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Status of HIV in Dominican Republic
– Reported, February 15, 2012
According to UNAIDS, the number of new infections appears to be declining. There is evidence that the drop in HIV prevalence may be due to an increase in condom use and a reduction in multiple sexual partners. However, there is a nearly sevenfold variation in HIV prevalence among the countrys provinces and a fourfold difference between its regions, with the highest prevalence along the northern DRHaiti border and the lowest prevalence in the central border region (DHS, 2007).
HIV prevalence in pregnant women was relatively stable for many years: The 2007 DHS reports that pregnant women have the same HIV prevalence as all women. However, in 2007, sentinel surveillance of pregnant women of all ages reported a median HIV prevalence of 1.5 percent and a seroprevalence above 2 percent in six of 11 sites, with the highest being 8.8 percent in a hospital in the northern border region. But positive signs continue to be seen: In the Santo Domingo National District, antenatal clinics have noted a decline in HIV prevalence, probably because of a successful prevention campaign held there.
A disproportionate contribution to the epidemic has come from two specific subgroups: (1) women with four or fewer years of formal education and (2) residents of bateyes (sugar cane plantations). Respectively, they represent 8.3 percent and 1.1 percent of the general population, yet they contribute 23.7 percent and 4.5 percent respectively to the number of persons living with HIV. Data from the 2007 DHS and the 2008 Behavioral Surveillance Survey with biomarkers (BSS+) point to these subgroups and geographical areas as important markers of the HIV epidemic in the DR. Infection levels among workers living in bateyes average 3.2 percent, according to the 2007 DHS.
The Dominican Republics epidemic is also driven by unprotected sex, sex with multiple partners, sex workers and their clients and partners, men who have sex with men (MSM), drug users in particular, injection drug users (IDUs) and/or members of mobile subpopulations that engage in risky sexual behaviors. For example, in the 2007 DHS, 24 percent of Dominican men reported having had sex with more than one partner in the preceding 12 months. In addition, according to UNAIDS, studies in 2006 reported prevalence among commercial sex workers (CSWs) who had received prevention information is 2.7 to 3.5 percent, depending on their location; by comparison, the overall estimated prevalence among sex workers was 4.8 percent (BSS+, 2008). In some sites, however, the prevalence among CSWs is declining and equals that of pregnant women. For example, in Santo Domingo, prevalence among sex workers has been decreasing over this decade and is approaching the same level as among pregnant women nationally. This may be attributable to the successful implementation of the 100% Condom Strategy by two nongovernmental organizations (NGOs) in several provinces as well as the U.S. Agency for International Development (USAID)/DR condom social marketing program that targets CSWs and has established more than 1,000 sales outlets throughout the country. Active migration (including migration between cities and the countryside, migration to and from Haiti, and migration to and from the United States) also increases the risk of HIV.
Other factors that put the Dominican Republic population at risk of HIV/AIDS include early age of sexual debut, high pregnancy rates among adolescent girls and young women, and the Dominican Republics popularity as a tourist destination coupled with increasing levels of sex tourism. These and other factors suggest the need to target interventions to young adults, provinces with high rates of tourism, women with low education levels, MSM, IDUs, and bateyes.
According to the World Health Organization (WHO), the estimated incidence rate of tuberculosis (TB) in the Dominican Republic (73 cases per 100,000 population in 2008) is one of the highest in the Americas. HIV-TB co-infection complicates the care and treatment of both diseases. Data on HIV-TB co-infection suggest 8.6 percent of new TB patients are infected with HIV. However, as the screening of HIV in TB patients has increased, reaching approximately 50 percent of all TB patients, some provinces are reporting co-infection rates as high as 20 percent. Therefore, the Dominican Republic has the potential for a burgeoning epidemic of TB along with HIV. To address this, national HIV-TB guidelines have been developed and are ready to be published, and HIV-TB activities have been included in national plans. Patients who are co-infected with HIV and TB receive TB treatment free of charge from the Government.
National Response
The Government of the Dominican Republic has responded aggressively to the HIV/AIDS epidemic. Established in 2000, the Presidential Council on AIDS (COPRESIDA) coordinates the HIV/AIDS National Strategic Plan for the Prevention and Control of HIV/AIDS and STDs 20072015. COPRESIDAs activities include implementing public policies, conducting prevention campaigns, providing care and treatment for people living with HIV/AIDS (PLWHA), promoting private sector involvement in response to the epidemic, and reducing stigma and discrimination. COPRESIDA has successfully engaged the private sector, and 120 businesses now have HIV prevention programs in the workplace. The Ministry of Health (MOH) implements HIV/AIDS services and provides diagnostic tests in the public sector. The National AIDS Program (NAP) develops HIV/AIDS-related norms, protocols, and surveillance. The Dominican Republic is working toward having a unified monitoring and evaluation plan, but there are increasing problems with data quality and data collection as health sector reform develops. The main lines of action of the NAP are:
Developing a management information system that collects accurate and timely data for decision making
Conducting information, education, and communication campaigns, including HIV prevention education in schools and with most-at-risk populations
Coordinating care and support for PLWHA, including financing from the Government to complement the Global Fund to Fight AIDS, Tuberculosis and Malaria Rolling Continuation Channel (RCC) grant
Reducing mother-to-child transmission
Ensuring blood supply safety
Monitoring and evaluating national and provincial health plans
Distributing condoms to individuals engaging in risky sexual behaviors
Since 1995, an AIDS law has made it illegal to discriminate against PLWHA. For example, it is illegal to require HIV testing for employment purposes. Although the law should protect the rights of PLWHA, enforcement is uneven and inconsistent, and stigma and discrimination against PLWHA and those engaging in behaviors putting them most at risk for HIV/AIDS are common. A revised AIDS law was drafted and presented to the Dominican Congress, which expects to begin review and consideration of the law in fall 2010.
