irrelevant to their epidemics. 22

23 Table 2: Integrity of the data in the UNGASS 2010 reports from Latin America by country and by indicator COUNTRY COMMITMENT AND ACTION KNOWLEDGE AND BEHAVIOUR IMPACT Central America and Mexico Costa Rica El Salvador Guatemala Honduras México Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone Argentina Brazil Chile Paraguay Uruguay Percentage of report Complete data Partial data Data not reported for the last period Source: [6]. Note 1: A plus sign + after an indicator refers to the reporting of data for that same indicator disaggregated by sex, age group, for more than a year or with more than one denominator. 23

24 Table 3: Consistency of the data in the UNGASS reports from Latin America by country and indicator COUNTRY COMMITMENT AND ACTION KNOWLEDGE AND BEHAVIOUR IMPACT 1 3 4a 4b 5a 5b 6 7 8a 8b 8c 9a 9b 9c a 14b 14c Central America and Mexico Costa Rica El Salvador Guatemala Honduras Mexico Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone Argentina Brazil Chile Paraguay Uruguay Percentage of report Consistent with guidelines Not available Not consistent with guidelines Source: [5]. Note 1: The use of the letters a, b and c after the number of the indicator refers to data disaggregated according to Table 1. 24

25 Alejandro loves music, art, expressing himself. He learned to play piano at an early age and then learned to play the guitar. Today he has a rock band, he sings and composes his own songs. Ale wants to be a musician and dreams about being on stage. Alejandro is 23 years old and is part of the first generation of children who were born with HIV. When he was 5 years old his mother passed away as a result of AIDS and his grandmother took care of his upbringing. At the age of six he began taking medication and still continues with the treatment. Ale feels that his relationship with HIV is different from other cases because ha has always lived with the virus. However, this relationship has changed over the years: as a child it involved health problems; as a teenager it was associated with his sexual awakening and whether or not he should reveal that he was living with HIV; and today HIV is beginning to represent a couple of pills two times per day. And it doesn t have to be anything more, he emphasizes. 25

26 The HIV epidemic in Latin America It is estimated that 1,600,000 people live with HIV in Latin America, of which 40,000 are 15 years of age or younger (Table 4 and Graph 1). In 2009, 100,000 persons acquired HIV and 66,000 died of AIDS (Table 4). Table 4: Estimated number of people living with HIV, new infections and AIDSrelated deaths (2009) Estimated number of adults and children living with HIV New HIV infections in adults and children AIDS-related deaths in adults and children Central America and Mexico Costa Rica 9,800 [7,500-13,000] [<500-1,100] <500 [<100-<1,000] El Salvador 34,000 [25,000-44,000] [1,200-4,000] 1,400 [<1,000-2,100] Guatemala 62,000 [47,000-82,000] 3,600-11,000] 2,600 [1,600-3,700] Honduras 39,000 [26,000-51,000] [<1,000-3,700] 2,500 [1,700-3,400] Mexico 220,000 [180, ,000] [ ,000] [6,400-12,000] Nicaragua 6,900 [5,200-9,100] [<500-1,300] <500 [<200-<500] Panama 20,000 [14,000-36,000] [<1,000-1,200] 1,500 [<1,000-3,600] Andean Countries Bolivia 12,000 [9,000-16,000] [<1,000-1,600] <1,000 [<1,000-1,200] Colombia 160,000 [120, ,000] [2,800-16,000] 14,000 [11,000-18,000] Ecuador 37,000 [28,000-50,000] [1,100-6,200] 2,200 [1,300-3,300] Peru 75,000 [58, ,000] [2,300-6,700] 5,000 [3,800-6,600] Venezuela Southern Cone and Brazil Argentina 110,000 [88, ,000] 7,500 [4,100-11,000] 2,800 [1,700-4,400] Brazil [460, ,000] [18,000-70,000] [2,000-25,000] Chile 40,000 [32,000-51,000] [1,400-4,300] [<1,000-2,200] Paraguay 13,000 [9,800-16,000] [<1,000-1,600] [<500-<1,000] Uruguay 11,000 [9,400-13,000] <1,000 [<500-1,200] <1,000 [<500-<1,000] Total 1,600,000 [1,400,000-1,800,000] 100,000 [81, ,000] 66,000 [50,000-79,000] Sources: [6,7]. Note: Corrections are underway to the data from Argentina, Uruguay and Paraguay. 26

27 Graph 1: Estimated number of people living with HIV by age group in 17 countries of Latin America (2001 and 2009) Source: [6]. Note 1: The data was estimated using newly available data and improved estimation methods, and therefore might not coincide with epidemiological data published earlier. HIV prevalence in Latin America is estimated at 0.4%. Four countries in Central America have a prevalence rate of at least twice that value: 0.9% in Panama and 0.8% in El Salvador, Guatemala and Honduras. The lowest prevalence rate is in Nicaragua and Bolivia, both countries have a prevalence of 0.2% (Table 5). In the case of Bolivia, efforts are underway to improve the availability of data in order to build more precise estimates regarding the epidemic. The groups most exposed to HIV have a much higher prevalence rate, as can be seen in all of the data for men who have sex with men, trans population, male and female sex workers and persons who use drugs (injecting and others) (Table 5 and Graph 2). However, it is interesting to note that except for men who have sex with men and female sex workers, the majority of Latin American countries do not report data on other populations most exposed to HIV, many times because it is considered irrelevant to their epidemics and/or because no studies were carried out to obtain the information [8]. It is worthwhile to mention that surveillance studies are costly and that there is strong competition to obtain the limited health systems resourses, which leads governments to give priority to other lines of investment in health. 27

28 Table 5: HIV prevalence in adults and children, in groups most exposed to HIV and in other vulnerable populations in Latin America ( ) Adults Young women (15 to 24) Young men (15 to 24) Persons who use drugs Sex Workers Injecting Others Men Women Men who have sex with men Trans population Garífuna population Central America and Mexico Costa Rica 0.3 [ ] 0.1 [ ] 0.2 [ ] 12.7 e El Salvador 0.8 [ ] 0.3 [ ] 0.4 [ ] e 9.8 e Guatemala 0.8 [ ] 0.3 [ ] 0.5 [ ] b 18.3 b Honduras 0.8 [ ] 0.2 [ ] 0.3 [ ] b 6.6 b 4.6 b Mexico 0.3 [ ] 0.1 [ ] 0.2 [ ] e 10.2 e Nicaragua 0.2 [ ] 0.1 [ ] 0.1 [ ] 4.2 e Panama 0.9 [ ] 0.3 [ ] 0.4 [ ] 2.0 a 10.0 a Andean Countries Bolivia 0.2 [ ] 0.1 [< ] 0.1 [< ] 0.4 f 11.6 d Colombia 0.5 [ ] 0.1 [ ] 0.2 [ ] 1.6 d Ecuador 0.4 [ ] 0.2 [ ] 0.2 [ ] 3.8 b 19.2 c Peru 0.4 [ ] 0.1 [ ] 0.2 [ ] 0.5 d 10.1 e 29.6 f Venezuela Southern Cone and Brazil Argentina 0.5 [ ] 0.2 [ ] 0.3 [ ] d 11.8 d 34.0 Brazil... [ ] [ ] [ ] 5.9 e e Chile 0.4 [ ] 0.1 [ ] 0.2 [ ] e Paraguay 0.3 [ ] 0.1 [ ] 0.2 [ ] 9.0 b 10.7 b 1.8 b 8.7 Uruguay 0.6 [ ] 0.2 [ ] 0.3 [ ] 18.5 a 9.5 a 19.3 b b Total 0.4 [ ] 0.2 [ ] 0.2 [ ] Source: [6,7]. Note: a=2004, b=2006, c=2007, d=2008, e=2009, f=

29 Graph 2: HIV prevalence in adults and in groups most exposed to HIV in Argentina (2010) Source: [9]. The number of people living with HIV above and below 15 years of age is increasing at a slower pace (Graph 3). This could be explained by the fact that the annual number of new infections has been dropping since the year 2000 (Graph 4) while the annual increase of AIDS related deaths has been slowing (between the 29,000 deaths in 1990 and the 57,000 deaths in 1999 there was an annual increase of AIDS related deaths of 96%, while between the 60,000 deaths in 2000 and the 66,000 deaths in 2009 the growth rate is 10%). Additionally, greater access to ART is prolonging the lives of people living with HIV. In spite of a trend toward an annual decrease in AIDS related deaths, the reduction of the HIV mortality rate continues to be a priority in Latin America. 29

30 Graph 3: Estimated number of people living with HIV in 17 countries of Latin America ( ) Source: [6]. Graph 4: New HIV infections and AIDS related deaths per year in 17 countries of Latin America ( ) Source: [6]. 30

31 The increase in the number of AIDS related deaths (Graph 5) might be linked to diverse factors of social vulnerability and disparity when accessing healthcare, particularly the point at which the individual seeks assistance at a healthcare center, is diagnosed, or starts treatment [10]. Graph 5: Estimated number of AIDS related deaths and new HIV infections in 17 Latin American countries ( ) Note 1: The data was estimated using newly available data and improved estimation methods, and therefore might not coincide with epidemiological data published earlier. Source: [6,7]. 31

32 Cazú has an immense passion for life. He loves the sun, the sea, nature, his family, and especially his friends. He often says: Love will come and go, but friends are forever. In his opinion, a "Cazú day" is a day that transmits joy, strength and a lot of positive energy. Cazú is 38 years old and has been living with HIV for 22 years. He has always been easygoing, honest, sincere, hardworking, and above all happy. HIV did not bring him or take away any of these traits. He continues being the same person, with the difference that he has contracted a virus. He believes that preconceptions and discrimination are what affect HIV-positive persons the most, much more than the virus itself, and believes it is necessary to put a stop to HIV and not to the people who are living with HIV. Cazú admits that some persons have been trivializing HIV, believing that with the treatments available the epidemic is under control. He points out, however, that it is not easy to live with HIV or to take the medication, nor is it easy to gain access to treatment or to make one s condition public. That is why he insists that everyone must take care of themselves and use a condom during sexual relations. When he received his diagnosis, Cazú was told he had 6 months to live. He said that for a long time he stopped doing a lot of things because he had the cemetery on his mind. Today, 22 years later, he notes that he is much better prepared to live than to die. 32

33 Achievements and challenges in the response to HIV Commitments on blood safety (Indicator 3) Twelve of the 16 countries that reported data screen 100% of donated blood units for HIV at blood centers or laboratories that follow standard operating procedures and participate in external quality assurance programs for the total units of blood donated (Graph 6). Nevertheless, in some countries it is necessary to review the quality of the information reported to confirm national representation (reporting exclusively on the public network of blood banks versus the inclusion of profit seeking or non profit private blood banks; the capacity to enforce the established national regulations; and a budding campaign for voluntary and altruistic blood donations). Chile did not report any information. Peru, Guatemala, Bolivia and Honduras reported that less than 100% of donated blood units are being screened to detect HIV under quality assurance criteria. The values reported range between 50 and 90%. It is worthwhile to note that to the extent in which the countries begin reporting this indicator in a more precise manner there might be an apparent reduction in the results, but in reality this will correspond to a better evaluation of the blood safety situation and consequently the two periods cannot be compared. Such is the case in Peru and Bolivia. Peru reviewed and cleaned up its information system between 2007 and 2009 in the wake of a blood transfusion accident that occurred in 2006; the reduction in the percentage of donated blood that meets quality assurance criteria with regard to the preceding report is due to the fact that more information was available for the latest report, and this allowed more rigorous enforcement of blood quality assurance criteria up to the level of the blood donor units (type I and type II) [8]. In the case of Bolivia, the UNGASS estimation guidelines are being applied better at present, even though only the public blood banks are enforcing external quality control measures [8]. Honduras is the only country with a blood safety level below 50%. The Health Secretariat performs screening for HIV on all blood units through the National HIV/AIDS Laboratory, but it does not systematically comply with external quality control criteria. The Honduran Red Cross is the main institution that complies with the quality assurance criteria required for this indicator [8]. 33

34 Graph 6: Indicator 3 Trend of percentage of donated blood units screened for HIV in a quality assured manner ( ) Source: [6]. Note: The information that Paraguay reported in the UNGASS 2008 Report was the most recent information available; it was from 2006 and was incomplete. In 2007, Paraguay reported 100% of units of blood analyzed. Commitments regarding access to antiretroviral therapy (Indicators 4, 6, 7 and 24) It is important for people to know their HIV status for their personal protection as well as to avoid infecting other people. Knowledge about one s own serological status is also a fundamental factor in seeking access to treatment. According to demographic surveys, in Latin America the percentage of men and women between 15 and 49 years of age who responded as having received an HIV test during the last 12 months and who knows their serological status continues to be low, with values between 4% and 30% (Table 6). Timely diagnosis of HIV continues to be an important challenge for Latin America. The percentage of people who responded as having received an HIV test during the last 12 months and knowing their serological status is higher in women (range of 1% to 66%) than in men (range of 1% to 39%) (Table 6). It is possible that the larger number of tests performed during prenatal care has contributed to this difference. In males as well as in females, people 20 years of age or over are the ones who most frequently admit to having received an HIV test during the last 12 months and knowing the results (Table 6). This result might be linked to the barriers that exist for carrying out HIV tests on young persons who are under age. Testing and counseling services do not cover the needs of the population in a satisfactory manner. In a report on 13 countries of Latin America, of 1,000 persons 34

35 who received an HIV test and counseling, the number of people over 15 ranged between in El Salvador to 33.3 in Panama, with an average of 57.6 among the nine countries that reported data [11]. Table 6: Indicator 7 Percentage of men and women aged who received an HIV test during the last 12 months and who know the result ( ) Year of Men Women Men Women the Study Both sexes UNGASS Indicator Central America and Mexico Costa Rica El Salvador % 14% 10% 10% Guatemala % 3% 4% 3% 6% 4% 3% 4% 4% Honduras % 19% 27% 10% 27% 27% 21% 23% 23% Mexico Nicaragua % Panama % 11% 12% 9% 17% 12% 10% 12% 12% Andean Countries Bolivia % 3% 2% 1% 3% 2% 2% 2% 2% Colombia % 36% 30% Ecuador Peru % 6% 7% 10% 26% 36% 5% 30% 22% Venezuela Southern Cone and Brazil Argentina % Brazil % 16% 13% Chile % 26% 39% 17% 53% 66% 19% 40% 30% Paraguay Uruguay % 27% 22% 9% 20% 18% 19% 17% 18% Source: [6]. Note: For Argentina, the data reported for the year 2009 in the UNGASS 2010 Report are based on a study carried out in For Uruguay, the data reported for the year 2007 in the UNGASS 2008 Report were preliminary figures, while the data reported for the year 2009 in the UNGASS 2010 Report was based on the same study but the figures were the final figures. 7 ART coverage shows significant variability in Latin America. The new WHO treatment guidelines identify the strongest, most effective, and most feasible firstline and second line treatment regimens; the ideal moment to begin ART; criteria for changes in antiretroviral regimen, and introduce the concept of third line regimens [12]. If one takes as a denominator the estimated number of people with 35

36 advanced HIV infection who need ART according to these new guidelines, the regional average is 51% (45 61%) [13]. According to reports from healthcare services, however, the percentage of people with advanced HIV infection who need to receive ART is above 70% in half of the countries in Latin America (in 9 out of 17 countries) [6]. ART coverage undoubtedly is the most important achievement of the region even though it has to be expanded and strengthened. The constant difficulties in supply and the high cost of antiretrovirals demonstrate the fragility of this achievement. There is an unequal distribution between men and women living with HIV who receive ART (Graph 7), which could be attributed to the different epidemiological distribution of HIV as well as to different barriers to gain access to treatment. Graph 7: Distribution between men and women of people who received antiretroviral treatment in 2009 Source: [6]. The large difference that exists in the percentage of persons under treatment between the estimated population and the population reported by the health care services could be linked to the low percentage of persons with HIV who have taken the test and know the result, as well as with the barriers to gaining access to HIV health care services. In some cases, the countries calculate the populations in need of treatment with a method that differs from the method recommended by UNAIDS, which generates different results for a single indicator, as in the case of Indicator 4 on the percentage of adult and child population with HIV who receive antiretroviral treatment. For example, in Panama the total estimated number of people with HIV was used as a denominator instead of the estimated number of people with advanced HIV who need ART, as prescribed by the WHO 2010 guidelines, and that is 36

