UNGASS 2006 United Nations General Assembly Special Session on HIV/AIDS. Country Report St Christopher and Nevis

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1 UNGASS 2006 United Nations General Assembly Special Session on HIV/AIDS Country Report St Christopher and Nevis 1

2 Table of contents Acknowledgments 3 Abbreviations 4 Status at a glance 5 Overview of the HIV/AIDS epidemic 6 National Response to HIV/AIDS epidemic 8 Prevention HIV education in schools Voluntary Counselling and Testing Prevention of mother to child transmission Blood safety Condom distribution Care, treatment and support Advocacy and human rights Mitigation of social and economic impact Major challenges faced 13 Challenges facing PLWHA Leadership and coordination Human and financial resources Institutional capacity Social and cultural norms Support required from country s development partners 15 Monitoring and evaluation environment 16 Bibliography 17 Annex 1: Consultation/preparation process for this national report 18 Annex 2: Core indicators for the Declaration of Commitment on 19 HIV/AIDS Annex 3: National Composite Policy Index Questionnaire 20 2

3 Acknowledgements The author acknowledges the contribution made by stakeholders and individuals who consented to interviews and facilitated the collection of the information at relatively short notice. A special thanks to the following persons without whose contribution this report could not have been completed Staff of the National AIDS Secretariat Permanent Secretary of Health Director, Community Based Health Services National Epidemiologist Non governmental organisations including faith based organisations and PLWHA Civil society Various Line Ministries Development partners (UNAIDS) 3

4 Abbreviations AIDS ARV BSS CAREC CCC CCT FHI GFTAM HIV ILO KABP MSM M&E NACHA NSP OECS PLWHA PMTCT SNHAG STI UNDP UNAIDS VCT Acquired Immune Deficiency Syndrome Antiretroviral Behaviour Sentinel Survey Caribbean Epidemiology Centre Clinical Care Coordinator Clinical Care Team Family Health International Global Fund for Tuberculosis, HIV/AIDS and Malaria Human Immunodeficiency Virus International Labour Organisation Knowledge, Attitudes, Behaviours and Practices Men who have sex with men Monitoring and evaluation National Advisory Council on HIV/AIDS National Strategic Plan Organisation of Easter Caribbean States People living with HIV/AIDS Prevention of mother to child transmission St Kitts/Nevis HIV/AIDS Group Sexually transmitted Infection United Nations Development Programme United Nations Programme for HIV/AIDS Voluntary Counselling and Testing 4

5 STATUS AT A GLANCE At the end of 2001, the Caribbean Epidemiology Centre (CAREC) estimated that approximately 347 persons were living with HIV/AIDS in St Christopher and Nevis. The national epidemiological data is believed to be an underestimate of the true numbers of persons living with HIV/AIDS since most of the testing occurs in the private sector or offshore in neighbouring islands. With the recognition that even relatively small numbers of persons infected could have a significant impact on the health, economic and development prospects of the Federation, the Government commissioned the formulation of a Strategic Plan for the National Response to HIV/AIDS in St Kitts/Nevis (NSP). This plan was developed in 2000 and over the next five years aimed to reduce the spread of HIV and its impact on families and communities affected. The NSP identified five priority areas for intervention. Implementation of the plan was delayed until 2003 when funds were mobilised through a World Bank Loan. Since then the components of the programme continue to be scaled up and include a prevention of mother to child programme, access to care, treatment and support for PLWHA and a number of creative and culturally sensitive strategies to increase voluntary counselling and testing (VCT). In addition to the development of the NSP, there has been significant improvement towards the achievement of the three ones. In 2005, the National Programme was reorganised so as to engage other sectors in the planning, implementation and monitoring of HIV/AIDS activities. The National Advisory Council on HIV/AIDS is the national authority charged with the responsibility of coordinating the national response. It has broad representation from key line ministries as well as civil society and PLWHA. Key functions of the council also include advocating for legislation that protects the human and civil rights of PLWHA, make policy recommendations concerning HIV/AIDS and mobilize resources to prevent and control the local epidemic. There have been marked improvements in the monitoring and evaluation environment. With support from a number of development partners, a national M&E framework is being developed. When completed it will include all national indicators as well as data collection instruments and methods for dissemination of the results. During the period under review ( ), the National Programme has made significant progress amidst many challenges. The key challenge remains that of sustaining the momentum created and building on the successes achieved thus far. 5

