Epidemiology of TB and HIV/AIDS in the Caribbean

1. Module 1 – March 2010 Epidemiologyof TB and HIV/AIDS in the Caribbean

2. Project Partners Funded by the United States Agency for International Development (USAID)and the Health Resources and Services Administration (HRSA)

3. Module Overview • Global epidemiology • TB, HIV, and TB/HIV • Regional epidemiology • TB, HIV, and TB/HIV • Summary

4. Learning Objectives Objectives: At the end of this presentation, participants will be able to: • Describe the current epidemiology of TB globally and in the Caribbean Region • Describe the current epidemiology of HIV and AIDS globally and in the Caribbean Region

5. A Global View Tuberculosis continues to be an important global public health problem, intensified by the human immunodeficiency virus (HIV) epidemic.

6. WHO Global TB Report, 2009 • 9.4 million new cases of TB in 2008 • Of these new cases, 1.4 million (15%) were HIV-positive • 1.8 million people died from TB in 2008, including 500,000 people with HIV; 4500 deaths per day • TB is a leading killer of people infected with HIV

7. WHO Global TB Report, 2009 (2) • TB prevalence and mortality rates are falling globally • However, multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis is compounding the TB problem world wide • Estimate 0.5 million MDR-TB cases world-wide • Mortality rate of MDR- and XDR-TB is comparable to those of TB before the era of TB antibiotics

9. Estimated Numbers of New Cases, 2007

10. Estimated TB Incidence Rate, 2007

11. Tuberculosis • About one-third of the world population is infected with Mycobacterium tuberculosis • 1 in 10 people infected will become sick with active TB disease in their life time • Conditions that weaken the human immune system, such as HIV, make people much more vulnerable to TB

12. Global HIV • WHO 2009: “The number of people living with HIV worldwide continued to grow in 2008, reaching an estimated 33.4 million...this reflects the combined effects of continued high rates of new HIV infections and the beneficial impact of antiretroviral therapy.”

13. Global HIV (2) • People living with HIV33.4 million [31.1 – 35.8 million] • New HIV infections in 2008 2.7 million [2.4 – 3.0 million] • Deaths due to AIDS in 20082.0 million [1.7 – 2.4 million]

14. HIV Testing for TB Patients, 2007

15. HIV/AIDS and TB • The terms “co-epidemic” or “dual epidemic” is often used to describe their relationship • HIV affects the immune system and increases the likelihood of people acquiring new TB infection • It also promotes both the progression of latent TB infection to active disease and relapse of the disease in previously treated patients

16. HIV/AIDS and TB (2) • At least one-third of the 33.4 million people living with HIV worldwide are infected with TB and are 20-30 times more likely to develop TB than those without HIV • If not treated appropriately, 90% of those living with HIV die within months of contracting TB • The majority of people who are co-infected with both diseases live in sub-Saharan Africa

17. Geographical Distribution of HIV-positive TB Cases, 2007 WHO Region Country

18. CHART RCU Office CAREC Office BAHAMAS BARBUDA ANTIGUA BELIZE HAITI ST. KITTS & NEVIS JAMAICA DOMINICA SAINT LUCIA ST. VINCENT & THE GRENADINES BARBADOS GRENADA TRINIDAD & TOBAGO GUYANA GUYANA SURINAME SURINAME

19. CAREC Member Countries • The CAREC member countries (CMCs) have experienced a resurgence of TB • During the first half of the 1980s, there was a progressive decline in the number of TB cases in CMCs, followed by a leveling off in 1988 to 1989 • Since that time, there has been a gradual but distinctly notable increase in TB in some member countries

20. Reported New and Relapse TB Cases for Select CMCs, 2004 - 2007

21. Regional HIV and AIDS statistics, 2008 and 2001 (First of 2 parts) Adults & children living with HIV Adults & children newly infected with HIV 2008 2001 2008 2001 22.4 million [20.8 – 24.1 million] 19.7 million [18.3 – 21.2 million] 1.9 million [1.6 – 2.2 million] 2.3 million [2.0 – 2.5 million] Sub–Saharan Africa 310 000 [250 000 – 380 000] 200 000 [150 000 – 250 000] 35 000 [24 000 – 46 000] 30 000 [23 000 – 40 000] Middle East & North Africa 3.8 million [3.4 – 4.3 million] 4.0 million [3.5 – 4.5 million] 280 000 [240 000 – 320 000 310 000 [270 000 – 350 000] South and South–East Asia 850 000 [700 000 – 1.0 million] 560 000 [480 000 – 650 000] 75 000 [58 000 – 88 000] 99 000 [75 000 – 120 000] East Asia 2.0 million [1.8 – 2.2 million] 1.6 million [1.2 – 1.6 million] 170 000 [150 000 – 200 000] 150 000 [140 000 – 170 000] Latin America 240 000 [220 000 – 260 000] 220 000 [200 000 – 240 000] 20 000 [16 000 – 24 000] 21 000 [17 000 – 24 000] Caribbean 1.5 million [1.4 – 1.7 million] 900 000 [800 000 – 1.1 million] 110 000 [100 000 – 130 000] 280 000 [240 000 – 320 000] Eastern Europe & Central Asia 850 000 [710 000 – 970 000] 660 000 [580 000 – 760 000] 30 000 [23 000 – 35 000] 40 000 [31 000 – 47 000] Western & Central Europe 1.4 million [1.2 – 1.6 million] 1.2 million [1.1 – 1.4 million] 55 000 [36 000 – 61 000] 52 000 [42 000 – 60 000] North America 59 000 [51 000 – 68 000] 36 000 [29 000 – 45 000] 3900 [ 2900 – 5100] 5900 [ 4800 – 7300] Oceania TOTAL 33.4 million[31.1 – 35.8 million] 29.0 million[27.0 – 31.0 million] 2.7 million[2.4 – 3.0 million] 3.2 million[2.9 – 3.6 million]