37 why coverage stands at 22% according to Panama while, according to the UNAIDS estimation methods it stands at 37%. In response to this situation, this report provides national estimates (Graph 8) along with the results produced by the method recommended by UNAIDS (Graph 7), which uses world renowned mathematical algorithms in order to allow a level of harmonization and comparability of the data reported among countries. Graph 8: Indicator 4 Estimated percentage of adult and child population with advanced HIV infection who are receiving ART according to the WHO 2010 guidelines (2009) Source: [6,13]. Note 1: The denominator is the number estimated by UNAIDS of persons with advanced HIV infection who need or meet the requirements for antiretroviral treatment. Note 3: Brazil s figure for this period has not been estimated. Note 3: Venezuela did not report any data. Three of the four countries with the highest estimated number of persons with HIV (Argentina, Brazil and Mexico) have a coverage rate higher than 50%, while the third country with the highest estimated number of persons with HIV (Colombia) has the lowest level of coverage in the region (Graph 7). Of the countries with the highest prevalence rate, El Salvador is the only one with a specific estimate of coverage higher than 50%, followed closely by Guatemala, while Panama and Honduras offer ART to only approximately one third of the people who need it (Graph 7). Graph 9: Indicator 4 Estimated percentage of adult and child population with advanced HIV infection who are receiving ART according to the WHO 2010 guidelines from among the persons who attend HIV health care centers (2009) 37

38 Source: [9]. Note 1: The denominator is the number of persons with advanced HIV infection who required antiretroviral treatment in 2009 according to the country report. Note 2: For Brazil, Costa Rica and El Salvador the data corresponds to the year More than 80% of the adult and child population of Latin America continues under treatment 12 months after initiating ART. In the countries that report data, the differences in the percentage of ART retention rates between men and women is slight. The percentage of ART treatment retention in the countries is not related to its estimated treatment coverage, since the retention rate is high independent of coverage, which suggests that the obstacles to gain access to the treatment are greater to initiate treatment than to continue it. This relatively high retention rate strengthens the idea that a greater effort is being made to follow up on the persons who are under treatment than to draw in persons with HIV who do not know their diagnosis. With regard to persons with HIV who have been diagnosed with tuberculosis, only in Costa Rica, Argentina, Mexico, Nicaragua and Peru more than 70% receive treatment for the two infections (Graph 9). The countries with the largest number of persons treated for HIV TV are Brazil (3.333 persons or 25.6% of the number of estimated persons) and Peru (529 persons or 70.5%) [9]. In the case of treatment coverage for HIV and tuberculosis, it is important to stress that optimal standardization of the estimation methods has not yet been achieved, especially with regard to denominators. Some countries use the total number of cases of tuberculosis diagnosed, while others use the estimated number of cases of tuberculosis. It is also difficult to build this indicator because in many countries the databases of the National TB Program and the National AIDS Program have not been unified, and because of this while building the indicator sometimes only the follow up of the National AIDS Program is reported. In El Salvador, Honduras and Mexico there was a drop in the percentage of treatment for HIV TB co infection. In El Salvador, the drop in the treatment for HIV 38

39 TB co infection between 2007 and 2009 could be caused by fluctuations in the estimated number of co infected persons. In 2008, the National AIDS Program estimated 74 cases of tuberculosis in persons living with HIV, 37 of whom received treatment for the two conditions in accordance with current protocols, which represents 50% of the projection in spite of the universality of the two treatments and the efforts of health care personnel to make a timely diagnosis of tuberculosis. Not all of the persons with HIV were receiving ART at the time the tuberculosis appeared, but 100% of those who were in fact receiving ART received treatment for the two infections after the tuberculosis appeared [8]. In Latin America it is necessary to strengthen the links between the tuberculosis and HIV programs and to improve reporting of the indicator on management of the coinfection. Graph 10: Indicator 6 Trend of estimated percentage of persons with HIV and Tuberculosis co infection who are receiving treatment for the two infections ( ) Source: [6]. Note 1: The data reported by El Salvador and Honduras for 2009 corresponds to Note 2: Chile did not report any data. Note 3: The data reported by Paraguay in the UNGASS 2008 Report were preliminary, incomplete and estimated figures for the year In Latin America, it is estimated that more than 80% of the adult and child population continue undergoing treatment 12 months after initiating ART (Graph 10). However, it must be pointed out that a large number of the countries in the region do not have access to this information in a systematic manner; that there is a large degree of variability in the manner of calculating this indicator; and that the results of cohort studies rarely are evaluated for this indicator. 39

40 In Nicaragua, Panama, Honduras, Bolivia and Guatemala the data shows a reduction between 2007 and 2009 (Graph 10). In Honduras, by using a different method of calculation, retention in 2007 was 72.8% (instead of the 91% reported earlier) and in 2008 it was 78.9% [8]. In Bolivia non comparable methods also were used in the two years reported, because only recently the National AIDS Program began setting up a monitoring and evaluation system to analyze cohort studies. In Nicaragua, the 2009 Universal Access report did not include either a numerator or a denominator for the number of persons who began treatment and were still undergoing treatment at 12 months [8]. In Panama, the indicator shows a percentage of adherence to the treatment 12 months after initiating ART much higher for the population of persons under the age of 15 (94%) than for the population of persons 15 or over (76,5%). This suggests that the child population is being recruited in a timely manner and that ART is initiated and followed through. As a matter of fact, it is easier to guarantee adherence in the child population than in the adult population, because there is a male or female caretaker who administers and supervises the treatment [8]. Eleven out of thirteen ART clinics that operate in the country managed to provide the numerator required to calculate the indicator, but the other two clinics which have the largest number of users had difficulties obtaining the data and an estimate had to be made. The weak information system, which is a generalized situation throughout the country, hinders the timely provision of data, especially at clinics with a large number of patients [8]. Graph 11: Indicator 24 Trend of the percentage of adult and child population with HIV still undergoing treatment 12 months after initiating antiretroviral treatment ( ) Source: [6]. Note: Paraguay reported 49.35% for the year 2007 in the UNGASS 2008 Report and 84.5% for the year 2009 in the UNGASS 2010 Report. 40

41 In the countries that reported data, there is only a slight difference between ART retention percentages for men and women (Graph 11), while between persons over and under 15 years of age it is noteworthy that in Mexico the retention rate of persons over 15 is almost 100% while among persons 15 years or younger the retention rate is (Graph 12). The last figure mentioned for Mexico is being reviewed by the health authorities. Graph 12: Indicator 24 Percentage of adult and child population with HIV still undergoing treatment 12 months after initiating antiretroviral treatment broken down by sex (2009) Source: [6]. Graph 13: Indicator 24 Percentage of population with HIV still undergoing treatment 12 months after initiating antiretroviral treatment broken down by age group (2009) Source: [6]. 41

42 The percentage of retention in ART in the countries is not related to their estimated treatment coverage, since retention is high independent of coverage (Table 7), which suggests that the obstacles to gain access to the treatment are more difficult to begin the treatment than to continue it. Table 7: Comparison between the percentage of persons with HIV undergoing antiretroviral treatment and the percentage who are still undergoing treatment 12 months after the treatment began (2009) Source: [6]. Estimated coverage of treatment according to WHO 2010 guidelines Percentage undergoing treatment 12 months after initiating treatment UNGASS Indicator 4 24 Central America and Mexico Costa Rica 68% 94% El Salvador 53% 90% Guatemala 44% 83% Honduras 33% 79% Mexico 54% 88% Nicaragua 40% 67% Panama 37% 77% Andean Countries Bolivia 19% 79% Colombia 17% Ecuador 30% 95% Peru 37% 86% Venezuela 84% Southern Cone and Brazil Argentina 70% Brazil 99% Chile 63% 94% Paraguay 37% 85% Uruguay 49% 87% 42

43 Commitments regarding prevention of mother to child transmission of HIV (Indicators 5 and 25) Taking an HIV test during pregnancy is the first step toward offering early administration of ART for the health of pregnant women and for preventing mother tochild transmission (PMTCT) of HIV. During the period , the majority of Latin American countries experienced an increase in the percentage of pregnant women who underwent HIV testing (11 out of 15 countries). Five countries in the region reported that in 2009 HIV testing was performed on more than 80% of pregnant women (Ecuador, Peru, Uruguay, Argentina and Panama), an increase with regard to 2008, in which only two countries (Argentina and Costa Rica) had at least those percentages. Five countries reported HIV testing of pregnant woman at a rate between 50% and 80% in There still are 5 countries (Guatemala, Bolivia, Mexico, Colombia and Paraguay) which in 2009 performed HIV testing on at least 50% of pregnant women. Venezuela did not report any data (Graph 13). And while Peru has a law making universal screening mandatory for pregnant women, Bolivia and Ecuador do not have a similar law. Nevertheless, Ecuador is attaining a high coverage of screening. Graph 14: Indicator 5 Trend of percentage of pregnant women who were tested for HIV ( ) Note 1: Costa Rica did not report any data for Note 2: Venezuela did not report any data. Source: [6,13,14,15]. 43

44 The national ranges for estimation of the percentage of women with HIV who receive antiretrovirals to reduce the risk of mother to child transmission are too wide ranging to be able to determine the magnitude of PMTCT activities (Graph 14). Nevertheless, it is estimated that in Latin America the average regional coverage of antiretrovirals for the prevention of mother to child transmission stands at 53% (37 81%). An important boost to the growing political support for PMTCT is the fact that the region has made a commitment to eliminate mother to child transmission of HIV and congenital syphilis by the year No country reported data broken down by type of antirretroviral regimen Graph 15: Indicator 5 Estimated percentage of pregnant women with HIV who are receiving antiretrovirals to reduce the risk of mother to child transmission (2009) Note 1: The denominator is based on a UNAIDS estimate of the number of pregnant women with HIV. Source: [6]. If one takes as a denominator the number of pregnant women diagnosed with HIV who attend health care centers, in six countries of Latin America (Nicaragua, Chile, Uruguay, Argentina, Ecuador and Costa Rica) antiretroviral medication is being provided to 80% or more of these women. In Venezuela, Guatemala, Mexico, Bolivia, Honduras, Colombia and Paraguay, less than 50% of pregnant women diagnosed with HIV who attend health care centers receive antiretroviral medication (Graph 15). 44

45 Graph 16: Indicator 5 Estimated percentage of pregnant women with HIV who attend HIV health care centers and receive antiretroviral medication for their own health and to reduce the risk of mother to child transmission (2009) Note 1: The denominator is the number of pregnant women who attend HIV health care centers. Note 2: The data for Argentina, Costa Rica, El Salvador and Uruguay is from Note 3: Contrary to other countries, in this indicator Mexico does not include women who receive antiretroviral medication for the sake of their own health. Source: [9]. The percentage of the population of pregnant women with HIV who receive antiretroviral medication in each country does not correspond with the adult and child population with HIV who receive ART. Uruguay, Chile, Argentina, Nicaragua, Ecuador and Panama are the only countries in which the percentage of persons receiving antiretroviral medication is larger for pregnant women than for the rest of the population (Graph 16). 45

46 Graph 17: Comparison between the percentage of adult and child population and the pregnant women population with advanced HIV who receive antiretroviral treatment according to the WHO 2010 guidelines from among the persons attending HIV health care centers (2009) Source: [9]. Regarding male and female newborn babies exposed to HIV in Latin America, only in 6 countries (Nicaragua, Panama, Ecuador, Argentina, Brasil and Paraguay) antiretroviral medication is administered to more than 50% as part of the PMTCT program. Of the 8 countries that report data on cotrimoxazol, only in Argentina and Nicaragua it is administered to more than 50% of the boys and girls exposed to HIV. Of the 7 countries that report data on virology tests, only in Nicaragua these tests are performed on more than 50% of the boys and girls exposed to HIV (Table 8). 46

47 Table 8: Indicators of universal access related to indicator 5 Newborns exposed to HIV who receive the recommended interventions (2009) Source: [6]. Receive antiretrovirals to prevent motherto-child transmission Receive prophylaxis with cotrimoxazol before they are two months old Are subjected to virology test before they are two months old Central America and México Costa Rica 33% 38% 38% El Salvador 42% 34% Guatemala 9% 13% Honduras 35% 42% Mexico 2% Nicaragua 63% 63% 63% Panama 56% 23% Andean Countries Bolivia 10% 10% 8% Colombia 12% 4% Ecuador 56% 1% Peru 43% Venezuela Southern Cone and Brazil Argentina >95% >95% Brazil >95% 32% Chile Paraguay 62% 36% Uruguay In Latin America the percentage of mother to child transmission of HIV is very high (Table 9). If one were to use for the calculation the estimated number of pregnant women with HIV and the risk of transmission according to whether or not they receive antiretroviral treatments, the majority of countries have a transmission rate far higher than what is considered optimal (less than 2%), which can be achieved if one enforces the WHO 2010 recommendations. The measurement instruments and methods used to calculate mother to child transmission of HIV vary a lot from one country to another. According to how the indicator is calculated based on statistical estimates or based on epidemiological surveillance data the percentage of transmission varies within a single country. The countries that report the lowest transmission rate, such as Costa Rica and Colombia, are including in the denominator only the number of pregnant women who receive both an HIV diagnosis and antiretroviral medication to reduce the risk of mother to child transmission (Table 9), which in the case of Colombia rules out more than 60% of the total estimated number of pregnant women who do not undergo an HIV test (Graph 47

48 14). What the indicator shows in these two countries is that when the recommendations for PMTCT are implemented, the transmission rate can be reduced to less than 2% and that the entire population of pregnant women with HIV must be allowed universal access. The challenge continues to be ensuring that all pregnant women have access to timely diagnosis and treatment for the sake of their own health and to reduce mother to child transmission. Health care and follow up of all newborns exposed to HIV must be strengthened along with the monitoring and evaluation system. Table 9: Indicator 25 Percentage of boys and girls exposed to HIV who are infected UNGASS Indicator Central America and Mexico 25 Percentage Numerator Denominator Comments Costa Rica 0.0% 0 39 El Salvador 10.9% Guatemala 30.0% Honduras This indicator stands at 0% because in and 2008 there were no cases of sons/daughters of mothers with HIV who are HIV positive. Even though there are cases of HIV positive women who did not receive antiretroviral treatment due to different circumstances, to this date there have not been any serological changes in the sons/daughters of these mothers despite the follow-up measures that are provided up to 18 months of age. It is worthwhile to note that the accumulated total of HIV positive boys and girls is 63 cases. The data comes from the Single System for Monitoring and Evaluation of HIV/AIDS. For 2008 the system reported 10.9% of HIV positive children under one year of age who were born from HIV positive pregnant women. The downward trend observed in previous years continues. Mexico No data available. Nicaragua 13.0% Spectrum was not used. The data reported was taken from the official statistics of the program. Panama No quality data available. Andean Countries Percentage Numerator Denominator Comments Bolivia Colombia 1.2% [27.5%] The follow-up system for 2009 identified 596 expectant women with HIV and since 7 infants under one year were diagnosed with HIV, this generates a percentage of mother-to-child transmission of 1.2%. According to Spectrum, there were 4,580 pregnant women with HIV and 1,260 infections in infants under one, which generates a percentage of mother-to-child transmission of 27.5%. The country considers the data from its follow-up system as official data. Ecuador 2.7% For the UNGASS report the country decided to calculate the percentage using the weighted average of the probability of mother-tochild transmission in pregnant women who did or did not receive treatment for HIV. The figure of 336 mothers for whom it was known whether or not they received treatment during pregnancy and/or childbirth was used for the weighted average. The numerator is the 26 HIV positive boys and girls born in 2009 and the denominator of the indicator (83) corresponds to the number of boys and girls born in 2009 who underwent a PCR test during the first year. Weighted average based on Spectrum estimates. Spectrum 2010 estimates that 835 infected mothers would need antiretroviral treatment in 2009, of which 560 are receiving treatment. In order to estimate the weighted average rate the 67% was multiplied by a 0.03 transmission Peru 11.9% rate. 48