6 Overview of the AIDS Epidemic The current surveillance system relies on the reporting of HIV and AIDS by laboratories (public and private sector) and providers hence only a portion of all infections is captured. The Health Information Unit maintains a coded registry of all cases reported. The level of information available about HIV positive persons is limited to gender and age. Reporting of the mode of transmission and risk behaviours is especially poor making it difficult to characterise the evolution of the local epidemic according vulnerable groups. The first case of HIV was reported in Since then a total of 239 Positive HIV tests have been reported up to the end of Over time there has been an increase in the annual number of tests performed from fewer than 1,000 in 1988 to 2,836 in The absolute number of HIV positive cases has varied since the inception of the epidemic in 1984, reaching a peak of 34 in 1996 and declining since then (Graph 1). Total Number of Positive HIV Reports in St.Kitts and Nevis from Positive HIV reports Year Historically the number of male HIV positive reports outnumbered females. For example in 1998, the ratio was 1.5 male to 1 female. However this ratio has decreased in recent times with a reversal of the ratio such that in 2004 females outnumbered males (1.2:1). The most affected age group continues to be 25 to 44 years especially among females. HIV infection among males tends to cluster in the 15 to 24 and 45+ age groups. The age and gender distribution remain a cause for concern and provide a strong rationale for more interventions directed at youth especially young women and girls. The data that is available about AIDS deaths is largely incomplete. From 1984 to 2002, there were 69 AIDS death reported. The absolute numbers have fluctuated over time and this is partly an artefact of small numbers as well as significant underreporting. The 6

7 current system also does not allow HIV reporting to be linked to deaths hence it is very difficult to determine the number of persons who have died from AIDS in a given year. During the period under review, the national surveillance system was augmented by seroprevalence studies among sub populations representing the general population (antenatal clients) and at risk populations (prison inmates). The results of the former study are not available however the prison study reported a seroprevalence of 2.4% (4/169). Of note is the fact that condemned prisoners were excluded from participation. Despite the relatively small numbers of reported HIV and AIDS cases, the data suggests that the local epidemic is slow but growing. It continues to take its toll on the reproductive and most productive segments of the population. Additionally data about the mode of transmission remains limited thus the role of MSM in HIV transmission is unknown. There is an urgent need to strengthen HIV surveillance (data quality and completeness) in order to increase its usefulness for public health action. 7

8 National response to AIDS Epidemic In 2000, through a process of broad national consultation with key stakeholders, a Strategic Plan for the national expanded response to HIV/AIDS in St Kitts/Nevis was developed. The plan identified five (5) priority areas for intervention over a five year period ( ). These areas included: (1) Prevention (2) Care, treatment and support, (3) Advocacy, (4) Research, surveillance and epidemiology and (5) Programme Coordination and management. The plan s full implementation was delayed until mid 2003 when funds were mobilised through a loan from the World Bank for the sum of US$4.04 Million and a grant for the OECS from the Global Fund for AIDS, Tuberculosis and Malaria. Prevention Traditionally the National Programme s emphasis has been on increasing awareness and education of the general population about HIV/AIDS. During the period under review, these efforts continued with increased intensity. During the period under review, the Ministry of Health facilitated a health education intervention entitled Sexuality and Me in the fifth and sixth grades of all primary schools in St Kitts reaching 679 students. In 2004, another health education intervention called HIV/ AIDS Facing the realities was delivered to 667 employees in eleven work places. A total of six thousand condoms were distributed during these sessions. In August 2005, the Ministry of Health facilitated a training workshop to prepare 18 high school students (11 girls and 7 boys) to perform the role of peer educators in their schools. Since the training, the students have formed an informal network called HAPEN (HIV/AIDS Peer Education Network) and continue to work alongside their advisors to deliver presentations and counsel peers in their respective schools. Throughout the year, HIV/AIDS related issues were included in the local healthy lifestyle column and staff of the National HIV/AIDS Programme were often guests on a number of radio and television programmes. Alliances with the media were strengthened and this provided increased visibility for the National Programme through regular coverage of events and airing of commercials. Vulnerable groups such as men who have sex with men and commercial sex workers have been identified as priority target groups for intervention however stigma and illegal status have made it difficult to identify and reach these groups. In 2005, the Ministry of Health collaborated with a non governmental organisation called St Kitts/Nevis HIV/AIDS Group (SNHAG) to deliver a prevention programme to men who have sex with men. Through the network, condoms, information and education materials were disseminated to the target population. There are currently no programmes for commercial sex workers. 8

