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Towards Elimination of Vertical Transmission of HIV and Syphilis as a public health problem in the Caribbean

XVII International AIDS Conference, AIDS 2008
August 3-8, 2008.
Lunch meeting

Mexico City. August 5, 2008.-

Thousands of people have come to Mexico City this week to discuss, reflect on and negotiate issues and concerns surrounding HIV/AIDS. The theme of this 17th International AIDS Conference is UNIVERSAL ACTION NOW. This theme provides a platform for all of us to assess our progress, reflect on gaps, and identify actions and strategies to expand and improve our efforts towards UNIVERSAL ACCESS to prevention, treatment, care and support services/programs. This is indeed a good time to take stock, three years after the UN General Assembly agreed to come as close as possible to the goal of Universal Access by 2010 (2005 World Summit Outcome Resolution).

The focus of our meeting today is on the Caribbean. The satellite session held on Sunday regarding achievement of Universal Access in the Caribbean and current realities clearly highlighted the potential of the region to make rapid progress towards the Universal Access goal. On the other hand, the need to ensure comprehensive quality care to pregnant women and their infants to sustain achievements on prevention of vertical transmission of HIV was identified as a must.

Along with HIV, syphilis, a neglected STI, is also a major public health problem in the region. As HIV, syphilis affects pregnant women and their newborns. While some countries have made significant progress in reduction of congenital syphilis, we must conclude unfortunately that, 13 years after the adoption of the Plan of Action for the elimination of congenital syphilis as a public health problem in the Americas, only few countries may have reached the target. Moreover, in many countries, efforts for the scale up of PMTCT services, do not include specific interventions for syphilis, resulting in missed opportunities, situation that is totally unacceptable from a public health as well as an ethical point of view.

Today, I'm pleased to present to you, along with UNICEF, a proposal that we believe will contribute to accelerate the achievements in the Caribbean, addressing in a comprehensive and effective manner two public health problems that affect our women and children: The Caribbean Initiative for the Elimination of the vertical transmission of HIV and Syphilis.

This proposal is not necessarily new. It represents only an integrated approach to intensify our action to meet regional goals. Allow me to review current Regional Commitments supporting this initiative:

The Caribbean Cooperation in Health (CCH-III) and the Caribbean Regional Strategic Framework for HIV/AIDS (CRSF) ratifying UNGASS call for Universal Access by 2010.

The Regional HIV/STI Plan for the Health Sector 2006-2015, endorsed by the PAHO/WHO Directing Council in September 2005, which includes an specific target for the "reduction in the incidence of mother-to-child HIV transmission to less than 5 percent by 2015 and reduction in congenital syphilis to fewer than 0.5 cases per 1,000 live births". These targets were further ratified by Member States in the PAHO Strategic Plan 2008-2012 and are reiterated in the draft Caribbean HIV/STI Plan for the Health Sector, 2008-2012.

The Abuja declaration, related to the join action between WHO and UNICEF to address vertical transmission of HIV.

The Action Plan for the Elimination of Congenital Syphilis in The Americas, adopted in 1995, during the 116th session of the Executive Committee of the Pan American Health Organization.

The MOU signed by PAHO and UNICEF for join action to address vertical transmission of HIV and Syphilis in 2005.

In May 2006 the World Health Assembly adopted the Strategy for the Prevention and Control of Sexually Transmitted Infections, followed by the Global Elimination of Congenital Syphilis Strategy for Action, which also provided new energy to the PAHO initiative.

With all these reiterated mandates in the Region, I embrace the theme of this IAC, "Universal Access now!", to call the attention to one specific piece that will advance that noble call immediately.

Let me share with you the rationale for this proposal:

Around 800,000 live births take place in the Caribbean annually. Of these an estimated 70% occur on the island of Hispaniola (Dominican Republic and Haiti). Antenatal care service coverage is reasonable to high in most Caribbean states and territories.

In most counties screening of pregnant women for syphilis is part of the routine antenatal care service package. In 2007 countries reports indicated a range in coverage for syphilis screening from 35% in Haiti to 100% in Belize, Cuba, St. Lucia, St. Kits and Nevis.

Although there has been no systematic and consistent reporting from all countries in the region, available data indicates that the prevalence of positive blood test for syphilis in pregnant women for the period 2000-2005 ranged from 0.5% to 4.0%. (source: Health in the Americas and CAREC, UNGASS). The reports also indicate that most pregnant women in the region with positive syphilis serology were given timely treatment and prophylaxis to their unborn infants.

Even though collection of data on the actual incidence of congenital syphilis in the regions is still a challenge, the available data from a limited number of countries indicated a decline in the percentage of syphilis sero-reactive infants born to syphilis sero-reative mother. For instance in Trinidad and Tobago the syphilis sero-reactivity rate for infants declined from 31% in 2002 to 9.0% in 2005.