49 Venezuela The National AIDS/STI Program and the National Directorate for Epidemiology are designing a number of Epidemiological Surveillance Studies to be made of the most-exposed populations. Among them is a study of the pregnant women who are receiving prenatal health care services. It is expected that after this study is completed enough information will be available to feed the estimation programs. Southern Cone and Percentage Numerator Denominator Comments Brazil Argentina 5.7% This figure comes from the jurisdictions that contributed information: the Autonomous City of Buenos Aires, Catamarca, Cordoba, Jujuy, La Rioja, Salta, San Juan, San Luis, Rosario and the 5th Health Region of Buenos Aires Province. Brazil The national program does not use Spectrum to estimate mother-tochild transmission. It monitors transmission based on the number and rate of cases of AIDS in boys and girls under the age of 5. According to this indicator, between 1998 and 2008 Brazil reduced by 49.0% the incidence of cases of AIDS in boys and girls under the age of 5 from 5.9% in 1998 to 3.0% in Chile 2.6% This indicator contains information stemming only from the public health system, since there is no information available from the private sector. The indicator takes into account the pregnant women who had access to the protocol to prevent mother-to-child transmission. Fifty-five of the 153 boys and girls who make up the denominator continue under study, so consequently the figures reported are preliminary figures. Paraguay 56.3% Corresponds to estimates for the year Uruguay 3.4% Indicator calculated by the Health Surveillance Department of the Public Health Ministry through the use of Spectrum. Source: [8]. The efforts to shore up PMTCT should go hand in hand with treatment for maternal syphilis and efforts to prevent congenital syphilis. In the report prepared by the Group for Horizontal Technical Cooperation the average rate of maternal syphilis reported at prenatal health care services in 12 countries is 0.87% [11]. 49

50 Commitments regarding support and education in boys, girls and adolescents affected by HIV and regarding information about HIV prevention in schools (Indicators 10, 11 and 12) There is scant data available on the percentage of orphaned and vulnerable boys and girls who receive at home basic and free external support for health care (indicator 10) or of the attendance at school of orphaned and non orphaned adolescents between 10 and 14 years of age (indicator 12), partly because many schools do not carry records of whether a child is an orphan or not. The data available is data from the National Surveys on Sexual and Reproductive Health. Honduras is the only country that reported data for these two indicators. In the Prevention through Education Ministerial Declaration [16], which was approved at the First Meeting of Ministers of Education and Health to Stop HIV and STIs in Latin American and the Caribbean held in Mexico in 2008, 30 ministers of health and 26 ministers of education made a commitment to give priority to HIV prevention at schools as a fundamental tool for the response to the HIV epidemic. The goals that were established and agreed upon in the Declaration by the Ministers of Health and Education of the region are: 1) by the year 2015, reducing by 75% the number of schools under the jurisdiction of the education ministries that do not provide comprehensive education regarding sexuality and 2) by the year 2015, reducing by 50% the number of adolescents and youths without access to health coverage services to appropriately attend to their needs in sexual and reproductive health. Nevertheless, only five Latin American countries (Costa Rica, Venezuela, El Salvador, Uruguay and Nicaragua) imparted at least 30 hours of education on HIV at 80% of public and private schools during the last school year. Six countries (Bolivia, Chile, Colombia, Panama, Paraguay and Peru) did not report any data (Graph 17). In El Salvador, the topic of HIV was incorporated into the Education Ministry s curricula at 100% of the country s schools in the year In 2009 a tremendous effort was made to train 8,000 teachers so as to cover some 2,000 schools during the year 2010 at which life skills based HIV education could be approached in a comprehensive manner. Nevertheless, the way the topic is approached depends exclusively on the type of education that the teacher received during his or her training, which means that up until now one cannot consider that a comprehensive focus is in place at 100% of the schools [8]. In Nicaragua, the Education Ministry s Learning for Life curricula includes 30 hours per course per year on a national level and is taught from 3rd grade through 11th grade as part of the subject Civics and Coexistence and from 4th grade through 9th grade as part of Natural Sciences [8]. 50

51 Graph 18: Indicator 11 Trend of percentage of schools where life skills based education for HIV prevention was imparted during the most recent school year ( ) Note: Bolivia, Chile, Colombia, Panama, Paraguay and Peru did not provide any data. Source: [6]. 51

52 Commitments regarding prevention of sexual transmission of HIV in adolescent and adult populations (Indicators 13, 15, 16 and 17) In the majority of countries with available data, less than 50% of the youth population of men and women between 15 and 24 years of age know how to prevent the sexual transmission of HIV and reject the main erroneous ideas about its transmission. Argentina, Chile and Nicaragua are the only countries in which more than 80% of this population is familiar with ways to prevent the sexual transmission of HIV (Table 10). In the countries that reported data, men begin sexual relations before 15 years of age more frequently than women. In the majority of countries, men as well as women begin sexual relations after the age of 15 (Table 10). The countries that report beginning at an earlier age are Brazil (with 35% of the population of both sexes beginning sexual relations prior to 15 years of age), Uruguay (with 37% of the population of both sexes) and Paraguay (with 64% of the female population). Sexual intercourse with more than one partner over the past 12 months is more frequent among men than among women in the 15 to 49 years age group (Table 10 and Graph 18) and in persons between 20 and 24 years of age than in persons who are either younger or older in this age group (Table 11). Given the existing discrepancy between the low percentage of people between 15 and 24 years who know how to prevent the sexual transmission of HIV and the higher percentage of people from among those who had intercourse with someone who is not their wedded or common law spouse and who reported having used a condom (Table 10), it is possible that those who have had intercourse with more than one partner have greater knowledge about how to prevent the sexual transmission of HIV. In all age groups, the use of a condom during the most recent sexual intercourse by people who reported having had intercourse with more than one partner during the past 12 months was higher among men than among women (Table 11). In Latin America, knowledge about HIV continues to be limited, and comprehensive sex education including concepts of masculinity and gender equality still have to be strengthened. 52

53 Table 10: Indicators 13, 15 and 17 on youth population between 15 and 24 years of age (2009) Identified how to prevent sexual transmission of HIV and rejected the main erroneous ideas about HIV transmission Had sexual intercourse prior to the age of 15 Reported having had sexual intercourse with someone who is not their wedded or common-law spouse during the past 12 months and having used a condom UNGASS Indicator Year of Study Men Women Both sexes Year of Study Men Women Both sexes Year of Study Men Women Men Women Central America and Mexico Costa Rica % 42% 42% El Salvador % % % 79% Guatemala % 22% 23% % 8% 11% % 13% 68% 43% Honduras % % 11% 13% % 17% Mexico % 4% 4% Nicaragua % 81% % 30% Panama % 15% 14% % 21% 24% % 17% 32% 14% Andean Countries Bolivia % 30% 24% % 7% 8% % 39% Colombia % 36% Ecuador % 27% 29% Peru % 20% 23% % 7% 8% % 82% 80% 32% Venezuela Southern Cone and Brazil Argentina % % Brazil % 50% 52% % 29% 35% % 52% 58% 37% Chile % 85% 82% % 8% 11% % 49% 55% 34% Paraguay % % 8% Uruguay % 44% 34% % 30% 37% % 71% 80% 86% 53

54 Source: [6] 54

55 Graph 19: Indicator 16 Percentage of men and women between 15 and 49 years of age who have had sexual intercourse with more than one partner over the past 12 months ( ) Source: [6]. 55

56 Table 11: Indicators 16 and 17 Total Percentage of men and women between 15 and 49 years of age who have had sexual intercourse with more than one partner over the past 12 months, broken down by sex and age groups, and percentage of men and women between 15 and 49 years of age who report having used a condom during their most recent sexual intercourse, broken down by sex and age groups ( ) Men Women Men Women Men Women Central America and Mexico Costa Rica Total With condom El Salvador Total With condom Guatemala Total 13.0% 0.6% 18.0% 0.7% 9.7% 0.6% With condom 78.9% 13.0% 68.5% 42.9% 47.4% 23.0% Honduras Total 31.7% 0.9% 28.7% 0.7% 14.4% 0.4% With condom 33.6% 16.9% 26.0% Mexico Total With condom Nicaragua Total 1.4% 1.8% With condom 12.2% 30.1% 16.0% Panama Total 30.7% 23.1% 53.6% 40.6% 47.8% 46.5% With condom 46.8% 16.9% 32.1% 13.9% 18.3% 7.0% Andean Countries Bolivia Total 10.0% 21.0% 11.0% With condom 43.9% 39.3% 30.7% Colombia Total 4.1% 5.6% 2.4% With condom 34.5% 36.3% 27.0% Ecuador Total With condom Peru Total 17.7% 0.7% 24.7% 3.0% 9.0% 1.0% With condom 73.4% 82.4% 79.5% 32.1% 64.9% 8.0% Venezuela Total With condom Southern Cone and Brazil Argentina Total With condom Brazil Total 66.0% 56.0% 74.0% 63.0% 78.0% 55.0% With condom 76.5% 51.8% 57.6% 36.5% 33.4% 30.0% Chile Total 16.0% 5.0% 29.0% 10.0% 21.0% 6.0% With condom 57.2% 48.9% 55.4% 34.1% 47.9% 31.0% Paraguay Total 6.6% 8.3% 4.4% With condom 5.0% 8.1% 4.0% Uruguay Total 40.0% 16.3% 52.1% 16.5% 13.8% 8.9% With condom 77.8% 71.4% 79.6% 85.7% 56.4% 56.0% Source: [6]. 56

57 Commitments regarding HIV prevention in male and female sex workers (Indicators 8a, 9a, 14a and 18) The majority of Latin American countries report more data about HIV prevention from female sex workers than for male sex workers (Tables 12 and 13), and this limits the possibilities of reaching conclusions regarding the population of male sex workers a group in which, whenever subjected to a study, a high prevalence of HIV has been found (Table 5 and Graph 2). Panama is the only country that reports data for all the indicators of male and female sex workers. In the majority of countries that report data (7 out of 10), more than 50% of female sex workers have undergone an HIV test and know the results (ranging between 52 and 100%). Brazil has the lowest percentage, with 18% (Table 12). According to the studies performed, the percentage of female sex workers who have had access to prevention programs fluctuates between 21% and 93% (Table 12). The percentage of female sex workers who know how to prevent the sexual transmission of HIV and reject the main erroneous ideas about its transmission is lower than 50% in seven of the eight countries for which there is data (Guatemala, Honduras, Bolivia, Colombia, Peru, Brazil and Paraguay) except in Panama, where it is 92% (Table 12). In practically all countries, the use of a condom by female sex workers is surprisingly higher than the percentage of those who have access to prevention programs and those who know how to prevent the sexual transmission of HIV and reject the main erroneous ideas about its transmission (Table 12). The use of a condom with the most recent customer is higher than 65% (range of 66 to 99%) in the 10 countries that report data for female sex workers (El Salvador, Guatemala, Honduras, Mexico, Panama, Bolivia, Colombia, Ecuador, Argentina and Brazil) and higher than 75% in three (Guatemala, Honduras and Uruguay) of the five countries that report data for male sex workers. In Latin America greater efforts are required to understand and prevent the HIV epidemic among male and female sex workers. It is worthwhile to note that many times studies involving sex workers suffer from validity and trustworthiness problems because they are not representative and the population is not large enough to define appropriate and representative sample populations. In view of this, many countries base this data on studies made by the programs and projects under way, which implies that the indicators represent intervened populations and consequently turn out to be so high. 57

58 Table 12: Indicators 8, 9, 14 and 18 on female sex workers (2009) (Female) Sex Workers Prevalence of HIV Underwent an HIV test in the past 12 months and knows the result Had access to prevention programs Identified how to prevent sexual transmission of HIV and rejected the main erroneous ideas about its transmission Reported having used a condom with their most recent client UNGASS Indicator Central America and Mexico Costa Rica El Salvador 4.1% 89% 77% 90% Guatemala 1.0% 93% 93% 3% 97% Honduras 2.3% 76% 33% 30% 79% Mexico 0.9% 59% 66% Nicaragua Panama 2.0% 52% 78% 92% 84% Andean Countries Bolivia 0.4% 45% 48% 87% Colombia 1.6% 42% 21% 24% 96% Ecuador 3.8% 97% Peru 0.5% 55% 5% Venezuela Southern Cone and Brazil Argentina 1.9% 99% Brazil 4.9% 18% 47% 42% 90% Chile 0.7% 85% 43% Paraguay 1.8% 100% 17% Uruguay Note: The majority of data on these four indicators come from special studies designed with different methods and encompassing small sized samples often taken in an urban context, and do not necessarily represent the national situation. Source: [6,7]. 58

59 Table 13: Indicators 8, 9, 14 and 18 on male sex workers (2009) (Male) Sex Workers HIV Prevalence Underwent an HIV test in the past 12 months and knows the result Had access to prevention programs Identified how to prevent sexual transmission of HIV and rejected the main erroneous ideas about its transmission Reported having used a condom with their most recent client UNGASS Indicator América Central y México Costa Rica El Salvador Guatemala 91% Honduras 87% Mexico 61% 45% Nicaragua Panama 59% 73% 91% 64% Andean Countries Bolivia Colombia Ecuador Peru 6% Venezuela Southern Cone and Brazil Argentina 22.8% Brasil Chile Paraguay 10.7% 28% Uruguay 19,3% 26% 76% Note: The majority of data on these four indicators come from special studies designed with different methods and encompassing small sized samples often taken in an urban context, and do not necessarily represent the national situation. Source: [6,7]. 59

60 Commitments regarding HIV prevention in men who have sex with men (Indicators 8b, 9b, 14b and 19) Of all the groups most exposed to HIV, the population of men who have sex with men is the group that has been studied the most in Latin America. As a matter of fact, several countries reported data for the four indicators for the first time in 2009, which might indicate that a greater emphasis is being placed on the need to have strategic information on one of the population groups most exposed to HIV. In more than half of the countries that report data, more than 50% of the persons who underwent an HIV test know the results, have access to prevention programs, know how to prevent HIV transmission and reject the main erroneous ideas about its transmission. The use of a condom is almost equal to or higher than 50% in all the countries that report data (range of 47 to 86%) (Table 14). Honduras, Peru and Uruguay reported data below 50% on all of the indicators for which data was reported (Table 14). In Peru, surveys on the behavior of men who have sex with men use for sampling purposes only the group with the highest risk, and additionally exclude those who know that they received a seropositive result from an HIV test. Even though only a few countries show data higher than 80% for these indicators (Table 14), among the population groups most exposed to HIV, men who have sex with men seem to be the group that has the most access to activities having to do with HIV prevention. Nevertheless, the high prevalence rates as well as the low investment in efforts aimed at this group contradict the figures. One explanation might be that many figures come from non representative surveys due to the lack of data regarding population size. In any event, one can see some progress from the year 2008 since at least 10 countries have made studies regarding population size, trying out several methodologies as demonstrated at the regional workshop organized by UNAIDS in Panama in December Very little emphasis has been given to the group of male sex workers and to the trans population, which seem to be highly affected by the epidemic and therefore require more research and responses. 60

61 Table 14: Indicators 8, 9, 14 and 19 on men who have sex with men (2009) Men who have sex with men (2009) UNGASS Indicator HIV Prevalence Underwent an HIV test in the past 12 months and knows the result Had access to prevention programs Identified how to prevent sexual transmission of HIV and rejected the main erroneous ideas about its transmission Reported having used a condom on the most recent occasion of anal sex with another man Central America and Mexico Costa Rica 12.7% 61% 64% 88% 65% El Salvador 9.8% 85% 58% 52% 55% Guatemala 18.3% 64% 75% 33% 78% Honduras 6.6% 29% 31% 8% 47% Mexico 10.2% 50% 38% 78% 64% Nicaragua 4.2% Panama 10.0% 76% 89% 78% 86% Andean Countries Bolivia 11.6% 35% 51% 55% 69% Colombia Ecuador 19.2% Peru 10.1% 6% 22% Venezuela Southern Cone and Brazil Argentina 11.8% 85% 96% Brazil 12.6% 19% 37% 62% 48% Chile 20.3% 25% 57% 65% 56% Paraguay 8.7% 100% 49% 63% Uruguay 9.1% 26% 47% Note: The majority of data on these four indicators come from special studies designed with different methods and encompassing small sized samples often taken in an urban context, and do not necessarily represent the national situation. Source: [6,7]. 61