22. Regional HIV and AIDS statistics, 2008 and 2001 (2) (Last of 2 parts) Adult prevalence (%) Adult & child deaths due to AIDS 2008 2001 2008 2001 1.4 million [1.1 – 1.7 million] 1.4 million [1.2 – 1.7 million] 5.2% [4.9% – 5.4%] 5.8% [5.5% – 6.0%] Sub–Saharan Africa 20 000 [15 000 – 25 000] 11 000 [7800 – 14 000] 0.2% [<0.2% – 0.3%] 0.2% [0.1% – 0.2%] Middle East & North Africa 270 000 [220 000 – 310 00] 260 000 [210 000 – 320 000] 0.3% [0.2% – 0.3%] 0.3% [<0.3% – 0.4%] South and South–East Asia 59 000 [46 000 – 71 000] 22 000 [18 000 – 27 000] 0.1% [<0.1%] <0.1% [<0.1%] East Asia 77 000 [66 000 – 89 000] 66 000 [56 000 – 77 000] 0.6% [0.5% – 0.6%] 0.5% [<0.5% – 0.6%] Latin America 12 000 [9300 – 14 000] 20 000 [17 000 – 23 000] 1.0% [0.9% – 1.1%] 1.1% [1.0% – 1.2%] Caribbean 87 000 [72 000 – 110 000] 26 000 [22 000 – 30 000] 0.7% [0.6% – 0.8%] 0.5% [0.4% – 0.5%] Eastern Europe & Central Asia Western & Central Europe 13 000 [10 000 – 15 000] 7900 [6500 – 9700] 0.3% [0.2% – 0.3%] 0.2% [<0.2% – 0.3%] North America 25 000 [20 000 – 31 000] 19 000 [16 000 – 23 000] 0.6% [0.5% – 0.7%] 0.6% [0.5% – 0.7%] Oceania 2000 [1100 – 3100] 0.3% [<0.3% – 0.4%] 0.2% [<0.2% – 0.3%] <1000 [<500 – 1200] TOTAL 0.8% [<0.8% – 0.8%] 0.8% [<0.8% – 0.8%] 2.0 million[1.7 – 2.4 million] 1.9 million[1.6 – 2.2 million]

23. HIV Prevalence (%) in Adults (15 - 49) in the Caribbean, 2007

26. HIV Vulnerable Populations • Youth: Forced sexual debut affecting 20% of young people • Women: Poor gender relations and gender based violence in and out of home (child abuse, coercion, rape of young women)

27. HIV Vulnerable Populations (2) • In 2007, HIV prevalence in the Bahamas, Barbados, and Jamaica in young males age 15–24 years was twice as high as for females • The reverse was true in the Dominican Republic, Haiti, and Trinidad and Tobago, where HIV prevalence in young females 15–24 years of age was twice as high as their male cohort in 2007

28. HIV Vulnerable Populations (3) • Migrant Workers (Legal and Illegal): motivated the desire for socio-economic improvement • Illegal status — isolation, exclusion, limiting access to health services • Men who have sex with men (MSM): Homophobia is rampant and homo-sexuality illegal in basically all countries of the Caribbean • Prevalence of MSM is 11% of HIV cases overall

29. HIV Vulnerable Populations (4) • Commercial sex workers/Transactional sex: Unprotected sex between sex workers and clients • A PAHO/CAREC study documented sex worker HIV prevalence rate of 11% in Guyana (2000) and 24.1% in Suriname (2004)

30. Caribbean: HIV/AIDS and TB • 2,135 new TB cases (all forms) were reported in CMCs in 2007 • 50% (1,066) were tested for HIV • 27% (291) were HIV-positive doubling the regional average for the Americas • Compared with data from the period 1997 to 2002, the proportion of TB patients tested for HIV has declined from 59 to 50% and the seroprevalence rate has been kept constant

31. Caribbean: HIV/AIDS and TB (2) • In 2007, 28% of co-infected patients received cotrimoxazole (CPT) and 39% anti-retroviral therapy (ART) • Between 2006 – 2007, the percentage of co-infected patients: • declined in the Bahamas (54% to 30%) and Jamaica (31% to 22%) • greatly increased in Guyana (13% to 28%) and Trinidad & Tobago (5% to 30%)

32. Caribbean: HIV/AIDS and TB (3) • HIV is driving the TB epidemic in the Region • Co-infection rates range 10%-40% • TB and HIV collaboration is needed to control and prevent both diseases

33. TB & HIV Co-infection in Select CMCs: 2003 - 2006

34. TB/HIV Co-infection: Bahamas, Belize, Guyana, Jamaica, St. Lucia, Suriname and Trinidad & Tobago, 2000 - 2006

35. Summary • The incidence of TB, HIV and TB/HIV varies within the region • Additional efforts to improve surveillance of both diseases is needed to more accurately describe the merging epidemics in the region • Lessons learned globally for addressing the co-epidemic can and must be applied regionally and at the country level