9 HIV Education in schools Students throughout the Federation have unequal access to HIV education in schools. The Ministry of Education has a policy that promotes health and family life education in all schools however the curriculum is not standardised and HIV content depends to a great extent on the teacher. Further there is a propensity to restrict instruction to students in remedial classes of secondary schools. A survey among 26 schools in the Federation (UNGASS indicator based on school survey) revealed that while guidance counsellors in the secondary schools had been exposed to life skills based education, none could be said to be qualified according to the criteria. Primary school curricula universally did not include life skills based HIV education however the older children (10-12 years) received general HIV education on an ad hoc basis from health care providers. In November 2005, HIV change agents piloted a life skills based HIV education programme for primary school children. Forty children, aged 10 to 12 years participated in the UNDP sponsored programme. Over a four week period, the children received 24 hours of tuition which included role play as well as well as didactic teaching. The programme was well received by the participants and will continue in 2006 provided that funds can be mobilised. Voluntary counselling and testing for HIV The programme began as a pilot in selected health facilities in By the end of 2005, there were 59 counsellors and the programme had been rolled out at all health facilities (21 sites) in the Federation. Despite increased capacity to deliver services, demand for and utilisation of VCT services continues to be low. In 2005, VCT (defined as client initiated) accounted for 27.7% (442/1596) of all HIV tests conducted by the Joseph N France General Hospital Laboratory (Laboratory HIV Register). There has been some success with outreach efforts and in December 2005, the National Programme hosted a National Testing Day. Seventy four persons were counselled and tested on that occasion. There are plans to continue to experiment with this approach as well as to reorient the testing strategy towards routinely offering VCT at all patient contacts with health care services. Prevention of mother to child transmission The prevention of mother to child transmission programme (PMTCT) was started in According to the national policy, all antenatal clients in the public and private sector are to be offered voluntary counselling and testing as a part of the service. Mothers who are HIV positive receive triple therapy commencing at 34 weeks and are offered elective caesarean section at term. Infants receive nevirapine within 72 hours of 9

10 birth. Mothers who are HIV positive are encouraged not to breastfeed their infants and the Government provides assistance to those mothers who cannot afford to purchase formula for their infants. Despite increasing availability of voluntary counselling and testing, uptake among antenatal clients was relatively low. In 2005, 31.2% (168/539) of pregnant women received counselling and testing for HIV (Data available for St Kitts only). Blood Safety Public health policy mandates that the blood supply should be free of HIV and other blood borne diseases. Before use, all blood collected must be screened. This includes ABO and RH typing, serological tests for syphilis, a test for hepatitis B surface antigen and tests to detect human immunodeficiency virus (1 and 2). In 2005, 534 units of blood were screened by the two blood banks in the Federation. This represented 100% of blood screened. All positive units are routinely discarded. Condom distribution Free condom distribution has been supported in the public sector for many years. Condoms are available from all health facilities. Brand name condoms are also available at traditional outlets such as pharmacies, supermarkets and a few petrol stations. In 2005, 75,435 condoms (Programme monitoring reports) were distributed by the public sector largely through family planning clinics and at major festivals and health events. There is a need to expand access to condoms through non traditional outlets as well as for condom social marketing to dispel the myths and social resistance surrounding condom use. A broader challenge remains to promote condom use and access to sexually active adolescents attending school. Adolescents below the legal age of consent for sex (16 years) still require parental consent to receive condoms and other non barrier contraceptives. Care, treatment and support In 2003, an HIV Policy and Procedure Manual was developed that included policies related to counselling and testing for HIV, national treatment guidelines and provisions for nutritional and psychosocial support for persons living with HIV/AIDS. It was launched in April 2004 and subsequently widely disseminated to health care providers. Medications to treat selected opportunistic infections such as tuberculosis, vaginal candidiasis, pneumonia and oral thrush were available prior to the period under review however public sector provision increased during