62 The percentage of men who have sex with men who took a test during the past 12 months and know the results increased in El Salvador and Costa Rica between 2007 and 2009, while it decreased in Argentina, Mexico, Honduras, Chile and Peru during that period (Graph 19). In the case of Peru, the methods used for the UNGASS 2008 and 2010 reports are not comparable. For the 2008 report Peru used the results of a survey on groups with a high exposure to HIV and for the 2010 report it used the results of the Demography and Health Survey, and it is known that this survey under reports everything related to hidden populations. Graph 20: Indicator 8 on men who have sex with men: Trend of the population percentage of men who have sex with men and who underwent an HIV test in the past 12 months and know the results ( ) Note 1: Nicaragua, Colombia, Ecuador and Venezuela did not report any data for Note 2: The study methods used are not always comparable and do not always allow national extrapolation. Source: [6]. 62

63 Indicator 9 on the scope of the prevention programs refers to the percentage of persons who know where to go for an HIV test and who have received condoms during the past 12 months from an information dissemination service, patient reception and consultation center, or sexual health center. The percentage of men who have sex with men and who had access to prevention programs increased in Costa Rica, Mexico and Honduras and decreased in El Salvador (Graph 20). Graph 21: Indicator 9 on men who have sex with men: Trend of the percentage of men who have sex with men and who had access to HIV prevention programs ( ) Note: Nicaragua, Colombia, Ecuador, Peru, Venezuela, Argentina, Paraguay and Uruguay did not report any data for Source: [6]. 63

64 Indicator 14 refers to the percentage of persons who respond correctly to the following five questions: 1) Can one reduce the risk of HIV transmission by maintaining sexual intercourse with a single partner who is faithful and not infected with HIV? 2) Can the risk of HIV transmission be reduced through the use of condoms? 3) Can a person who looks healthy be infected with HIV? 4) Can a person become infected with HIV through a mosquito bite? 5) Can a person become infected with HIV through sharing food with an infected person? It is expected that the countries will report this indicator every two years. The majority of countries did not report data prior to 2009 on the percentage of men who have sex with men and who know how to prevent HIV transmission, and consequently it is difficult to monitor progress. With regard to the countries that reported data, the percentage increased in Argentina, Costa Rica and El Salvador and decreased in Peru and Honduras (Graph 21). In the case of Peru, it is worthwhile to reiterate that the data does not come from the same sources, and so a trend cannot be defined. Graph 22: Indicator 14 on men who have sex with men: Percentage of men who have sex with men who identify how to prevent the sexual transmission of HIV and reject the main erroneous ideas about HIV transmission ( ) Note 1: Nicaragua, Colombia, Ecuador, Venezuela and Uruguay did not report any data for Note 2: The study methods used are not always comparable. Source: [6]. 64

65 The use of condoms by men who have sex with men is practically equal to or higher than 50% in all of the countries that report data (Table 24). The percentage of men who reported having used a condom during the most recent instance of anal intercourse with another man increased in Chile but decreased in Costa Rica, Mexico and El Salvador (Graph 22). Graph 23: Indicator 19 on men who have sex with men: Trend of the percentage of men who report having used a condom during their most recent anal intercourse with another man ( ) Note: Nicaragua, Colombia, Ecuador, Peru, Venezuela and Argentina did not report any data for Source: [6]. 65

66 Commitments on HIV prevention in persons who use drugs intravenously (Indicators 8c, 9c, 14c, 20 and 21) The majority of countries do not report data on indicators related to persons who use drugs intravenously because they consider them irrelevant to their HIV epidemic [5]. In the four countries for which some data exists, a limited percentage of persons who use drugs intravenously underwent an HIV test and know the results (range 13 to 32%); have not had access to prevention programs (range 20 to 40%), do not know how to prevent HIV transmission and do not reject the main erroneous ideas about its transmission (range 30 to 32%), and usually do not use a condom (an average of 46%). Nevertheless, of the four countries that report data, an average of 66% (range of 40 to 91%) reported having used sterile injection material on the most recent occasion they injected themselves (Table 15). Even though HIV prevalence in persons who use drugs intravenously is at least 5% in the countries that report data (Table 15), in % of the notified cases of AIDS in the region represents persons who use drugs intravenously, and Argentina and Uruguay are the countries that reflect a percentage that is higher than average [10]. Table 15: Indicators 8, 9, 14, 20 and 21 on persons who use drugs intravenously (2009) Persons who use drugs intravenously (2009) UNGASS Indicator HIV Prevalence Underwent an HIV test in the past 12 months and knows the result Had access to prevention programs Identified how to prevent sexual transmission of HIV and rejected the main erroneous ideas about its transmission Reported having used a condom the last time they had sexual intercourse Reported having used sterile injection material the last time they injected themselves Central America and Mexico Mexico 5.0% 32% 20% 28% 40% Southern Cone and Brazil Argentina 64% 91% Brazil 5.9% 13% 40% 32% 70% 54% Paraguay 9.6% 30% 22% 71% Note 1: The majority of data on these five indicators come from special studies designed with different methods and encompassing small sized samples often taken in an urban context, and do not necessarily represent the national situation. Note 2: With regard to indicator 20, three countries reported data broken down between women (25% in México, 65% in Argentina and 36% in Paraguay) and men (29% in México, 63% in Argentina and 33% in Paraguay); the sexdisaggregated data for Argentina and Paraguay correspond to Source: [6,7]. 66

67 Cilene is a teacher and an actress. Her passion for the theatre began when she discovered that the theatre could present a representation of life as it really is, like a reflection in a mirror, and thereby serve as a vehicle to reach out to many people. Through the Preventive Theatre Company, Cilene dedicates her time to staging plays and other public performances that focus on the topic of HIV and AIDS. Cilene is 47 years old and for the past 14 has been living with HIV. When she was diagnosed with HIV she thought she was going to die, until she came to realize that it was the beginning of a new, different life in which she would have to take care of her health just like every other living person has to take care of his or her health. In this new life, Cilene decided to become an instrument to break the shackles of silence. Cilene asks herself: Where are the 34 million persons who live with HIV in the world? She believes that humankind has to break the shackles of silence and give a voice to the persons who are living with HIV. She wants to be the voice of a woman talking to other women who are living with HIV, and believes that preconceived ideas are responsible for the shackles of silence. She noted, however, that even though there might not yet be a cure for HIV, there is a cure for preconceptions. 67

68 National Commitment During the national consultations carried out in 2010, the essential achievements and challenges were identified to help guide the national commitments in the response to HIV in Latin America (Table 16). Table 16: Achievements and challenges identified during the 2010 National Consultations ACHIEVEMENTS Prevention of HIV transmission Incentives implemented to increase the number of men who take HIV tests and user-friendly services for young people. Several countries reported improvements in the prevention of mother-to-child transmission in accordance with the commitments of the Regional Initiative for the Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis. Costa Rica has managed to attain zero cases of mother-to-child transmission of HIV during the past two years. Significant leadership in treatment aspects in several countries (Mexico, Brazil and Costa Rica), which have achieved universal access to treatment in accordance with the goals that were set. CHALLENGES Limited dissemination of methods of prevention and transmission and voluntary access to testing (including link to sexual and reproductive health). The prevention programs are not reaching populations outside of the capital cities. Few prevention policies and programs aimed at the most exposed populations. Religious leaders do not always agree with innovative prevention programs. A lack of data regarding the effectiveness of prevention programs, and there is a particular need for evaluation studies. In spite of the Regional Ministerial Declaration on sex education signed in 2008, progress in this area has been slow. Limited resources to approach priority populations such as the youth population, especially sexuallydiverse youths. Prevention of mother-to-child transmission of HIV Treatment In spite of this, 9 out of 17 countries of the region reported coverage below the regional average (54%). There are a very limited number of comprehensive sexual and reproductive health programs that are free of stigma and discrimination for HIV-positive women. Lack of standardization of price of antiretroviral medication. Topics dealing with counterfeit medication. Increase in the production of generic ARV. Shortage of medications in 2010, attributed to poor 68

69 Significant mobilization of resources, particularly with a focus on the most exposed populations, through successful proposals presented to the Global Fund. planning, administrative weaknesses, and a limited supply of ARV on the local market. High turnover of health care personnel, especially in rural areas. Stigma and health personnel discrimination toward men who have sex with men and trans population. Cross-cutting areas Lack of a harmonized national M&E system Launching of an Agenda for Women and Girls in six countries. Greater coordination and alignment between the regional networks of civil society organizations. In spite of the efforts to obtain more information regarding the most exposed populations, said information is still insufficient. There is a particular need for studies regarding population size, HIV prevalence, and the rate of stigma and discrimination in various sub-populations. Limited financing for civil society organizations, including organizations at the community level. Source: [17]. The governments still do not have the ability to ensure the safety of their citizens and guarantee access to justice. Commitments regarding financing of the national responses to AIDS (Indicator 1) Monitoring and evaluation of the availability and use of financial resources for a national response to HIV allows one to evaluate the commitment and national action, for the purpose of generating responses based on evidence and results, and optimizing the mobilization, allocation and use of financial resources in order to obtain more effective national responses to HIV. This has become an important key issue due to the global economic crisis. Through the use of UNGASS Indicator 1 on national and international spending on AIDS by category and source of financing it is possible to determine in detail where the funds assigned to the national response to HIV come from and how said funds are invested. The funds spent are tracked and the source of financing (public, private or international) is identified under eight main categories and subcategories of spending: 1) prevention, 2) care and treatment, 3) vulnerable children and orphans, 4) strengthening of the management and administration of the program, 5) incentives for human resources, 6) social protection and social services, 7) enabling environment and community development, and 8) research. Indicator 1 can be completed through the use of various tools: NASA (National AIDS Spending Assessment), the National Health Accounts, AIDS sub accounts, or resource flow surveys. UNAIDS recommends use of the NASA method, which is a comprehensive and systematic tool with added value based on three aspects: a) the interventions and functions 69

70 are listed under analysis categories used by all national HIV response authorities (expense categories), which allows an amount of regional and global harmonization and standardization, b) the focus is worldwide on the basis of 6 vectors (source of financing, financial agents, interventions, beneficiary populations, service providers, and expense items) and c) it includes other sectors in addition to the health sector (social mitigation, justice, education, and labor). The information provided by Indicator 1 can be used to monitor implementation of the National Strategic Plan in order to design public strategies and policies and support the mobilization of resources, including the development of projects for financing by the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as to monitor the progress toward goals adopted at the international level, such as the UNGASS 2001 Declaration of Commitment and the Millennium Development Goals. For the UNGASS 2010 reporting period the countries were asked to report on Indicator 1 for 2007, 2008, and 2009 according to availability of data. Ten countries reported spending for 2007, 16 countries reported spending for 2008, and 7 countries reported spending for 2009, as can be seen in Table 17. Table 17: Latin American countries that reported on indicator 1, Argentina Bolivia Brazil Chile Colombia Costa Rica Ecuador El Salvador Guatemala Honduras Mexico Nicaragua Panama Paraguay Peru Uruguay Venezuela Based on the results reported by the countries in the region for this period, it is possible to determine some indications of trends in the region s investment in AIDS. It can be seen that there was an increase between 2007 and 2009 in the total investment in HIV and AIDS in 10 out of 13 countries of the region that reported for more than one year during the period analyzed. 70

71 Graph 24: Investment in AIDS by country in US Dollars, Indicator 1 encompasses three sources of financing: public, private, and international sources. Even though one can see a constant increase in the total amount invested in the majority of countries, on the regional level there seems to be a reduction in the percentage of total investment from public sources and an increase in the percentage that comes from private sources. Private sources include corporations and profit seeking institutions, funds for homes, non profit organizations, and sources of private financing for other categories. International investment has remained stable over the three years at approximately 4.5% of the total investment in HIV/AIDS. Graph 25: Investment in AIDS by source of financing,

72 This apparent reduction in the total percentage of investment from public sources in the region is reflected in the financing of care and treatment activities: between 2007 and 2009 one can see a reduction in the total percentage of financing for care and treatment coming from public sources and an increase in the percentage financed by private sources. Graph 26: Investment in care and treatment by source of financing, On the topic of prevention, one can see a reduction in financing by public sources of prevention activities between 2007 and 2008 and, further on, a slight increase between 2008 and 2009 to 53% of the total investment in prevention. In 2009, 36% of the investment in prevention reported was financed by private sources. This represented a 72

73 reduction compared to 2008, but was nevertheless a significant increase from 2007, when approximately 9.5% of the investment in prevention was financed by private sources. Graph 27: Investment in prevention by source of financing, Despite the variations in the percentage of investment financed by public and private sources during the 2007 to 2009 period, on average 95% of the total investment in AIDS in the region was financed by domestic sources (public and private), and on average 79.5% was financed by public sources, which suggests a certain level of sustainability in the response in the region. However, this situation varies between countries: in 2008 four countries (Bolivia, Honduras, Nicaragua and Peru) reported a larger investment by international sources than by domestic sources. Eight countries reported spending itemized by type of private financing source, so as to be able to identify the percentage and in which line items a contribution to the response is being made by the consumer and/or direct disbursement. The main expense item of this source of financing is prevention, particularly to provide male condoms, counseling and tests. In three countries the investment by consumers or through direct disbursement corresponds to more than 95% of the total national expenditures for the provision of male condoms, and in two other countries it corresponds to more than 70% of the investment in this line item. Considering the proven effectiveness of the condom to prevent HIV infection, it is considered worthwhile to investigate why the investment by public sources in this line item is limited. Consumer investment in prevention ranges from 1.29% of the total national investment in prevention in El Salvador to 39.3% in Mexico in With regard to care and treatment, the main expense item of this source of financing is treatment of opportunistic infections and antiretroviral therapy. The consumers investment in care and treatment as a percentage of the total national investment in this line item is, on average, lower than the investment in prevention, ranging from 1.45% in El Salvador to 18.03% in Honduras in It is worthwhile to carry out a more in depth 73

74 analysis of the spending by private sources, in particular by the consumer or through direct disbursement in each country, to identify possible challenges in terms of access to prevention or to treatment. The Global Fund to Fight AIDS, Tuberculosis and Malaria is the main source of international resources to support the national responses to HIV and AIDS in Latin America. In 2008, approximately 47.6% of the investment from international sources came from the Global Fund. In Graph 28 one can see that, in the six countries that reported in an itemized manner the investment by international financing sources, the total percentage of the investment in AIDS financed by the Global Fund varied from 2.34% in Argentina to 46.8% in Bolivia, with an average of 21.7% for all six countries. With regard to international support for the national responses to AIDS in the region, the Global Fund investment is followed by the investments from bilateral organizations and the United Nations agencies. Graph 28: Financing from the Global Fund, 2008 From 2007 to 2009 the main expense item is care and treatment, followed by prevention (Graph 29). From 2007 to 2009 one can notice a regional trend toward an increase in the percentage of total spending used for prevention activities and human resources and a reduction in care and treatment activities and in the strengthening of management, social protection, and an enabling environment. Graph 29: Investment in AIDS by expense category,

75 Based on the data reported by the countries for 2007, 2008 and 2009, one can determine the profile of the investment in AIDS of the Latin American countries for prevention, care and treatment, and other purposes. In more than half of the countries (12) that reported data on the investment by expense category in 2008, the investment is spent primarily on care and treatment. This trend is inverted in five other countries, where the investment is aimed primarily at prevention, followed by care and treatment. In 2008, the investment in care and treatment corresponds on average to 49% of the investment, ranging from 9.8% in Nicaragua to 76.6% in Brazil. The investment in prevention was, on average, 27.9% for all the countries of the region, ranging from 6.1% of the investment in Brazil to 67.3% in Costa Rica. Graph 30: Profile of investment in AIDS, % 20% 40% 60% 80% 100% Prevención Atención y Tratamiento Otros 75

76 Graph 31: Profile of the investment in AIDS per country, by the most recent year available (as indicated in Table 16) Regarding investment in care and treatment, on average the countries that reported spending on care and treatment broken down by sub category of spending invested approximately 32% in antiretroviral treatment, ranging from 5.9% in Bolivia to 92.9% in Venezuela. Graph 32: Investment in antiretroviral medication of the total investment in care and treatment,