The Government has implemented programs to address HIV treatment. For example, HIV testing is provided by the Government free of charge. In addition, the Government has been administering free antiretroviral therapy (ART) for PLWHA since 2003. According to COPRESIDA, there are approximately 15,500 adults and children receiving ART as
of June 2010. According to the WHO/UNAIDS/UNICEF Towards Universal Access report, ART coverage rates were still low at 38 percent in 2007. Moreover, ART coverage rates are low for children, at less than 45 percent of those who need ART (UNAIDS, 2010). Program sustainability is also uncertain because international donors fund ART rather than the national budget. The Government has not made a commitment to provide additional funding for ART.
Currently, the Government works with a number of international donors to combat HIV/AIDS, including the William
J. Clinton Foundation, UNICEF, the United Nations Population Fund, the World Bank, and the Global Fund. The Global Fund has made significant investments in HIV prevention in the Dominican Republic since 2004 through a second round grant for $56.8 million which was completed in June 2009. The follow-up RCC grant is for $89 million, 65 percent of which is for procuring antiretrovirals. The U.S. Government (USG) provides nearly 30 percent of the Global Funds budget worldwide.
USAID Support
Through USAID, the Dominican Republic received $5.75 million in fiscal year (FY) 2009 for essential HIV/AIDS programs and services. USAIDs HIV/AIDS programs in the Dominican Republic are implemented as part of the
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Launched in 2003, PEPFAR is the USG initiative to support partner nations around the world in responding to HIV/AIDS. Through PEPFAR, the USG has committed approximately $32 billion to bilateral HIV/AIDS programs and the Global Fund through FY 2010. PEPFAR is the cornerstone of the Presidents Global Health Initiative (GHI), which commits $63 billion over six years to support partner countries in improving and expanding access to health services. Building on the successes of PEPFAR, GHI supports partner countries in improving health outcomes through strengthened health systems, with a particular focus on improving the health of women, newborns, and children.
One component of the GHI and PEPFAR are country-led plans called Partnership Frameworks (PFs). The Dominican Republic was one of the first countries in Latin America and the Caribbean to develop an HIV PF through PEPFAR. In 2009, through PEPFAR, a Partnership Framework Implementation Plan was approved by the U.S. and Dominican Governments and other country stakeholders. This five-year plan will provide approximately $86 million to support HIV/AIDS activities in the country through four USG agencies (USAID, CDC, the Department of Defense (DOD), and the Peace Corps). The USG has committed approximately $47 million for the first three years of this program to bilateral HIV/AIDS programs through NGOs and the Dominican Government.
USAID, in collaboration with PEPFAR, is the lead bilateral donor in the Dominican Republic. Its efforts include supporting NGOs to implement prevention activities and strengthening the Governments voluntary counseling and testing (VCT) and prevention of mother-to-child transmission (PMTCT) programs. USAID has a five-year, $35 million contract to help overhaul and strengthen the countrys HIV/AIDS, reproductive health, and child survival programming and will establish additional mechanisms once the additional funding becomes available. Areas of focus include HIV/AIDS prevention and care, VCT, pre-and post-natal care, orphans and vulnerable children (OVC), and PMTCT. The Agency also provides ongoing technical assistance to the MOH to implement a unified procurement and logistics system as well as monitoring, evaluation, and information systems.
USAIDs 20072012 HIV/AIDS Strategic Overview for the Dominican Republic focuses on prevention efforts on the Haitian border and in the five eastern-most provinces, where at-risk populations are concentrated. The plan addresses HIV/AIDS prevention, including VCT, and care for HIV-infected and -affected individuals. Countrywide, USAID works with approximately 22 NGOs and faith- and community-based organizations, implementing about 40 HIV/AIDS activities. At the national level, USAID collaborates with the Ministry of Education to strengthen sex education and life skills curricula and assists the NAP in developing updated PMTCT and VCT norms and protocols, a national condom policy, and expanded HIV/AIDS care services. USAID conducts operations research in the country, including a national survey of TB drug resistance and TB-HIV co-infection. Other programs supported by the Agency have focused on estimating the number of children who are infected with HIV/AIDS, have been orphaned by AIDS, or have mothers living with AIDS. USAID-supported programs achieved the following recent successes:
Distributing more than 77 million condoms from July 2003 to July 2009. PANTE brand condoms constitute more than 62 percent of condoms available in high-risk zones
Reaching 77,220 adolescents and youth in 2009 with messages about abstinence and being faithful through life skills programs in schools
Administering HIV counseling and testing for PMTCT to 67,267 pregnant women and providing them with their test results
Supporting palliative care for 31,608 adults infected with and affected by AIDS in 2009
Serving 1,025 OVC in 2009
The USG is the largest single donor to the Dominican Republics health sector, including its contribution through the Global Fund. The PEPFAR team comprises USAID, CDC, DOD, Peace Corps, and Department of State.
Credits: UNAIDS
More Information at:
http://www.usaid.gov/our_work/global_health/aids/Countries/lac/domreppub_profile.pdf
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