11 Prior to 2003, antiretroviral therapy was not available in the public sector largely because of prohibitive costs. With increased regional and international momentum fuelled by initiatives such as 3 by 5, there was a thrust toward increased access to medications especially in underdeveloped and developing countries. With prices considerably lower as a result of negotiations with pharmaceutical companies, St Kitts and Nevis were able to scale up treatment such that in % (38/39) of persons with advanced HIV disease were receiving medications. During the period under review there was also significant capacity building in clinical management of HIV/AIDS including the nutritional components. Currently there is a multidisciplinary Clinical Care Team that monitors the quality of care given to all persons living with HIV/AIDS. Individuals on the team also act as technical resources for care providers of PLWHA. Advocacy and human rights There has been little progress in the creation of supportive environments that protect the human rights of persons infected and affected by HIV. National policies denounce compulsory testing for general employment purposes however mandatory testing is still required for enrolment in the armed forces, by non national who require a work permit and those applying for citizenship. Further the extent to which such policies are enforceable in the private sector make them ineffective without enactment in legislation. There is no legal redress for PLWHA who have experienced discrimination. Further currently no mechanism exists to report and investigate discrimination experienced by PLWHA. Through the PANCAP Project on HIV/AIDS, Law, Ethics and Human Rights, a comprehensive national assessment of HIV/AIDS related laws and policies was to be conducted in Although funding was available, the review was not done because of the unavailability of a legal consultant to spearhead the process. While there has been little movement on the reformation of human rights legislation, there has been some advocacy in this priority area. In November 2004, St Kitts hosted the CARICOM/UK Champions for change Conference. This was a forum to promote dialogue and raise awareness on the issue of HIV/AIDS among key stakeholders from the Caribbean. The meeting included a session for Parliamentarians to assist them in acquiring the skills with which to advocate, propose and reform legislation as well as to monitor and mobilise available resources within their countries. Selected participants left the forum highly motivated and pledged to be champions for change in the fight against stigma and discrimination in their own settings. 11

12 Knowledge and behaviour change There have been no recent population based knowledge, attitudes and behaviour (KABP) surveys. A formative assessment conducted in 2004 by Family Health International (FHI) among youth 15 to 19 years revealed a high level of knowledge about HIV among participants despite high levels of risk behaviour. In 2005, a behaviour sentinel survey (BSS) was conducted by Earl and Phillip consulting Group in youths (in and out of school) in the Federation. The results of this assessment however are not yet available. Mitigation of social and economic impact Work place initiatives There is an increasing appreciation of the potential impact of HIV/AIDS on productivity and the work place. Most work places have received HIV/AIDS related information through educational sessions conducted by the Ministry of Health. In the local context, a large enterprise was defined as one that had at least 100 employees. Only one large enterprise (5.3%) had a draft Health and Safety Policy that included HIV/AIDS similarly only one met all the criteria for work place programmes (UNGASS indicator based on work place survey). It should be noted that while the definition called for a work place programme to provide VCT as well as STI diagnosis/treatment and provisions for HIV/AIDS related medications; given the local context it was said to be present if the employers provided health insurance coverage for HIV related services. There is a current initiative coordinated by the Labour Department in collaboration with International Labour Organisation (ILO). Under the project, technical support is provided to companies to develop work place HIV/AIDS policies. 12

13 Major challenges faced Despite the progress that has been made, many challenges remain. The fact that the number of new HIV infections continues to increase speaks volumes about the impact that current efforts have had on the evolution of the epidemic. Challenges facing PLWHA Stigma and discrimination associated with HIV/AIDS continues to exist. This affects the willingness of PLWHA to be more visible champions for change and advocates for human rights. It may also act as a deterrent to persons who want to get tested for HIV. While there has been some increase in the awareness of the general public, technical support is needed to develop and implement a comprehensive strategy to address stigma and discrimination. While there has been a thrust towards greater involvement of PLWHA in programme planning and implementation, they remain invisible on the front line in the fight against HIV/AIDS. Further the ability of PLWHA to provide peer support to each other has been limited because of fear and reluctance to disclose serostatus even among PLWHA. There needs to be capacity building and boost confidence among PLWHA to more adequately prepare them to participate fully in the national expanded response. Leadership and coordination Significant political commitment has been demonstrated by the Prime Minister both regionally and nationally however maintaining sustained interest remains a challenge. Leaders should be more visibly associated with HIV/AIDS and to the extent possible people living with and affected by HIV/AIDS. Leadership has not extended to include all persons such as other ministers of government, religious leaders and social celebrities. The response to HIV/AIDS has been driven predominantly by the Ministry of Health. While the National Strategic Plan embodies a multisectoral response, it has been particularly challenging maintaining interest and engaging non health sectors in the planning and implementation of HIV/AIDS related activities. To date sectoral plans from key line ministries have not been submitted and the Ministry of Health remains the key implementer of activities. In 2005, an attempt was made to restructure the National Programme and introduce a National Advisory Council on HIV/AIDS (NACHA). This body has broad representation from key line ministries as well as civil society and PLWHA. It is an effort to share responsibility for confronting the local epidemic. Its ability to function and successfully mobilise support for the national response beyond the Council s launch will be determined by the leadership and maintenance of interest and commitment among members. 13