77 In the Latin American countries the epidemics are characterized by being concentrated in the most exposed populations, including men who have sex with men, female sex workers, users of drugs intravenously, and the trans population. The data on financing of the response provided by Indicator 1 allows one to identify the percentage of prevention resources that is being used for the populations where the epidemic is concentrated in the countries of the region. In Colombia, Peru and Venezuela the three countries that reported investment in prevention broken down into sub categories for the three years from 2007 through 2009 an exploration was made of possible trends of investment in prevention activities aimed at persons with HIV and most exposed populations. The findings show that there has been an increase in prevention investment aimed at MSM in Venezuela and at SW in Colombia and Peru. In Colombia and Peru there was a drop in the spending aimed at MSM between 2007 and 2008 and then an increase between 2008 and 2009, leading to a larger total investment by Peru than in 2007 and a smaller total investment by Colombia. In a similar fashion, in Venezuela spending aimed at SW dropped between 2007 and 2008 and then increased again between 2008 and 2009, reaching a total that was higher than the spending in In Colombia, Peru and Venezuela one can appreciate an increase in the total investment in prevention aimed at men who have sex with men and female sex workers, which corresponds to a maximum of 3.1% of the total spending on prevention in Colombia and Venezuela, while in Peru 14.2% was for prevention in men who have sex with men and 22.8% for prevention in female sex workers. Due to the profile of the epidemics in these countries, this information suggests that there still is a need for the countries to intensify their prevention activities aimed at the populations most exposed to the epidemic in order to contain and to begin to revert the epidemic. Graph 33: Investment in prevention in MSM and SW in Colombia in US$,

78 Graph 34: Investment in prevention in MSM and SW in Peru in US$, Graph 35: Investment in prevention in MSM and SW in Venezuela in US$, Commitments regarding national policy (Indicator 2) The Group for Horizontal Technical Cooperation (GCTH) in Latin America and the Caribbean, which is made up of 21 National AIDS Programs and nine regional networks of persons with HIV, recognizes the need to increase the degree of participation of civil society organizations in the drafting of the National Strategic Plans (NSP) [11]. According to the National Composite Policy Index, the civil society organizations assigned a grade of between 3 and 3.8 on a scale of 10 to their contribution to the strengthening of the political commitment in the national response to HIV and the process of budgeting for and drawing up the National Strategic Plan [11]. According to a 2010 survey on stigma and discrimination under the leadership of the Non Governmental Organizations Delegation to the UNAIDS Executive Board of persons who participated in CSO and who represent all the key groups (including HIVpositive persons), in Latin America 75% of the people who participated answered that negative attitudes and behaviors due to HIV do exist (see Table 18). Between 44% and 78

79 61% of the persons consulted said that there are indeed various forms of stigma and discrimination of an institutional nature, such as at work, at health care centers, and in schools. Table 18: Demonstrations of stigma or discrimination related to HIV in Latin America according to responses from 251 persons with HIV or groups in which they work Negative attitudes and behavior due to HIV or association with certain groups 75% Discrimination at the workplace (exclusion or forced admission) 61% Loss of employment 57% Health care professionals do not help or refuse to provide care 49% Exclusion from family activities 46% Exclusion at school 44% Criminalization and other discriminatory laws 39% Involuntary disclosure of HIV status by health personnel, government officials, or the press 34% Social exclusion 30% Physical threats 25% Discrimination for travel or immigration 22% Religious exclusion 20% Arrest or isolation 9% None of the above 5% Source: [18]. Note: More than one question may be answered. In 10 of the 17 countries there are laws, regulations and policies that obstruct access to comprehensive HIV care (see Table 19). In Nicaragua, Bolivia, Colombia, Venezuela, Brazil and Uruguay, both the governments and the CSOs coincide in responding that such an obstruction exists, while in Costa Rica, Honduras and Ecuador only the government responded that obstruction exists and in Panama the civil society organizations were the ones who gave such a response. In El Salvador, Guatemala, Mexico, Peru, Argentina, Chile and Paraguay, the governments and the CSOs coincided in responding that there are no juridical or legal issues that obstruct comprehensive HIV care. In 10 of the countries of the region (Costa Rica, El Salvador, Guatemala, Nicaragua, Panama, Bolivia, Venezuela, Argentina, Chile and Uruguay), the government responded that women are not included in the national strategic plan, while in six countries (Honduras, Mexico, Colombia, Ecuador, Brazil and Paraguay) they are in fact included (see Table 19). Peru did not report any data. 79

80 Table 19: Response in the National Composite Policy Index (2009) Laws and regulations that protect persons with HIV from discrimination Civil Society Central America and Mexico Costa Rica El Salvador Guatemala Honduras Mexico Nicaragua Panama Andean Countries Bolivia Colombia Ecuador Peru Venezuela Southern Cone and Brazil Argentina Brazil Chile Paraguay Uruguay Source: [19]. Laws, regulations and policies that protect specific population groups Government Civil society Sí No No data Laws, regulations and policies that hinder access to prevention, treatment, care and support to vulnerable population groups Government Civil society Mechanisms to record, document and respond to cases of discrimination against persons with HIV and vulnerable population groups Women are a specific component of the national strategic plan Women are included in the national strategic plan Campaigns to inform and educate people regarding violence against women Civil society Government Government Government 80

81 To Roberto reading is the most marvelous thing in the world. It allows him to live other lives and to learn how to understand his own. Reading, traveling and eating are among his favorite things and are the things he missed the most when he was suffering from ill health a few years ago. Reading and sharing what he has read are two things that have merged into his sole passion. Roberto is 43 years old and has been living with HIV for 5 years. After being diagnosed he went through a very difficult period health-wise and the only thing he wanted was to go back to his daily routine: to drink coffee, read, listen to music, go to a play, watch movies, chit-chat with his friends, drink a glass of wine and eat. During that period his sister was of great support and he is still thankful that she was there at his side. Today he has recovered and is in good health. He is very much in love and enjoys the love and companionship of his partner, Ángel. He has started a new job at a magazine and is back to practicing yoga. He loves to spend time with his young niece. Roberto does not was to become known as the man with HIV. He knows that his life is far too valuable for it to take second place to a virus. 81

82 Conclusions and recommendations for programs and public policies Prevalence of HIV In Latin America the prevalence of HIV among the population has remained relatively stable over the past two decades. This undoubtedly is an achievement, even though the epidemic continues to seriously affect certain key groups. So as to be able to detain and reduce considerably the epidemic by the year 2015, the best practices of public health and disease control recommend that HIV response be focused more on the key groups, including the careful gathering of information and analysis in order to respond to the dynamics of the epidemic in each key community, in a partnership with the communities and maintaining a focus on human rights [20]. Blood safety According to the data reported, a high degree of blood safety has been achieved in Latin America. Nonetheless, it is recommended to maintain and strengthen the external controls of blood quality and to improve the information systems for the construction of indicator 3, so that it can provide a complete picture of the situation on the national level. Access to antirretroviral treatment A timely diagnosis of HIV continues to be an important challenge for Latin America. In the region it still is necessary to promote the expansion of HIV testing policies along with a more disseminated use of rapid tests, particularly among the key and most vulnerable populations, including youths under 18 years of age, in order to recruit in a timely manner persons with HIV who are not aware of their diagnosis. Important benefits are obtained from early detection of HIV, among them enhanced control over the evolution of the infection and its transmission, and this results in reduced spending on health care and the maintenance of a healthy and productive life. ART coverage undoubtedly is the region s most important achievement. It is worthwhile to underscore that this achievement continues to be fragile, as can be seen from the difficulties with the supply of antiretroviral medication that frequently is reported by all of the countries in the region. It is probable that the cost of antiretroviral treatment will become increasingly higher since the region is the one that relies the most on second line and third line medications, which are extremely costly. It is imperative to maintain and broaden ART coverage while striving to shore up adherence to the treatments. This is why it is essential to identify the socioeconomic barriers and the barriers in the health care system that are hindering universal access to the treatment, both of the general population and of the most exposed groups, in persons with HIV TB co infection, in pregnant women, and in exposed newborns. At the same time, it is urgent for the region to make an effort to develop evidence based prevention programs in order to drastically reduce the number of new infections in the populations that are key to the epidemic. To improve the estimates of treatment coverage. The countries, particularly those with a larger load of tuberculosis and HIV, need to strengthen program links between tuberculosis and HIV, as well as the information 82

83 systems so that they can better reflect the progress made in the approach to the coinfection. Prevention of mother to child transmission of HIV The challenge continues to be ensuring that all pregnant women have access to timely diagnosis and treatment for their own health and to reduce mother to child transmission through the strengthening of prenatal care programs. Health care and follow up treatment for newborns exposed to HIV in the region also needs to be strengthened, as well as measurement of this indicator. Support and schooling in boys, girls and adolescents affected by HIV Recognizing that this indicator is probably less relevant in Latin America than in other regions of the world, there is an information gap regarding the level of social protection obtained by the persons affected by HIV that merits an analysis in the region. Prevention of sexual transmission of HIV and information about HIV prevention in schools In Latin America, knowledge about HIV continues to be limited. Taking into consideration the Ministerial Declaration of Mexico 2008 Prevention through Education [16], the level of stigma and discrimination toward the persons who live with HIV and the sexually diverse communities, as well as the prevailing inequality and gender violence, it is of primary importance to expand according to scale and to strengthen education regarding HIV and comprehensive sex education. It is recommended that the countries develop adequate monitoring systems to be able to report on Indicator 11. Prevention of HIV in the most exposed groups Among the groups most exposed to HIV, men who have sex with men seems to be the group with the most access to HIV prevention activities. Nevertheless, the high rates of prevalence and the small investment aimed at this group contradicts this information. With regard to female sex workers, notable progress has been made in access to tests and the use of the condom, but there is a large variability regarding knowledge and access to prevention programs. In particular, little emphasis has been given to the group of male sex workers and trans persons who, since they are quite affected by the epidemic, require greater investigation and responses. With regard to users of drugs intravenously, even though progress has been made with regard to access to sterile injecting material, there seems to be limited access to HIV prevention activities. This situation has to be resolved. Attention also is drawn to the scant availability of information on the use of drugs (alcohol, cocaine) and its relationship with HIV in a region afflicted by the use of substances and the resulting violence. It is urgent for the region to make an effort to develop evidence based prevention programs to drastically reduce the number of new infections in populations that are key to the epidemic: monitoring systems tailored to prevention interventions need to be developed. 83

84 Financing of the national responses to AIDS The availability of economic resources in the countries is dissimilar and with very large gaps between them. According to NASA reporting, there is greater availability of resources in South America than in Central America. The funds are aimed for the most part to treatment and, to a lesser degree, to prevention. Recommendations to improve the efficiency of investment in HIV in the region: o Advocacy to ensure that investments are based on evidence, promoting the incorporation of this strategic information at decision making bodies and increasing the awareness of national authorities so that they can improve the focus of the interventions, particularly in the area of prevention, toward those areas or populations where the epidemic is concentrated or where there is a greater risk of contracting HIV. o Increasing domestic investment in the response to HIV and advocating for a greater mobilization of resources. According to the universal access goals established by the countries, it is estimated that on a worldwide scale for the year 2010 $25.1 trillion will be needed to respond to the epidemic in middle and low income countries, and a third of this amount should be from domestic sources. It is estimated that Latin America will need $3.1 trillion for 2010 [21] and $6.1 trillion for 2015 [22]. Even though an increase has been seen in the resources invested by Latin American countries in their national responses to the epidemic, in order to achieve the established goals and sustainability of the investment and the achievements attained in the responses, as well as expansion of the access to treatment, it will be necessary to increase domestic investment in the national response to HIV and to strengthen efforts for a greater mobilization of resources from international sources. o Investing in research, and in particular strengthening efforts for the evaluation of programs. By combining the results of program evaluation studies and the data on financing of the response, it is possible to determine if the funds are being assigned in the most efficient and effective manner, focused on successful interventions. o Institutionalizing the measurement of AIDS spending in a complete and timely manner so as to have itemized including information for sub categories of spending and populations and updated information on hand in order to strengthen the monitoring and evaluation mechanisms in the country and to have said information available for decision making and strategic planning purposes. Strengthening of the health care and health information systems In order to provide a response to HIV, it is necessary to strengthen the health systems and to integrate HIV care into the primary care services so as to improve the coordination of health care for persons with HIV and to increase the effectiveness of resources invested in health care. It is necessary to strengthen the availability of timely strategic information on HIV in Latin America so as to inform the development of public policies that correspond to the epidemiological profile of HIV. The priority topics of health information required to increase the impact of public policies are: the realization of continuous studies to 84

85 estimate and project the prevalence of HIV in the population groups most exposed to HIV; the careful gathering of information and analysis to respond to the dynamics of the epidemic in each key community; estimates of population size in each country; strengthening of systematic epidemiological surveillance; the development of modes of transmission exercises; improvement of the information systems for the construction of indicators on prevention and on treatment coverage and retention; treatment of HIV TB co infection; follow up of boys and girls exposed to HIV; and the monitoring of prevention interventions. One of the challenges is how to obtain this information uniformly and consistently so that the data can be analyzed in a trustworthy manner. Coordination between the governments and civil society organizations Strengthening the single multi sector authority (National AIDS Committees, CONASIDA or any other) will help to shore up the active and effective participation of the CSOs in the planning, budgeting, and follow up and evaluation processes. Strengthening the spaces for exchange of information and analyses in Latin America in order to promote horizontal cooperation between countries. It is recommended to generate spaces for the review of policies and norms that will allow the development of prevention and control activities, taking into account respect for human rights and a reduction in stigma and discrimination, as well as to establish political and technical spaces to track compliance with policies and norms. It is essential for civil society to be technically and politically trained to carry out activities to monitor public policies, social control and political incidence, and it has been recognized that there are civil society organizations in the region that already have carried out activities to monitor UNGASS goals and which have in depth knowledge of the topic. This experience must be expanded to more civil society groups in all of the countries. It is essential for the technicians of the National AIDS Programs to increase their familiarity with UNGASS goals and to expand said knowledge to the persons responsible for AIDS policies in the municipalities. 85

86

87 In Ilsa s opinion, passion is not something to talk about; it is something that does not change. To her, the process of being transgender is a passion, because it is what makes her feel fulfilled; it is what she wants to be and what she wants to project. Ilsa is 21 years old and has been living with HIV since she was 16. When she took an HIV test for the first time it was negative and she promised that from that point on she would be careful. But then she faltered again and one year later she became infected. The HIV diagnosis turned into a challenge and a new responsibility: to learn how to take care of herself and to find a balance in life. In 10 years she imagines herself progressing physically as well as financially, with a home and car of her own. Even though she admits that discrimination and transphobia are a part of her life, she no longer cares what other people think about her but about what she would like for herself.. Her diagnosis represented a significant change and a difficult process. This is why to Ilsa it is very important that HIV should not be kept under wraps; one has to share one s experiences and not remain silent so that HIV won t be something for only a few, but instead something for everyone. 87

88 Appendix 1: Report presented by the Latin American and Caribbean Group for Horizontal Technical Cooperation in HIV/AIDS Analysis of the strategic response by means of a review of the National Strategic Plans and UNGASS 2010 in thirteen Latin American Countries To carry out this study six Central American countries (Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica and Panama), six South American countries (Ecuador, Peru, Colombia, Uruguay, Bolivia and Argentina) and Mexico were used as reference. Analysis of basic juridical, legal and political aspects With the exception of Uruguay, all of the countries that are a part of this analysis have a law on the response to HIV/AIDS and additional legal norms as well as organizations that are committed to the topic. Nevertheless, the civil society organizations (CSOs) feel that the degree of enforcement of the laws is not what was expected. According to the National Composite Policy Index (NCPI), which measures from 1 to 10 the progress made on the topic of development and enforcement of national policies, strategies and laws on AIDS, the average score is between 3 and 5.1 points (see Table 20). The NCPI covers the areas of prevention, treatment, care and support, human rights, civil society participation, gender, workplace programs, stigma and discrimination, and surveillance and evaluation. For the purposes of this analysis we defined as high level scores those between 7 and 10 points, as mid level scores those between 4 and 6 points and as low level scores those between 1 and 3 points. The NCPI analysis indicates that enforcement of the laws and the design of public policies regarding HIV to a certain extend depend on the effective mobilization and greater leadership of the CSOs, while the NCPI grades at between 3 and 3.8 points the CSOs contribution toward strengthening the political commitment of leaders in the national response to HIV and the formulation of policies. The assessment of the political support received by the national HIV programs from the states or governments ranged between 7 and 8 points, with ideal scores such as in the case of Nicaragua (10 points). There are also spaces for concerted action, such as the National AIDS Committees (CONASIDA, with different names according to each country), which have an average existence of 12 years. There are diverse evaluations of these spaces, ranging from some described as leaders to others that are non operational or which have poor coordinating ability. Protection of the human rights of the persons affected by HIV is a key component in the response to the epidemic. According to the NCPI, in the Central American and South American countries civil society has an average perception of 6 points with regard to the policies, laws and regulations in force in that area. In the case of Mexico, however, this perception is graded at 4 points. Table 20: Average score by bloc of countries according to the National Composite Policy Index (NCPI) 88

