The HIV/AIDS epidemic in the Latin America and Caribbean Region

Introduction Despite its shared heritage, the region of Latin America and the Caribbean (LAC) encompasses great diversity. Populations range from several thousands in some Caribbean island states to Brazil, with over 150 million inhabitants. The region is home to some of the most impoverished countries in the world, while many others boast strong institutions, civil society groups, academic centers of excellence and health infrastructure. It is the one region of the world in which the Spanish and Portuguese languages predominate, and where the influence of the Catholic Church is most extensive. These and other factors have uniquely influenced local and national responses to the HIV/AIDS epidemic, resulting in examples of both astonishing success and disappointingly slow progress. After twenty years of the AIDS epidemic, HIV has spread worldwide and become one of the leading causes of death in many countries [1]. Although AIDS on the American continent was first reported in the United States, the first cases outside the US occurred in Haiti in 1983 [2]. Since then, all the countries in the LAC region have been affected in different degrees. In a recent publication [3], PAHO estimates that the impact of AIDS mortality in the region as a whole has reduced life expectancy by about 0.6 years in men. The papers in this special edition on AIDS in Latin America and the Caribbean address a variety of themes and issues relevant to the region. They provide insight into the status of the HIV epidemic and its trends in different population groups, and assess the scope and effectiveness of responses. The LAC region pioneered access to antiretroviral therapy (ART) for the developing world as soon as it was available in 1996. Chequer and colleagues note that most of the region's countries have provided at least some access to ART, with approximately 150,000 people now receiving treatment. The overwhelming majority of these are in Brazil - the country with the highest number of people living with HIV/AIDS - where significant improvements in quality of life, reduced mortality and economic savings have been achieved. Nevertheless, even as the cost of ART falls, inequities persist in and between countries in the region. The authors propose strategies to overcome these inequities and identify constraints which remain. An epidemiological overview is presented by Calleja and colleagues. Although HIV was first detected in this part of the world, prevalence rates have not reached the levels of sub-Saharan Africa. Nonetheless, they are steadily increasing both in general populations and among vulnerable groups, particularly among men who have sex with men (MSM) in several Latin American countries. Rates are highest in the Caribbean basin, although data collection is limited or inconsistent in many places. The papers highlight the need to continue to improve data collection and introduce new tools to monitor behavioural trends. As Noriega and colleagues observe in their description of the evolution of HIV/AIDS surveillance since the first AIDS case reports in 1986, surveillance in the region need to be strengthened and adapted to reflect best practices and current trends in the epidemic. Since 1997, WHO and UNAIDS have produced estimates of the HIV/AIDS epidemic in this region. The methods and parameters used to estimate the burden of generalized HIV epidemics per country have previously been published [4]. Here, using Honduras as a case study, Soto and colleagues present the rationale and methods being used to reliably estimate prevalence in low level or concentrated epidemics. As the authors note, estimating the burden of HIV/AIDS is an iterative process which requires regular updating and review. Touzé and colleagues review both established and new patterns of injecting drug use in the region. Although some successful prevention efforts have occurred in Brazil and Argentina, harm reduction strategies are relatively new in most of Latin America. As injection drug use becomes a more serious concern, the need for policies and programs to prevent HIV infection amongst injection drug users is becoming more important. An overview of the HIV epidemic among men who have sex with men in Latin America and the Caribbean is presented by Cáceres. The discrimination and stigmatisation experienced by these men have made them difficult to reach, even though they are concentrated mainly in urban centres, and programs oriented to MSM exist in most countries. The paper describes the diversity among MSM and their potential bridging role through interaction with other vulnerable groups. As elsewhere in the world, responses increasingly focus on reducing marginalization through the strengthening of gay organizations. The role of mobile populations in HIV transmission is well known. The long history of migration to the North – both legal and illegal – by Latin American men and women has fed literature and art across the continent. Bronfman and colleagues present the preliminary results of a multi-centre study which analyses the socio-economic, cultural and political contexts that give rise to population mobility and its relationship to vulnerability to STI/HIV/AIDS in Central America. Two papers are presented related to economics. The first, by Izazola and colleagues, shows that despite relatively low prevalence rates in the region, considerable resources are being spent on the response to HIV/AIDS, with great variation between countries in both the amount and type of expenditure. The second economics paper by Opuni estimates the resources required to fight HIV/AIDS in Latin America and the Caribbean, compared with previously published global estimates [5]. The paper reveals only a small discrepancy between the model estimates and those of country specialists, lending confidence to the overall consistency and reliability of the estimates currently being made. Multisectoral responses are essential to overcoming the HIV/AIDS epidemic. The LAC region has a rich history and diversity of political, social and other civil society organizations. Over the years, the number of non-governmental organisations (NGOs) contributing to the response has steadily increased, and many, though not all, countries have actively supported them in this role. However, a wide gap remains between community needs and the capacity of such organizations to meet them. The paper by Hearst illustrates the vitality of the NGO sector in a series of collaborations between the University of Sao Paulo and more than 50 Brazilian NGOs. This series of articles provides an important perspective on this dynamic part of the world, illustrating how societies can harness vibrant and diverse forces to achieve great success in fighting this disease. It also contains some timely reminders about the challenges which lie ahead.