14 Human and financial resources The coordination of the National HIV/AIDS Programme has been the responsibility of the National AIDS Secretariat. Until the latter part of 2005, the unit was staffed by two persons that included a coordinator and health educator. While there has been significant investment and capacity building of the staff, limitations remain in programme management and monitoring and evaluation. While the opportunity to scale up prevention and care and treatment efforts has been made possible through significant increases in donor funding such as the World Bank and Global Fund for Tuberculosis HIV/AIDS and Malaria, this has not been without challenges. The procedures for accessing such funds are onerous and lengthy resulting in delays in procurement and programme implementation. The need for transparency and accountability are appreciated however there needs to be an attempt to simplify the financial procedures and processes in order to accelerate implementation. Institutional capacity HIV surveillance is weak compounded by the limited capacity to conduct behavioural research. This has contributed to a poor understanding of the scope and magnitude of the local epidemic as well as the underlying factors that contribute to its continued escalation. Without this information, it is very difficult to determine which interventions are more likely to mitigate the impact of HIV/AIDS. HIV surveillance needs to be strengthened if it is to produce high quality and complete information that will be useful for programme planning and decision making. While tremendous progress has been made in the scale up of comprehensive care and treatment, an array of essential support services remain largely inadequate. This includes provisions for psychosocial support, home based care and laboratory capacity for monitoring CD4 counts and viral load. With respect to the latter, identification of appropriate low volume technology that can be used in smaller countries has been a challenge. Social and cultural norms The cultural and social norms provide a formidable challenge to efforts to mitigate the impact of HIV/AIDS and until these constructs change, it will continue to undermine efforts to prevent and control the spread of HIV. Of significance are gender norms that make Caribbean women of any socioeconomic or professional stratum relatively subordinate to their male partners in matters related to sex. Additionally multiple partners are tolerated and even expected from males. Further men who have sex with men feel the need to engage in bisexuality in order to avoid social ostracism and censure. 14

15 Support required from development partners The National Programme requires continued support in sustaining the momentum in monitoring and evaluation. Technical expertise is required in database development and management at the national level. Stigma and discrimination are among the greatest barriers to preventing the spread of further infections, providing adequate care and support and alleviating the impact of HIV/AIDS. Given its importance, there is a need for support for the development of a communication strategy to reduce stigma and discrimination. There is also a need for assistance with conducting the national assessments of HIV related laws and policies. This is a critical step in the legal and policy reform. The National Programme is often bombarded with requests for data and it sometimes overwhelms the staff responding to myriads of requests. It would be helpful if agencies could meet and decide on a comprehensive set of global indicators to measure the progress in various areas. There is also a need for advocacy among agencies to promote the sharing of monitoring and evaluation results. There is a need to advocate regionally for the incorporation of life skills based HIV education in the curriculum of both primary and secondary schools. Life skills in communication, negotiation, conflict resolution, personal risk assessment and decision making are vital for young persons. Capacity building among teachers is also needed to support their delivery of the curriculum to the students. The capacity for managing, implementing and monitoring effective HIV responses needs to be strengthened. An effort should be made to increase access of programme staff to courses in programme management, implementation and assessment. In order to ensure timely and appropriate action based on the most accurate guidance available, HIV related surveillance and knowledge systems need to be greatly improved. This information must serve as the primary backbone of a response to HIV, mapping out the needs and challenges and revealing progress toward desired results. There is a need for development partners to provide technical support to build capacity in behavioural surveillance and knowledge management. 15