89 National Composite Policy Index Bloc of Central American countries Average score (Range 1 10 points) Bloc of South American countries Mexico Progress in the legal, regulatory and social spheres What was the response, from a civil society viewpoint, to ensure enforcement of the laws and policies related to HIV/AIDS? Political support received from the government or State by the National HIV/AIDS Programs To what extent has civil society contributed to the strengthening of the political will of leaders in the national response to HIV/AIDS and to the formulation of policies? Degree of satisfaction with the efforts made by the countries to increase the participation of the most vulnerable and exposed populations in the national responses to HIV/AIDS Civil society s perception on how it would grade the current policies, laws and regulations to promote and protect human rights with regard to HIV Relevant information Nicaragua received an ideal score of 10 points Analysis of prior strategic planning, monitoring and evaluation Perception of the efforts made with regard to strategic planning of the national HIV/AIDS programs Perception regarding the extent to which civil society has participated in the process of strategic planning, drawing up budgets, and the National Strategic Plan for HIV/AIDS Perception of progress made in implementation of the surveillance, follow up and evaluation component from the standpoint of the governments Prevention, treatment, care and support The government perception of the efforts made to implement treatment, care and support for HIV/AIDS Civil society s perception of the efforts made to implement treatment, care and support for HIV/AIDS The governments perception of the efforts made to implement HIV/AIDS prevention programs Civil society s perception of the implementation of HIV/AIDS prevention programs Argentina did not report on this indicator

90 Analysis of the drafting, monitoring and evaluation of the NSP The National Strategic Plans (NSPs) provide a broad description of the international commitments agreed upon (MDGs, UNGASS, Universal Access) and link them to their general management plans and to health sector plans. Construction of the NSPs was satisfactory, with prior planning and an evaluation of the previous plan (with the exception of Uruguay and Argentina); and received financial technical assistance from UNAIDS. The design of the NSPs followed the guidance on preparation of strategic plans or the World Bank s ASAP method, and include a monitoring and evaluation plan as well as quantifiable indicators and goals (with the exception of the El Salvador NSP that does not include goals). The ministries of health led the preparation and implementation of the NSPs through the National Programs on HIV/AIDS. In Honduras, El Salvador, Nicaragua, Costa Rica, Panama, Argentina and Mexico, this was accomplished with co responsibility of the NACs or the Country Coordinating Mechanism (CCM). On average the governments rate the efforts made in strategic planning at mid level (6.5 points in Central America, 7 points in South America, and 7 points in Mexico), while the participation of the CSOs in the processes of strategic planning, budgeting, and National HIV/AIDS Plan is rated at a low level (3.8 points in Central America, 2.8 points in South America, and 2 points in Mexico). This score seems to suggest that it is necessary to balance the degree of participation of the government and the civil society organizations in the planning and decision making processes. In the NSPs, the following were identified as weaknesses: limited participation; fragile epidemiological surveillance systems with slow progress with regard to scientific research; economic and human resource difficulties (for example, a high turnover of personnel); monitoring and evaluation mechanisms still in a development phase; diminished institutional leadership in the CONASIDAs; incipient prevention programs; and insufficient comprehensive care. Attention is drawn to the case of Panama, where reference is made to the existence of several plans without a correct evaluation. These weaknesses and limitations are repeated in the UNGASS 2009 reports, and are accompanied by a shortage of medications, under reporting and, in particular, the persistence of stigma and discrimination. It is worthy of note that in the NCPI, from the governments viewpoint the achievements in enforcement of the surveillance, follow up and evaluation component was graded at a high level (7.3 points in Central America, 6.8 points in South America and 8 points in Mexico). General characterization of the vision, mission, and general and specific goals of the NSPs While comparing the strategic description of the NSPs we found the following common features: Their vision, which coincides with the principles of Universal Access; contemplates reduction of the prevalence and impact of STIs and the HIV epidemic; and includes comprehensive inter sector health care as well as respect for human rights. The plans from Colombia and Argentina do not include a vision statement. 90

91 Their mission includes mainly multi sector participation and coordination of the CSOs, as major players, and the government for an effective response and for comprehensive HIV care, with an emphasis on the most vulnerable groups. The NSPs from Peru, Colombia and Argentina do not include a mission statement. Their strategic axes basically include comprehensive care, prevention, monitoring and evaluation and institutional strengthening. The general objectives of the NSPs respond to the recommendations from UNAIDS. These are ambitious objectives, very close to Universal Access. Guatemala has a shared responsibility with regard to goals (government and individual) from the standpoint of equal standing in the eyes of the law. The specific objectives have conceptual similarities and respond to aspects that have been regarded as priorities: comprehensive quality care; access to prevention, promotion and educational services; access to treatment; and a human rights focus, among others. Peru makes a particular type of description, by stating its objectives in terms of quantified goals. Practically all mention the availability of manuals, guidelines and national norms for technical and efficient HIV care. In other cases, these are in the process of being created or updated (like in Nicaragua, Panama, Uruguay and Bolivia). Some of them mention as scientific evidence the existence of partial research and study activities. The Mexico NSO refers to national surveys on demography and health, as well as national surveys on HIV. Other NSPs do not describe any, so there is no representative evidence on which a national response can be based. A descriptive characterization of the epidemic The epidemiological profiles described in the NSPs have similar characteristics. In the region the epidemic is concentrated, with a high prevalence in the vulnerable groups of MSM and SW. There is an increase in the number of persons with HIV, partly due to the survival of persons who live with the virus but who have access to treatment. It is recommended to develop new studies to obtain greater knowledge about the profile of the epidemic; studies that break down population data according to diversity, sexual orientation and gender age, ethnic group and socioeconomic status. The average HIV positive man woman ratio is 2.55 men for each woman in Central America, 2.35 men for each woman in South America, and 4.6 men for each woman in Mexico. In all of the countries analyzed, the concentration of cases according to age coincides with the 15 to 49 years old age bracket (adolescent and youth population in fully productive and reproductive age). The priority populations described in the NSPs correspond to the epidemiological profile: MSM, SW, pregnant women, prisoners, uniformed services, adolescents and youths, mobile populations, indigenous and afro descendant populations, persons who live with HIV/AIDS, customers of SW and other populations, in that order. The NCPI provides us with the viewpoint of the civil society organizations regarding the priority assigned to the most vulnerable and exposed populations: degree of satisfaction regarding the efforts made by the countries to increase the participation of the most vulnerable and exposed populations in the national responses to HIV/AIDS. The 91

92 average score of the 13 countries in the study is at mid level (5.5 points in Central America, 5.6 points in South America, and 7 points in Mexico). Characterization of the prevention programs In the three country groups the governments perception regarding the efforts made for implementation of HIV prevention policies stood at an average of 6 points, while the CSOs in the countries analyzed gave these efforts an average score of 5.1 points. Progress perceived in the implementation of HIV prevention programs in 2009 contained in UNGASS 2010 The major achievement perceived by government players has been the implementation of communication campaigns information, education and communication activities which include actions to heighten the awareness of health personnel as well as various sectors of the people. They underscore the work done to prevent vertical transmission, among others. For the actors from the CSO and the cooperation agencies, among the major achievements are the prevention of vertical transmission and an increase in the CSOs and vulnerable populations participation in prevention activities. The budget increase for prevention, heightening awareness to the test, increasing awareness regarding prevention, and dissemination of the information also stand out. Problems pending resolution in the efforts made to implement HIV prevention programs in 2009 According to the government players, among the problems pending resolution are: ensuring a public budget that balances prevention and care; coordinated work with vulnerable groups; parameters for the evaluation of prevention measures; and improvement of the coverage of services. Additionally, the civil society organizations and the cooperation agencies consider that it is necessary to have more campaigns with CSO participation, adapting them to different scenarios, and to improve the strategies for prevention information. Other important aspects are budgeting funds for prevention activities, the training of human resources, decentralization of health care services, and improving pregnant women s access to screening. Characterization of the treatment programs Regarding implementation of HIV treatment, care and support, the NCPI provided data that shows that the CSOs in the three groups of countries recognize the efforts made (with an average of 6.23 points), while the government gave this aspect a higher score (with an average of 7.7 points). Progress perceived in the implementation of the treatment, care and support services related to HIV In the eyes of the government players the foremost achievement has been the progress in antiretroviral treatment services, which in some countries involved decentralization of the health care services and improved availability of medications and supplies. Other achievements mentioned are the updating of procedure manuals, the 92

93 setting up of pharmacotherapeutic technical committees, improvement of the records system, and the development of budgets. The CSOs particularly appreciate the improvement in access to and decentralization of the antiretroviral care and treatment services, as well as in coordination with the tuberculosis programs and the program management model based on experience. Problems to be resolved in the implementation of treatment, care and support services related to HIV The government players feel that the assignment of sufficient human resources and the training of health teams still have to be resolved. Even though they admit that progress has been made, efforts are still needed to achieve Universal Access through the decentralization of treatment services and public financing of antiretroviral medication, early detection, and the initiation of therapy in the earlier stages of the infection. As challenges that have to be tackled they mentioned the strengthening of comprehensive care and integration of private medical care. In the opinion of the CSOs and the cooperation organizations, the greatest challenge is to achieve Universal Access to care and treatment. Among the problems mentioned the most are: the structural and functional problems of the health services; the need to decentralize treatment and to have trained human resources; to attend to regional inequalities; to improve coordination; to give comprehensive care to opportunistic infections; to regulate pediatric care; and to update the guidelines for the care of adults. Analysis of Latin American indicators that are not measured in the UNGASS reports Since the year 2006, due to the commitments to achieve universal access to prevention, care and treatment by the year 2010, the WHO, UNICEF and UNAIDS have tried to monitor the components of the health sector s response to HIV. The Universal Access Progress Report 2010 (the fourth report since 2006) [13] evaluates the situation at the close of 2009 and considers the global status of the health sector s response to HIV, the progress made and the challenges that remain to achieve universal access. HIV screening and counseling services In the Universal Access Progress Report 2010, the indicators from the Latin American countries show varying degrees of progress. The screening and counseling services do not cover population needs in a satisfactory manner (Graphs 36 and 37) but it is expected that access to the test will be guaranteed, especially for the most vulnerable groups. On a scale of 1,000, the number of persons over 15 who received HIV screening and counseling ranges from116.6 in El Salvador to 33.3 in Panama, with an average of 57.6 among the nine countries that reported data. Graph 36: Estimated number of services with HIV screening and counseling per 100,000 adults,

94 Source: [13]. Graph 37: Estimated number of persons over the age of 15 who received HIV screening and counseling per 1,000 adults, 2009 Source: [13]. The countries that reported a greater availability of services are not necessarily the countries that have achieved the broadest coverage, since economic, socio cultural, and geographic access barriers can intervene as well as variability in the quality of the services. Since in the region the HIV epidemic is concentrated, it is important to know the type of care being received by the vulnerable groups. In the Universal Access Report, only 11 countries reported data on STI care given to female sex workers. The figures are low, with an average of 2.6 services for each 1,000 female sex workers (Graph 38). Uruguay has the most positive data, with 9.33 of each 1,000 female sex workers receiving specific services. Costa Rica has the lowest figure of all, with 0.14 per each 1,000. Graph 38: Number of services specifically for female sex workers where care is provided for sexually transmitted infections per each 1,000 female sex workers 94

95 Source: [13]. The prevalence of syphilis reported in the pre natal care services range between 3.43 in Paraguay and 0.07 in Honduras (Table 19). The average of the 12 countries that provided data is 0.87%. With the exception of Paraguay, which has a high rate, the prevalence of syphilis has dropped to 0.64%. Table 21: Prevalence of syphilis at pre natal care services COUNTRIES Prevalence of syphilis at prenatal care services Honduras 0.07% Chile 0.15% Mexico 0.27% El Salvador 0.29% Peru 0.33% Nicaragua 0.45% Guatemala 0.55% Colombia 1.14% Argentina 1.40% Brazil 1.60% Paraguay 3.43% Number of reporting countries 11 Source: [13]. HIV Expenditures In the countries that were analyzed, generally speaking the majority of the resources come from government contributions. The figures reported by each country in their 2008 NASAs as general expenses for HIV show an availability of different resources (Graph 39). 95

96 The percentage of health expenditures from the Gross Domestic Product (GDP) ranges from 8.4% in Brazil to 4.3% in Peru with an average of 6.9%, while HIV spending per capita ranges from 3.6% in Honduras to 0.5% in Brazil, with an average of 1%. Graph 39: Percentage of the gross domestic product spent on health and percentage of the spending on HIV/AIDS from health expenses in 12 countries of Latin America, 2009 Source: [23,24]. In this analysis it is important to begin with the percentage of the GDP spent on health and that spent on HIV/AIDS (see Table 20). The average per capita investment in prevention of the countries that provided NASA data was US$1.63, but this amount drops to US$0.91 if one takes out Costa Rica, which shows an investment much higher than the rest of countries (US$ 6.62). Table 22: Percentage of the budget invested in HIV prevention, in absolute values and in per capita value, 2009 COUNTRIES Population Investment in Prevention

97 % budget US$ US$ per capita Argentina 40,276,400 Bolivia 9,862,900 37% 2,774, Colombia 45,659, % 21,478, Costa Rica 4,578, % 30,311, Ecuador 13,625, % 16,194, El Salvador 6,163,100 Guatemala 14,026,900 Honduras 7,466,000 60% 17,078, Mexico 109,610,000 26% 88,830, Nicaragua 5,742,800 31% 4,668, Panama 3,453,900 Peru 29,164,900 33% 16,910, Uruguay 3,360,900 AVERAGE 1.63 Source: [9,25]. Table 23: Percentage of the budget invested in care and treatment, in absolute values and in per capita value, 2009 Investment in Care and Treatment 2009 COUNTRIES Percentage of the budget US$ US$ per patient under treatment Argentina 0 Bolivia 31% 2,302,913 2, Colombia 80.90% 109,843,840 6, Costa Rica (2008) 27.30% 11,908,842 4, Ecuador 38.40% 12,250,152 2, El Salvador (2008) 0 Guatemala (2008) 61.80% 31,688,658 3, Honduras 25.40% 7,229,881 1, Mexico 70% 251,700,000 4, Nicaragua 15% 2,261,070 2, Panama 0 Peru 51% 26,067,790 1, Uruguay 0 Source: [13]. With the exception of Panama and Uruguay, all of the countries have received grants from the Global Fund (Graphs 41 and 42). In Central America the country that received the 97

98 most financing was Guatemala, followed by Honduras, El Salvador, Nicaragua and Costa Rica. With regard to performance, the country that had the best execution was Costa Rica, followed by Honduras, Nicaragua and El Salvador. Guatemala still has not exceeded a 50% execution rate. In South America, the funds continue to be spent (with the exception of Argentina, which completed spending its allocation in 2008). Peru was the country that received the most financing, followed by Colombia, Bolivia, Argentina and Ecuador. The best execution of the grant was made by Peru, followed by Bolivia, Ecuador and, last of all, Colombia. Graph 40: Record of Central America s access to Global Fund financing ANTECEDENTE DE ACCESO AL FINANCIAMIENTO DEL FONDO GLOBAL Aprobado Ejecutado Diferencia % de ejecucion ANTECEDENTE DE ACCESO AL FINANCIAMIENTO DEL FONDO GLOBAL 90,000,000 $us 120.0% 80,000,000 $us 70,000,000 $us 99.5% 100.0% 60,000,000 $us 79.4% 81.1% 79.7% 80.0% Financiamiento 50,000,000 $us 40,000,000 $us % 60.0% % de ejecución 30,000,000 $us 20,000,000 $us 10,000,000 $us 0 $us 46,701,954 $us 37,062,845 $us 9,639,109 $us 85,088,239 $us 42,115,161 $us 42,973,078 $us 61,152,893 $us 49,599,767 $us 11,553,126 $us 33,467,401 $us 26,671,410 $us 6,795,991 $us No se presentaron varias propuestas, sin resultados positivos. Se presento a la 10ma. ronda PMARS 0 $us 0 $us 0 $us 3,583,871 $us 3,566,949 $us 16,922 $us 40.0% 20.0% 0.0% EL SALVADOR GUATEMALA HONDURAS NICARAGUA PANAMÁ COSTA RICA Source: [26] Graph 41: Record of South America s Access to Global Fund financing 98

