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HIV/AIDS in Latin America and the Caribbean Editorial
  The Lancet July 26 2008; 372:263
from Jules: by the way NATAP has been providing HIV treament education programs in the Carinbbean for many years, in San Juan (where 400 attend every event), in Santo Domingo (for 950 attendees at one particular forum), and in the Virgin Islands.
Mexico City is gearing up to host the XVII International AIDS Conference (AIDS 2008) on Aug 3-8. Around 20_000 people are expected to attend this biennial meeting, which for the first time is being held in Latin America and the Caribbean. The conference should provide a unique opportunity to focus attention on a region that often gets sidelined in the global response to HIV/AIDS.
Nearly 2 million people are estimated to be living with HIV/AIDS in Latin America and the Caribbean-more than in the USA, Canada, western Europe, Australia, and Japan combined. Most transmission is through unprotected sex but of growing concern is the spread from unsafe injecting drug use. The average HIV prevalence rate in adults in Latin America is low (0·5%) compared with Africa (5%), yet the numbers of people affected are still considerable. Most infections are in men who have sex with men, followed by sex workers and their clients, intravenous drug users, and migrants. An increasing problem in the region is that many men have sex with both men and women, which is contributing to the rapid spread of the epidemic in women. The Caribbean, with an adult prevalence rate of 1%, is the second hardest-hit region in the world after sub-Saharan Africa. Heterosexual sex is the main mode of HIV transmission, and women and young people are especially vulnerable. Although the prevalence has stabilised in several Caribbean countries such as the Dominican Republic and Haiti (more in urban than rural populations), none of the Latin American countries have experienced a significant drop in prevalence since the start of the epidemic, and the total number of new infections has been predicted to increase.
The amalgam of cultures and populations, socioeconomic disparities, languages, and sexual proprieties means the HIV epidemic is not homogeneous and it is hard to make generalisations from one country to the next. In this region the subject of HIV/AIDS is often swept under the carpet. Some of the common factors that characterise this region and prohibit an effective response include: generalised poverty, homophobia, gender inequality, lack of access to health-care and educational services, immigration and emigration, the absence of leadership in some countries, the lack of research into patterns of transmission, pressure from the Catholic Church that hinders prevention efforts, and laws that are inadequate in the context of the epidemic. Furthermore, the poor investment in health and research has been a huge challenge because most of the international donors and grant funders target resources to Africa and south Asia. Indeed, to Latin America's credit, over 90% of the total resources for HIV/AIDS come from domestic public sources.
Nevertheless, Latin America has a much better infrastructure than Africa and a record of large public-health successes. Brazil, with its courageous drug policies, has made universal access to antiretroviral drugs a reality. Since the 1990s, the number of Brazilians dying from AIDS-related illnesses has fallen by 50%. The antiretroviral programme currently reaches 80% of the infected population, which is similar to the coverage in wealthier, more developed nations. In Mexico, blood-transmitted infections are now under control due to safeguards on the blood supply being put in place by the government early in the epidemic. In terms of individual prevention campaigns, Latin America has some of the boldest and most creative programmes anywhere in the world, such as the anti-homophobia campaign spearheaded by Jorge Saavedra in Mexico.
One of the major themes at the conference will be tackling stigma and discrimination, which is particularly pervasive in the region but also happens elsewhere. For too long the needs of vulnerable populations have been neglected. In Mexico the adoption of a rights-based perspective to address the challenge of HIV/AIDS globally needs to reaffirm that universal access to prevention, treatment, and care is a human right and that no form of stigma and discrimination will be tolerated.
There is still an enormous amount to do to bring about the large reductions in HIV prevalence in the high-risk groups. The global-health architecture needs to put Latin America in their plans. Not to do so is unfair and shortsighted, because there are likely to be good returns on investment. At the meeting, people from Latin America and the Caribbean will have the chance to show the world the reality of the different epidemics the region is confronting, the responses in place, and the obstacles to overcome. Garnering the world's attention for 5 days must have a lasting impact and re-energise the HIV community in the region.
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