16 Monitoring and evaluation environment In 2005, the Ministry of Health established a monitoring and evaluation team headed by the National Epidemiologist. With the assistance of a consultant, the team was charged with the responsibility of harmonising the various programme indicators and development of a monitoring and evaluation plan. When completed the plan will define the programme s indicators, tools for data collection and analysis as well as a strategy for dissemination of the information. The National Epidemiologist is based in the Health Information Unit of the Ministry of Health. He is the focal point for the collection of all HIV/AIDS related information. Data from health facilities (including laboratories) and the Clinical Care Coordinator is collated and disseminated for the use at all levels. HIV surveillance reports are available quarterly and annually however a comprehensive programme report has not been written since This should change shortly with the development of the Monitoring and Evaluation Plan. There is recognition of the need to strengthen capacity in monitoring and evaluation. Training for the M&E team was scheduled for 2005 however had to be postponed because of the availability of the trainers/facilitators. The training has been re-scheduled for

17 Bibliography Boisson EV, Gatwood J, Williams-Roberts H and Trotman C. HIV Seroprevalence among male inmates in Her Majesty s Prison, St Kitts and Nevis. CAREC, Ministry of Health, St Kitts and Nevis Camara B and Branson D. CAREC-CDC Estimates of People living with HIV/AIDS in the CAREC Member Countries at the end of CAREC, PAHO/WHO. June Caribbean Epidemiology Centre. Status and Trends. Analysis of the Caribbean HIV/AIDS Epidemic CRF Consulting. Strategic Plan for the National Response to HIV/AIDS in St Kitts and Nevis Caribbean Conference of churches. Guidelines for Caribbean Faith Based Organisation in developing policies and action plans to deal with HIV/AIDS. November Ferdinand K and Williams-Roberts H. HIV Policy and Procedure Manual. A guide for health care professionals in St Kitts and Nevis. Ministry of Health. October Mc Lean Roger. Report on behaviour change communication. Formative assessment of in school youths years in St Kitts and Nevis. Family Health International. June UNAIDS. Strengthening the Caribbean Regional Response to the HIV Epidemic. Report of the Caribbean Technical Expert Group Meeting on HIV Prevention and Gender. October UNAIDS. Guidelines on construction of core indicators. July

18 Annex 1: Consultation/preparation process for this national report A local consultant was contracted to collect the information for the UNGASS indicators and to write the UNGASS report. The steps for the development of the report included: 1. Identify data needs by reviewing the core indicators listed in the UNGASS guidelines. 2. Determine the most appropriate sources of data and methods for collection (interviews, desk review, surveys). 3. Gather data from the sources identified using the appropriate methods. 4. Data was analysed and the report drafted with feed back from key stakeholders especially with regard with to challenges and support required from development partners. 5. Report finalised and circulated to key stakeholders including Permanent Secretary in Ministry of Health. Data for the report was collected through the following surveys: 1. School survey 2. Work place survey Civil society participation Part B of the National Composite Policy Index Questionnaire was completed through a series of interviews conducted with civil society organisations. Participants represented the following organisations: Social Security St Kitts/Nevis Chamber of Industry and Commerce St Kitts Christian Council St Kitts Cooperative Credit Union FACTTS (PLWHA support group) The staff from the National Programme completed the Part A of the National Composite Index while the monitoring and evaluation sections were completed by members of the M&E team. Technical support was provided through UNAIDS in the formatting of the report and identification of key sections to be included. 18

19 Annex 2: Core indicators for the Declaration of Commitment on HIV/AIDS National Commitment and Action National composite policy index Informant interviews Government funds spent on HIV/AIDS Desk review US$347,500 National Programme and behaviour Prevention Percentage of schools with teachers who have been trained in life skills based education and who taught it during the last academic year Percentage of large companies who have HIV/AIDS work place policies and programmes Percentage of HIV positive pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother to child transmission Care and treatment Percentage of women and men with advanced HIV infection receiving antiretroviral combination therapy Percentage of transfused blood units screened for HIV Knowledge and behaviour Impact Percentage of young women and men aged who are HIV infected Percentage of adults and children with HIV still alive 12 months after initiation of antiretroviral therapy Percentage of infant born to HIV infected mothers who are infected * Not available School based survey Work place survey Programme monitoring reports Programme monitoring reports Laboratory Blood Bank Register Programme monitoring reports Based on formula (default values used) ( ) 0% 5.3% 1 of 3 HIV positive pregnant women received a complete course (Antenatal seroprevalence data not available) 97.4% 100% *N/A *N/A 100% 20.9% 19