99 ANTECEDENTE DE ACCESO AL FINANCIAMIENTO DEL FONDO GLOBAL Aprobado Ejecutado Diferencia % de ejecucion ANTECEDENTE DE ACCESO AL FINANCIAMIENTO DEL FONDO GLOBAL 80,000,000 $us 120.0% 70,000,000 $us 60,000,000 $us 50,000,000 $us 86.0% 74.5% 100.0% 100.0% 80.0% Financiamiento 40,000,000 $us 30,000,000 $us 20,000,000 $us 10,000,000 $us 0 $us Source: [26] 23,530,298 $us 56.4% ,262,606 $us 10,267,692 $us 67,157,214 $us 57,767,739 $us 9,389,475 $us 30,328,202 $us 28.5% 8,632,605 $us 21,695,597 $us Noaccedio a ningun financiamiento del Fondo Global ECUADOR PERU COLOMBIA URUGUAY BOLIVIA ARGENTINA 0 $us 0 $us 0 $us 25,170,491 $us 18,753,978 $us 6,416,513 $us 25,170,491 $us 25,170,491 $us 0 $us 60.0% % de ejecución 40.0% 20.0% 0.0% Conclusions After comparing the data available in the various reports and policy documents from the Latin American region the following conclusions can be made: The epidemic is concentrated in the region, with a prevalence rate lower than 1% in the case of pregnant women and higher than 5% in the case of vulnerable or high risk groups (such as MSM and SW). The bracket is the most affected age group, and the epidemic is concentrated in urban areas and in the more densely populated cities. Top rated juridical and legal instruments have been developed with the governments and with representative multi project institutions. The national plans drawn up in the region have coincidences focused on complying with international commitments. The studies carried out are still insufficient, partial and, in certain cases, not very representative and lack enough scientific evidence to get to know the epidemic in the required dimension. In all countries prioritization of populations for implementation of the National Strategic Plans coincide in indicating that MSM, SW, pregnant women, persons with HIV, and youths and adolescents are the main beneficiaries. In the NCPI it was found that civil society s perception to increase participation of the most vulnerable groups in the national responses is in the middle range. The availability of economic resources in the countries is dissimilar and with very broad gaps between them. According to NASA report, there is a greater availability of resources in South America than in Central America. The larger share of the funds is being invested in treatment and in a lesser degree in prevention, according to the data reported by the countries. The governments rated the efforts to implement HIV prevention policies (6 points on a scale of 10) higher than how the CSOs rated the prevention programs (5.1 points on a scale of 10). The perception of the CSOs in South America do not approve of this effort, while in Central America and Mexico, with a score of more than 5 points, there is a higher approval level of this effort. 99

100 Progress in the region with regard to coverage of care and treatment has been the most relevant achievement over the past few years, according to what was reported in the UNGASS reports. Special recognition was given to efforts to improvement access to treatment and steps to prevent mother to child transmission of HIV. With regard to access to prevention and treatment, the countries that have reported a greater availability of services are not necessarily the countries that have achieved the broadest coverage, which compels one to think about other intervening variable such as barriers to access. Considered to be among the most important challenges with regard to implementation of prevention programs are the need to ensure sufficient financial and human resources to implement prevention strategies as well as to work with the vulnerable groups in a coordinated manner. Recommendations Taking into account the availability of information in the Latin American region and the data analyzed, the following recommendations can be made: Priority must be given to actions in favor of political, technical and economic support by the different actors in the countries that show the most needs, inequalities and difficulties to achieve Universal Access. Strengthening the sole multi sector authority (National AIDS Commission, CONASIDA or otherwise), since this will help to increase the active and effective participation of the CSOs in the planning, budgeting, follow up and evaluation processes. Information for action is required in the epidemiological, sociological and economic spheres, but this has to be accomplished through the use of precise, diverse, representative and periodically updated scientific studies. Exploring the advantages of horizontal cooperation could facilitate these processes. For greater efficiency in the efforts to counter HIV the planning processes must be maintained and scaled up in the countries based on scientific evidence. The NCPI reports that the CSOs are dissatisfied over the lack of compliance with public policies and laws, but that they approve the policies and laws to protect human rights with regard to HIV. It is necessary to strengthen the CSOs overall, the vulnerable groups with regard to advocacy, and the governments with regard to the effective implementation of public policies and laws. Strengthening the spaces for exchange of information and analysis in Latin America so as to promote horizontal cooperation between the countries. It is recommended to generate spaces for the review of policies and norms in order to allow the development of prevention and control actions, taking into account respect for human rights and the reduction of stigma and discrimination. Likewise, establishing political and technical spaces in order to track compliance with policies and norms. Even though access to treatment is one of the region s most significant achievements, it is necessary to seek mechanisms for the sustainability of financing with an increasingly committed contribution from the governments that will allow reduction of the dependence on external cooperation. 100

101 Strengthening the national and regional monitoring and evaluation systems and making the information available to different sectors. Establishing agendas for research and evaluation of the aspects that are relevant to the countries and which will allow them to measure qualitative and quantitative progress by making a correlation between the processes and products and the results and impact of the interventions. It is important to strengthen the monitoring and evaluation of HIV prevention interventions. In order to better understand the results of the NCPI scores in the UNGASS reports it is necessary to evaluate other aspects such as the quality of expenditures (effectiveness and efficiency) and the flow of information to partners and populations in general regarding progress in the implementation of prevention programs, among others. Expanding testing in order to diagnose persons with HIV in a timely manner, and to guarantee them a full life requires strengthening the human resources and health systems in the region. 101

102 Table 24: Spending on HIV/AIDS in Latin America and the Caribbean with regard to per capita GDP and health expenditures COUNTRIES Population 2009 GDP (US$) GDP per capita 2009 (US$) Percentage of 2007 GDP spent on health Amount spent on health per capita 2007 (US$) US$ Spent on HIV/AIDS US$ per capita Percentage of the GDP Percentage of spending on health per capita Argentina (2009) ,0% 663 0,00 0,00% 0,0% Bolivia (2008) ,0% ,75 0,05% 1,1% Brazil (2008) ,4% ,22 0,04% 0,5% Chile (2007) ,2% ,61 0,08% 1,1% Colombia (2008) ,1% ,97 0,06% 1,0% Costa Rica (2008) ,1% ,53 0,17% 2,0% Cuba ,4% 585 0,00 0,00% 0,0% Ecuador (2008) ,8% ,34 0,06% 1,2% El Salvador (2008) ,2% 206 0,00 0,00% 0,0% Guatemala (2008) ,3% ,66 0,13% 2,0% Honduras (2008) ,2% ,81 0,21% 3,6% Mexico (2009) ,9% ,28 0,04% 0,6% Nicaragua (2008) ,3% ,61 0,23% 2,8% Panama (2008) ,7% 396 0,00 0,00% 0,0% Paraguay (2008) ,7% 114 0,00 0,00% 0,0% Peru (2008) ,3% ,76 0,04% 1,1% Uruguay (2008) ,0% 582 0,00 0,00% 0,0% Venezuela (2008) ,8% ,76 0,03% 0,6% 102

103 Note: GDP at nominal price per capita according to estimates of the International Monetary Fund Sources: [23,24]. 103

104 Communicating is Williams passion. He loves to talk: he talks with the ocean, with God, with himself he even talks in his sleep. Williams gives HIV prevention talks to young people, and enjoys talking with them. He also likes to listen and has learned to respect other people s opinions. Williams is 33 years old and has been living with HIV for the past 14. He took an HIV test out of curiosity and never imagined that it might turn out positive. When he found it he was afraid of dying; of what people would say when they found out; and of the distress his mother might feel. Nevertheless, he feels that he has learned to live with the virus, and although he is aware of his illness he does not allow his HIV to make his decisions for him. Today Williams feels calm and sure of himself. He says that during these 14 years living with HIV he has learned how to hug others, how to allow others to hug him and to always say what he wants: what he likes and what he does not like. He does not consider himself special or different just because he lives with HIV. He is a dreamer who often fantasizes; a man who does not like to be alone, who talks a lot, and who knows that he has a virus in his body. That is the only difference

105 Appendix 2: Quality and participation of civil society organizations in the process of drafting the UNGASS 2010 Report for Latin America: An analysis of the experience in nine countries In support of their demands, the United Nations through its agencies and organizations has postulated the importance having the civil society organizations participate in monitoring the execution of government policies and programs. It is understood that the persons who will benefit from these policies are the main interlocutors of public power in the dialogue about its scope and how it can be implemented. With regard to the HIV/AIDS epidemic, the characteristics of the transmission of the virus; the stigma that brands people with HIV and AIDS; and even the need for the person to make a commitment to follow the treatment increases the importance of participation by the persons who are affected and infected. It is from this standpoint that the CSOs have tried to set up networks of community groups and persons who will make a commitment to monitor the agreements established by the governments during the United Nations General Assembly Special Session on HIV and AIDS in 2001, seeking to help identify gaps, obstacles, and eventual opportunities for fulfillment of the commitments assumed. Responding to an invitation from UNAIDS, the Latin American and Caribbean Council of AIDS Service Organizations (LACCASO) carried out a study in nine countries of the region with the purpose of determining the degree of participation of the organizations that struggle against AIDS in the UNGASS monitoring effort and in the preparation of the biannual report that the countries send to UNAIDS on fulfillment of the goals. To carry out this study a survey was prepared with open ended questions that covered four topics: the formal insertion of civil society representatives in the bodies that make decisions regarding the national responses to HIV/AIDS; the participation of civil society in the construction of the most recent country report on fulfillment of the UNGASS goals; a comparison between this process and the process; and recommendations for continuation of the process. The nine countries (Argentina, Uruguay, Brazil, Peru, Bolivia, Guatemala, Mexico, Panama and Nicaragua) were defined according to their interest and availability to participate in the study. This report presents a synthesis of the results presented in the national consolidated reports. An attempt was made to identify and underscore common points. Individual mention of any country is made only to illustrate a comment or when the fact mentioned represents an exception with regard to the group of reports. The information gathering effort resulted in 83 questionnaires being answered by different networks and community organizations: Table 25: Number and profile of the organizations and networks that responded to the LACCASO questionnaire 105

106 Country Persons with HIV Men who have sex with men / Lesbians, Gays, Bisexuals, Trans Type of organization Women (Sex Workers, HIV Positive, others) Human Rights and others Youths/ Sex Education Argentina Uruguay Brazil Peru Bolivia Guatemala Panama Mexico Nicaragua Total Total Even though they are different in terms of size, population, cultural dynamics and health care models, the countries included have in common the concentration of the epidemic in certain populations such as trans, gay men and female sex workers. Social inequality is also a common characteristic, albeit in different magnitudes. Some of these countries, such as Panama, are considered middle or high income countries, and even though they contain pockets of poverty they do not always receive funds from the global financial contribution earmarked for countries considered poor. The countries also differ with regard to the HIV/AIDS epidemic and the organization of a health, political and social response. In countries such as Brazil, Mexico and Argentina, for example, the epidemic is older and a public policy to face it has existed for several years, while in countries such as Panama and Guatemala recognition of the epidemic and the consequent organization of a government response is more recent. Inserting civil society into the development of a national response to HIV and AIDS Asked about the existence of mechanisms to allow civil society participation in the processes of making decisions on AIDS policies, eight of the nine countries responded that such mechanisms do exist. With the exception of Argentina, all of the countries have a National AIDS Commission on which the civil society organizations are represented. Nevertheless, the effectiveness of the participation and even that of the commission was severely questioned, as can be seen, for example, in the report from Nicaragua. In order to analyze the participation of civil society, one has to specify exactly what civil society is. The existence of a pocket of civil society is a limiting factor, which requires establishing complementary mechanisms to represent all actors ( ) In fact, civil society s participation in CONISIDA has been more stable than the Government s. Nonetheless, as one respondent points out, there are decision making structures in which civil society no longer participates and on many occasions civil society has to make an effort so as not to 106

107 lose visibility in the response to the epidemic. The report from Peru states: It is acknowledged that spaces for participation do exist, but these spaces are perceived as limited. In the opinion of some of the more critical respondents, these are some spaces in which the representatives of the GLBT population, for example are like a bump on a log; the information is already closed and the spaces are solely to comply with the requirement to make the process appear like a participative process, but no contributions are allowed, much less the making of demands. In other words, not always are civil society s positions taken into account when the time comes to make a decision and many times they do not manage to adequately present matters related to segments other than the one they represent, which is the case in Nicaragua. CSO participation tends to be more effective in the regional or municipal commissions or councils, according to the reports from Brazil and Peru. Additionally, experience on the local level is not always reflected in the national indicators that are used to draw up the country report. Only in Brazil does the National AIDS Program have a specific sector aimed at cooperation with civil society. In the report from Brazil it is noted that due to the policy of decentralization, the National Department of STIs, AIDS and Viral Hepatitis is playing a minor role along with Civil Society in comparison to the previous periods. A large part of this role was transferred to the states and municipalities, and this in various cases has harmed the sustainability of the civil society organizations because the capacity for dialogue between the administrators and the CSOs varies significantly. Uruguay, Guatemala and Nicaragua state that in their countries the function of cooperating with the CSOs is assigned to their National AIDS Commissions. The remaining countries affirm that they have no knowledge of a specific body within the National AIDS Program in charge of a dialogue with the civil society organizations. The reports from Peru and Mexico state that inserting the CSOs into state or municipal bodies in charge of taking action would facilitate a dialogue. In Bolivia, the CSOs participate in the meetings of the National AIDS Program, but do not have any decision making power. The report from Mexico mentions the support to projects and other community initiatives as a strategy for cooperation with the CSOs developed by the National AIDS Program. In Argentina no action has been taken by the National AIDS Program to strengthen the participation of civil society. Constructing the 2010 Country Report Asked if monitoring UNGASS goals is part of the CSOs agenda, Brazil and Mexico responded affirmatively even though the Mexican organizations for the most part know nothing about the process or the mechanisms used to track them. Uruguay and Argentina said that they are not a specific item on the CSOs agenda, even though some institutions attempt some monitoring and even draft reports in consultation with the other organizations (Uruguay); actions to monitor the UNGASS Goals are reported as part of the Civil Society agenda, with the caveat that it still has not been assumed as a task of all of the organizations and that the majority participate only at the time the country report is being constructed. The insertion of the organizations only at the moment the country report is being constructed also is mentioned in the report from Bolivia, which affirms that followup action is taken only when a report has to be drafted; the information does not reach all of the civil society organizations; and within the civil society organizations there is no 107

108 coordination to support tracking of these indicators. The remaining countries affirm that this still is not a priority agenda item for the CSOs, despite the efforts of some organizations in Nicaragua, Argentina, Uruguay and Peru that have become involved in international projects with this goal in mind. The reasons indicated for this gap are: a lack of knowledge about the goals and their importance to the national policies on AIDS; the lack of specific training to understand the UNGASS indicators and to convert the information produced and accumulated by the CSOs into consistent data; and the lack of human and material resources that would allow prioritization of this activity. As the report from Peru states, UNGASS monitoring can be accomplished because it is part of a project and recourses are available to carry it out. The manner in which civil society was mobilized to participate in the drafting of the report varied slightly from country to country. In all of the countries included in this diagnosis, with the exception of Brazil, there were organizations that responded that they were not included in the process. The following table shows how and when the CSO representatives were contacted in order to incorporate them into the process. Table 26: Process of including civil society into the process of preparing the country report Country When Who How Mechanism used to coordinate participation of CSOs Argentina November 2010 MS Letter to certain organizations The organizations do not know if a mechanism was established to coordinate CSO participation in the process or if the government has a strategy for dissemination and communication, with the exception of a letter of invitation sent to the groups that participated in the 2008 process. Uruguay September 2009 October 2009 MS UNAIDS Consultant E mail to certain organizations Brazil June 2009 CNAIDS Announced during the meeting This was done as a survey by sending a form via e mail. Additionally, A meeting was held and civil society was invited, but the invitation was issued close to the date of the meeting and no funds were available to provide transportation for organizations in the interior of the country. A message to Movimiento Sida, Red de PVHA and Fórum UNGASS Brasil asking them to appoint representatives to the Work Group that would be tasked with drawing up the country report. Peru The respondents did not identify the phases of the process or the coordination mechanisms Bolivia June 2009 ProNaSida E mail to certain organizations A direct invitation to the GLBT community and to Red Bol+; the government did not disseminate any information to civil society organizations. Guatemala October 2009 PLWHA Network The government did not have a strategy for dissemination and communication. Panama Toward the end Governmen Direct invitation There was no strategy or mechanism to of 2009 t or UNAIDS to certain coordinate civil society participation or to consultants organizations Mexico Mid 2009 Pro Na sida e mail to the organizations Nicaragua September 2009 CONISIDA Announced during a meeting disseminate or communicate the process itself. A preparatory meeting was held, a two day meeting for a joint response to the questionnaire (Government and CSO), a final review and comments were received via e mail. E mail interviews with some organizations. Additionally a forum was held to analyze the second part of the report. 108