As you all very well know the Caribbean region, with an estimated 0.9-1.2% of HIV prevalence rate in the general population has the second highest estimated burden of HIV infection in the world. Mother to Child transmission of HIV constitutes an estimated 8-10% of all transmissions in the region. (UNAIDS 2008 Update)

In their 2007 Universal Access and UNGASS progress reports most countries in the region have reported promising and significant achievements in the screening of pregnant women for HIV as part of their PMTCT programs. HIV testing of pregnant women in 2007 ranged from high, 93.0% in Cuba, 83.0% in The Bahamas, 75% in Trinidad and Tobago, to low, 46% in Dominican Republic and 43% in Haiti

Currently ARVs are available in most countries and territories in the Caribbean region for HIV positive pregnant women to reduce the vertical transmission of HIV to their newborns. Of those women who attended antenatal clinic services and were tested for HIV the ART coverage ranged from high of 100% in Cuba, Dominica, St. Kits and Nevis, St. Vincent and the Grenadines; 86% in The Bahamas, and below 50% in Dominican Republic, Suriname, Turks and Caicos and Haiti. The percentage of infants born to HIV positive mothers that were tested before 12 months of age in the region was 100% in Belize, Turks and Caicos Islands, 96% in The Bahamas and below 40% in the Dominican Republic 20.0% Haiti.

In summary, country reports indicate encouraging progress in addressing both, vertical transmission of HIV and syphilis, which is fundamental to open the discussion on elimination of these two public health problems.

We know, however, that there are clearly residual gaps in the coverage of services, and a lack of data to adequately monitor the status of vertical transmission of HIV and Syphilis in the Caribbean.

Based on this analysis, PAHO and UNICEF have taken action to jumpstart the development of the initiative to eliminate vertical transmission of HIV and syphilis in the Caribbean. Over the weekend a first meeting was convened with a small group of resource persons from the Caribbean to review evidence and assess the feasibility of this initiative.

Today we are pleased to share with you the conclusions and recommendations of this technical working group, and invite you to consider the possibility of making the Caribbean the first region in the world to eliminate vertical transmission of HIV and Syphilis as a public health problem.

As PAHO and UNICEF, we believe the conditions are favorable and the potential is there to achieve this target. We are convinced that we can achieve this ambitious target if we join forces and focus our efforts. We advocate for a comprehensive and integrated approach to address both congenital syphilis and HIV infection in infants born to HIV positive mothers. After all, both efforts are aimed at the same pregnant woman, her newborn, and family.

As we proceed, we recognize that successful design and implementation of this initiative will depend on strong partnership between all stakeholders. From a UN perspective, PAHO/WHO and UNICEF, who share the responsibility for PMTCT in the global task division, UNFPA, the leading agency in the area of sexual-reproductive health; our constituency, the Governments, and of course all our Caribbean partners, including CARICOM, the Pan Caribbean Partnership (PANCAP), CHART, Regional institutions, Civil society, the private sector, PEPFAR, and the Global Fund.

Key elements of the elimination effort will have to include strengthening of health systems, in particular maternal and child health services, diagnosis and treatment support and strengthening of surveillance, monitoring and evaluation. Strong focus and determination to reach those vulnerable groups that are often not reached with services will require active social participation and community involvement.

I invite you to listen to the conclusions and recommendations of the technical working group and provide your feedback.

Let us all join forces to protect the achievements and address this unfinished agenda protecting the new generation from the start, let us take universal action now!

More information:

PAHO Press Releases:
- Caribbean public health authorities propose to eliminate vertical transmission of HIV and syphilis by 2015 [08/07/2008]
- United Nations: Countries in Latin America and the Caribbean should improve, expand sexuality education [08/07/2008]
- Ministerial summit on HIV shows high level of commitment, says PAHO [06/20/2008]
- Latin American Countries Launch Programs to Improve Health Care for Sexual Minorities [05/15/2008]
- Education, prevention, treatment, testing—essential tools to combat HIV [01/29/2008]

OPS Notas de Prensa [08/07/2008]:
- Autoridades en salud pública del Caribe proponen eliminar la transmisión vertical del VIH y la sífilis para el 2015 [08/07/2008]
- Naciones Unidas: los países de América Latina y el Caribe deben mejorar y expandir la educación sexual [08/07/2008]
- Cumbre ministerial sobre VIH y jóvenes muestra un alto nivel de compromiso, dice OPS [06/20/2008]
- Países de las Américas lanzan programas para mejorar la atención en salud de minorías sexuales [05/15/2008]

For more information, contact: Hirnschall, Dr. Gottfried PAHO Senior Advisor on HIV/AIDS/STI and opening remarks speaker at the event; and/or Del Riego, Dr. Amalia Health Systems Advisor in the PAHO’s office in the Bahamas and closing remarks speaker at the event.