20 Annex 3: National Composite Policy Index questionnaire Findings: I Strategic Plan St Kitts and Nevis developed a Strategic Plan for the National Expanded Response to HIV/AIDS in The plan identified five priority areas for intervention over the years It was developed with broad stakeholder consultation and included input from civil society and PLWHA networks. It included major sectors such as Health, Education, Labour, Youth, Social development and Gender Affairs and Tourism. The NSP includes an operational plan and states the formal programme goals which are to reduce: the spread of HIV infection and the impact of HIV/AIDS on individuals, families and communities. The plan was costed and includes a detailed budget for each of the priority areas. While there is no National Development Plan, both the medium term economic strategy and the poverty reduction strategy ( ) incorporate HIV/AIDS and recognise the implications for development and poverty eradication is the local epidemic is not adequately addressed. Both documents address prevention, care and treatment as well as reduction of gender inequalities. II Political Support The Prime Minister of the Federation is the CARICOM spokesperson for health. He has openly advocated for reduction of stigma and discrimination as well as optimal provisions for care, treatment and support of PLWHA. His passion and commitment are not equally demonstrated by other elected officials. While the terms and conditions governing the operation of the National Advisory Council on HIV/AIDS have been outlined in the National Prevention and Control Bill (2001), it was never enacted. In the absence of legislation, in 2005 Cabinet provided a directive to activate the committee. The committee which has broad representation from key stakeholders in the public and private sector including PLWHA networks and faith based organisation held its first meeting in December of

21 III Prevention Prevention is a key priority area identified in the NSP. The National Programme has had always promoted information, education and communication on HIV/AIDS in the general public. While the plan also identifies key vulnerable populations such as men who have sex with men, commercial sex workers and youth for targeted intervention; very few programme exist for the former two at risk groups. HIV/AIDS is a relatively neglected part of the health and family life curriculum (HFLE) in both secondary and primary schools. There is a need for significant capacity building among educators to prepare them to deliver the appropriate content to students. The school curriculum provides the same reproductive health information to boys and girls. During 2003 to 2005, a number of programmes were piloted and subsequently rolled out including: Voluntary counselling and testing Prevention of mother to child transmission of HIV programme Programmes to ensure universal precautions in health care settings IV Care and support During 2003 to 2005, access to antiretroviral therapy improved significantly. ART is available in the public sector at no cost to all PLWHA who meet the clinical criteria for treatment. Care has also expanded to include provisions for treatment of opportunistic infections, nutritional management, psychosocial support and home based care. While there are no specific provisions for children who are made vulnerable by HIV, there is a social safety net (through the Ministry of Community and Social Development) that protects children irrespective of the underlying factors. Children attend public school at no cost to parents/guardians and a hot lunch is provided in the primary school and for selected children in need in secondary schools. Provisions are also made for school supplies and uniforms as needed. 21

22 V Monitoring and evaluation In 2005, with the assistance of a consultant and regional partners, the Federation began to develop a monitoring and evaluation plan. When completed, it will include national indicators as well as data collection tools and a strategy for the disseminated of information to stakeholders. There is a functional Health Information System. The National Epidemiologist is the focal point for the collection and collation of all HIV related data. HIV surveillance needs to be strengthened and significant capacity building is needed in research and knowledge management. VI Human rights There are no specific non-discrimination laws which specify protection for persons living with HIV/AIDS. There are no formal mechanisms to report and monitor human rights abuses of PLWHA. The legal environment remains hostile to marginalised groups such as commercial sex workers and men who have sex with men. This has made it difficult to identify these groups for targeted interventions. Legal and policy reform remains one of the weakest areas and achieved relatively low scores on the questionnaire. A great deal needs to be done to create a supportive legal environment for PLWHA and vulnerable at risk groups that promote inclusion and foster prevention and care and treatment efforts. VII Civil society participation There has been an effort to involve civil society in all stages of planning and implementation of the NSP. There is also representation on the National Advisory Council for HIV/AIDS which ensures that they continue to play a significant part in the national expanded response. While civil society has not been a key advocate of national policy formulation, they have always been willing to mobilise resources (financial) to support the implementation of prevention activities. 22