109 Participation of the actors All of the reports state that the National AIDS Programs, as well as other government organizations, participated in their preparation. All of the reports likewise state that representatives from various segments of civil society organizations also participated. However, with regard to the criteria defined for election of the CSO representatives there are differences between the countries. In Brazil and Mexico the representatives were chosen by means of an election from among organized leaders. In Nicaragua, the organizations that are active in the field were invited, but nevertheless not all sectors were represented (for example, street children and faith based organizations), nor were all key populations, such as female sex workers. Guatemala coincides by affirming that the criteria used were to include representatives of the vulnerable populations. Uruguay and Bolivia indicated that the criteria were established within the sphere of the National AIDS Commissions since the 2008 report was drafted, and in Peru, Argentina and Panama the criteria for selection of the participating NGOs is not known. With regard to complaints from certain groups that feel that they are not taken into account in the reports, there were none in Mexico, Argentina and Uruguay, even though the Mexico report notes that in part this might be related to the low level of importance that the organizations gave the process. In Nicaragua one organization believes that only organizations that received recourses from the Global Fund were taken into account. In Brazil, only two of the 14 organizations that answered the questionnaire said that the demands from certain groups had not been considered. In Bolivia and Panama female sex workers and trans felt that they had been excluded, and there was no consensus between the participants from Panama and Peru regarding whether or not there had been any complaints about CSO representation. According to the reports from those countries, the disagreements between the respondent organizations could be related to the fact that the group of organizations is unfamiliar with the process. The respondents involved in the preparation of the report felt that they were welltreated and respected during the process of constructing the UNGASS 2010 report, even though being well received and listened to does not necessarily convert into being taken into account; what became clear is that it was necessary to maintain one s position so that it would not be changed (Uruguay). No country mentioned the preparation of a shadow report. Civil Society s contribution Asked if there was any difference between the data in the reports prepared by the CSOs and the data from the government, the organizations all agreed that there was no difference with regard to the data itself but that there were differences regarding their analysis and interpretation. Special mention was made of the optimism with which the government interpreted some of its achievements. I feel that the government sector was interested in showing that progress was made and in claiming that goals that were not achieved were met. Even though at that time the launching of the new Strategic Plan was fairly recent, the information was weak and, in my opinion, some of the data had been doctored. (Panama). The government rated its performance better than civil society, often confusing actions (not sustainable over time) with public policies or programs, and on 109

110 many occasions the government confuses information or dissemination activities with prevention actions. Furthermore, a lot of government data and information do not have supporting documents to back them up, or these documents have not been presented (Argentina). The mechanism used to minimize these differences were the debates during the forums to present the results in the countries in which this type of dynamics was used (Brazil, Nicaragua, Mexico). Additionally, the governments did not make any substantial changes to the reports as a result of these discussions, partly because the knowledge accumulated by the civil society organizations had not been systematized and did not have any scientific confirmation that would allow it to be incorporated (Nicaragua, Panama). In spite of this the respondent organizations recognized that the information contributed by civil society was useful to help qualify the quantitative data included in the report, even though it was not necessarily incorporated into part A of the UNGASS monitoring guide. In all of the countries there was mention of the incorporation of CSO contributions into part B of the country report. Asked if there was any difference between the CSOs and the government s viewpoint in the country report sent to UNAIDS, once again there were remarks about differences in interpretation, especially regarding the scope of the prevention activities carried out in schools; regarding universal access; and regarding attention to the needs of orphaned children or children with HIV/AIDS (Brazil). A similar remark appears in the report from Bolivia, which states neither is there any support for orphaned children, and prevention was another topic that did not get a good score; the two parties were confronted but that part of the questionnaire was not changed: the data was presented the way it was obtained. The topic of orphans also appears in the report from Panama, which states that no effort was made to gather information regarding orphans from the sources. Other areas of disagreement can be seen in the report from Panama, where there also is a remark about expenditures and AIDS, since it is not clear why it dropped since the epidemic is on the upswing. Disagreement with regard to spending is also mentioned in the report from Uruguay. The report from Peru affirms that the information does not recognize gender topics nor does it provide visibility of the situation of the trans population. And Mexico mentions differences in some points related to universal coverage of treatment and prevention campaigns for specific populations, and on the topic of human rights disagreement also ensued. The reports recognize the participation of the United Nations agencies that are active in the country, particularly UNFPA. UNAIDS role as facilitator was mentioned by all, even though countries such as Uruguay, Panama and Guatemala mentioned a shortage of resources to support actions for the coordination and political mobilization of leaders, especially those who do not live in the capital cities. When asked to grade UNAIDS performance on a scale of 0 to 10, less than half of the respondents complied. From among those who did, the average score per country was 6.5 Brazil, 5.0 Bolivia, 8.0 Mexico and Argentina, 6.5 Panama and 7.5 Guatemala. 110

111 Final considerations Differences and similarities between 2008 and 2010 When asked to compare the process of constructing the country report in 2008 and 2010, the majority of respondents preferred to describe the differences instead of mentioning progress or setbacks due to the fact that the two processes were different. In Mexico and Brazil it was more technical, less politicized and relatively easier, because the channels for dialogue already existed. In Uruguay, Nicaragua and Peru, even though it was easier due to the same reasons, it was not as inclusive. The organizations from Guatemala reported that there were significant changes since some indicators show a little progress while others remained stable; the important thing is that there were studies that served as a referent for the data included in the report. The report from Argentina adds that in 2008 a different work method was chosen: civil society and the government responded jointly to the entire questionnaire and so both the debate and the consensus reached were greater. In 2010, however, the government alone answered part A of the questionnaire and the community organizations and UN agencies answered Part B of the questionnaire. This method facilitated the incorporation of remarks from the CSOs but only in part B of the questionnaire. According to the report from Bolivia, the difference between 2008 and 2010 is vast because when the drafts of the 2008 UNGASS reports were presented they were full of errors and the fact that the cooperation agencies and civil society were not involved in the entire process was criticized. In 2010 it is recognized that the cooperation agencies and civil society have been more involved, even though the government s position regarding certain policies is still very harsh and leads us to conflicts. In Panama the opinions were divided: for some the 2008 process was better because there was greater participation by the CSOs, while for others the 2010 effort was better organized. Establishment of new alliances With regard to the creation of new alliances, Argentina has indicated that some organizations state that a consensus has been reached to demand creation of CoNaSida. Almost half of the Brazilian organizations mentioned strengthening of the cooperation between the organizations involved and Nicaragua reported likewise. The other organizations do not consider that this process has contributed to either establishing or strengthening new alliances. Feedback from civil society organizations Asked about the process of getting the organizations involved to provide feedback to the other civil society organizations, some of the respondents from Brazil and Argentina responded that yes there had been feedback, primarily through the use of Internet and other electronic media, but they also noted that this is a major challenge due to the lack of human resources in the organizations that can take care of this task. In Uruguay, feedback has been accomplished mainly through the publication of reports and through electronic communication and a few meetings that were held for that purpose, but there are organizations that claim that there was no feedback process and no debate afterward or that feedback was more or less provided. The report from Bolivia notes that the 111

112 timeframes for debate and construction of the report were very limited; furthermore, tools were not prepared to define qualitative and quantitative indicators prior to the work of preparing the report. In Peru it was considered that this is a responsibility but it is not felt that all of the representatives have the capacity to fulfill this task. In general, there is no definitive knowledge in this regard; it is presumed that the representatives of large institutions have a larger share of this commitment and carry it out, since it is easier for them to disseminate whatever information they are able to gather. According to the report from these countries and the other countries where it was considered that there was no feedback (Panama, Mexico, Nicaragua and Guatemala), in addition to a lack of human and financial resources to distribute and share information regarding this process, there is scant mobilization with regard to the UNGASS topic, and so no demand is being created for the representatives of the CSOs to share and discuss the government reports. This is confirmed by the question on the flow of information, since the organizations that responded coincided in pointing out that the cultural trait of demanding public information does not exist, and consequently there are information and empowerment problems. One of the respondents said that there is a lack of motivation and interest; in the eyes of the government, in particular, the country report is simply a procedure, (Nicaragua), or there is a lack of economic resources to devote oneself to following up the UNGASS report, a lack of time for greater involvement, a lack of a culture of sharing information, and not everyone has access to Internet. For its part, the report from Peru says that contrary to previous years, where the information was said to come only from the Health Ministry and the consultants, there have been no complaints about the flow of information. Training of the organizations for UNGASS monitoring Eight of the 14 Brazilian organizations that responded to the questionnaires believe they are sufficiently trained to carry out UNGASS monitoring, and point to the UNGASS Forums created by the CSOs (an action that was coordinated by Gestos and by GAPA São Paulo) as spaces where this training is carried out. On the other hand, the report from Peru states that there is practically a consensus on the opinion that training is still very limited. The community groups state that there is an even greater need, and it has been noted that CONAMUSA might be the one to organize said training. Along the same lines, the report from Guatemala states that generating information about us and for us is important, in which case an active and continuous training system must be generated by all of the actors who work in this area, to become familiar with the UNGASS tool and its importance. The other countries agree with this need for training on the topics of monitoring and political incidence from the UNGASS standpoint. Gaps and deficiencies with regard to coordination with civil society With regard to the problems of coordination between government and civil society for UNGASS monitoring, the report from Uruguay states that the government constructed a CONASIDA that has not been really functional with regard to the discussion of public policies, and the way the epidemic has been represented is not necessarily the most adequate way nor the one that reflects the real state of the epidemic. The report from 112

113 Bolivia says that civil society has to find a mechanism to make its decisions and recommendations prevail regarding the response to HIV. In the country there are municipal, departmental and national governments, and each one is in favor of its own activities. Furthermore, in the authorities opinion HIV is not a priority issue for the country. In Peru s opinion, the aspect that stands out the most are the various dynamics, conditions and capacities of the representatives, with training being the main recommendation to overcome this gap. Panama and Argentina underscore the lack of a continuous dialogue previously planned by the government and civil society around UNGASS goals, and Nicaragua points out that it is considered that the main deficiency lies in the fact that a space for participation other tan CONISIDA has not been consolidated, since CONISIDA is very limited and it has left out many organizations that do prevention work, especially at the rural level, and the results of its work have not been made visible. Practically summing up the other reports, the document from Mexico stresses the lack of planning, resources, infrastructure and training of the civil society organizations; communications difficulties; the varying viewpoints of the government and CSOs; scant representation of all the states; lack of a monitoring and evaluation system at the national level; fiscal policies that do not respond to the nature of CSOs by cataloging them as a business; financing restrictions; and deterioration of trust in the CSOs. Even though there is recognition of the need and importance of UNGASS monitoring and suggestions regarding actions such as intensifying the dialogue or bringing about greater participation of the actors in the monitoring of UNGASS goals (Brazil), no government of any country has yet outlined a formal strategy for continuation of the dialogue or for a greater mobilization of the CSOs on the topic. An exception occurs, however, whenever there is a specific project for this objective, like in Brazil, where the UNGASS Goals have been on the agenda of the national NGO movement on AIDS since 2003 by means of systematic actions carried out with support from UNAIDS and the Brazilian Government (Gestos HIV+, Comunicação e Gênero, GAPA- SP and Fórum de ONG de São Paulo). Positive experiences are described starting with initiatives from the community, such as the project to monitor UNGASS goals on sexual and reproductive health, which involved some of the countries included in this diagnosis such as Argentina, Brasil, Peru, Mexico and Uruguay [27] in spite of the fact that, due to financial limitations, it could not have a greater scope and impact in the region even though UNAIDS Geneva has described it as an innovating action that utilizes UNGASS goals to coordinate the responses to HIV and matters pertaining to sexual and reproductive health, mobilizing the AIDS movement and sectors of the women s movement [28]. Recommendations Based on the reports submitted, the respondent organizations presented the following considerations: A dialogue between the government and civil society organizations is a relative novelty in Latin American cultures, which have a history of colonizing, authoritarian or dictatorial governments. That is why it is a process that demands investment in a learning and continuous improvement effort, with defined strategies and funds earmarked for this purpose. 113

114 It is essential for civil society to be technically and politically qualified to carry out actions to monitor public policies, social control and political incidence. There is recognition of the existence of civil society organizations in the region that already have carried out activities to monitor UNGASS goals with a vast knowledge of the area. This experience must be expanded to more civil society groups in all of the countries. It is essential for technicians of the National AIDS Programs to develop greater familiarity with UNGASS Goals. It is important for this knowledge to be expanded toward the persons responsible for AIDS policies in the municipalities. It is recommended to strengthen the dialogue between the other United Nations organizations regarding the goals to overcome HIV and AIDS and also within the region, so that this may lead to support actions for a more effective and coordinated mobilization and political incidence of the CSOs in relation to the topic. It is essential to have greater availability of financial resources to allow organization and coordination of the NGOs and networks that provide a response to HIV and AIDS and to build monitoring mechanisms. Even though there is a profusion of e mail contacts, whenever the country report is being prepared one cannot do without national and local personal contact or without specific projects for the monitoring of UNGASS goals. Likewise, it is essential to strengthen the civil society organizations so that the accumulated knowledge, once it has been systematized and confirmed according to a scientific method, can play a relevant role in the dialogue with the government, especially at the time of interpreting government data and analyzing policies. The monitoring of UNGASS goals, as well as civil society s dialogue with the governments regarding the goals and the best ways to achieve them, cannot be curtailed at the time the report is being constructed, and this has to be a continuous process involving civil society as well as the United Nations agencies. It is recommended that, during the second half of 2011, meetings be initiated with the civil society organizations in all of the countries to inform them about the new global directives to respond to HIV and AIDS that will be approved by the United Nations between June 8 and 10, It is recommended that in Latin America UNAIDS promote strategies to: a) facilitate in all of the countries the creation and strengthening of spaces for permanent dialogue between civil society, the government, and the other United Nations organizations; b) support the participation of CSOs in the national delegations for the next meeting to review United Nations goals in June 2011; c) support the immediate translation of relevant documents during the process of negotiating the 2011 outcome document, which is scheduled to begin on April 19, 2011; d) to begin discussions with the CSOs about how to establish regional mechanisms to monitor the goals that will be established in Latin America at the Regional Consultation in Mexico (March 1 to 3, 2011). We stress the need for specific actions to include and strengthen the trans population in these processes, because even though this population is disproportionately affected by the epidemic in all the participating countries, during the research it continues to be only slightly visible in the reports and policies, hidden behind acronyms such as MSM and GLBT. 114

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117 When she was diagnosed with HIV, Marcela became determined to defend her rights. This is when she became an activist, which is her passion. Changing a reality that is unjust solely because of living with a virus is the desire of Marcela, who lives each day intensely and taking advantage of what she considers is a second chance at life. Marcela is 44 years old and has been living with HIV for 22. When she was diagnosed at 22, she was expecting a positive result because she had not been taking care of her body. Two of her sisters died because of AIDS, and that motivated her to struggle for the rights of all persons with HIV. At the onset of the epidemic, Marcela used to meet secretly with other persons living with HIV, until she decided that if she wanted other people to view her just like any other person she would have to come out into the light, stop hiding herself, and show her face since there wasn t anything she should feel ashamed of. Today Marcela has free access to antiretroviral therapy for HIV. Between the train and the two buses she has to use, it takes her an hour and a half to go from her house to pick up her medication. She considers that there still are large obstacles to gain access to the medication, even though it is being provided free of charge. That is the purpose of her struggle nowadays: to continue working so that good health won t be the privilege of a few, but a right of all people. Marcela is the coordinator of the Latin American and Caribbean Movement of Women who Live with HIV/AIDS and is a member of Red Bonaerense de PVVS, Argentina