The HIV epidemic in Latin America has remained stable for a number of years.1 At the end of 2013, there were roughly 1.6 million people living with HIV in this region - an HIV prevalence of 0.4%. In the same year, there were an estimated 94,000 new HIV infections and 47,000 deaths from AIDS-related illnesses.2
Although HIV prevalence in Latin American countries is relatively low, the number of people affected is still substantial. For example, Brazil has an HIV prevalence of 0.4% but this still equates to 730,000 people living with HIV. The vast majority of people living with HIV in Latin America (75%) live in four countries; Brazil, Colombia, Mexico and Venezuela.3
Key affected populations in Latin America
Though HIV prevalence is generally low, HIV prevalence among groups such as men who have sex with men and transgender women is particularly high.4
Men who have sex with men in Latin America
Men who have sex with men (MSM) are the group most affected by HIV in Latin America. However, HIV prevalence among this group varies greatly between countries. For example, it is as high as 20% in Chile and Panama, falling to 7% in Nicaragua.5
There are many reasons for high levels of HIV transmission among this group. Only 51% of MSM are thought to have access to HIV services, a level which has remained largely unchanged for several years. Moreover, access to HIV testing, counselling and treatment is extremely low, dropping to just 6% in Peru and 9% in Panama.6
Homophobia and the ‘machismo’ (strong/aggressive masculinity) culture are common throughout the region and sex between men is highly stigmatised. As a result, large numbers of MSM do not identify as homosexual and have sex with women as well as men, forming a 'bridge' population.7
As one civil society worker explains, MSM are often hesitant to reveal how they became infected with HIV and many are mistakenly classed as heterosexual:
"Unless he’s a total queen, a man will always be [counted as] heterosexual. Plus, people don’t want to be recognised [as homosexual]." - Ruben Mayorga, civil society worker, Guatemala City 8
Transgender women in Latin America
HIV prevalence is particularly high among transgender women who engage in sex work. For example, in Ecuador and Panama, HIV prevalence among this group who participate in sex work is 32% and between 20-30% in Argentina, Bolivia, El Salvador, Honduras, Paraguay, Peru and Uruguay.10
Research has shown how transgender people have fewer educational and social opportunities, often resorting to sex work for an income.11
Sex workers in Latin America
In 2013, 6.1% of female sex workers (FSW) in Latin America were thought to be living with HIV. Male sex workers tend to be much more affected by HIV than FSW. For example, 69% of male sex workers in Suriname are estimated to be living with HIV compared to just 4% of FSW.13
Data for transgender sex workers is low, however, a meta-analysis in 2008 reported an HIV prevalence of 27% among this group.14
Despite a high HIV prevalence, HIV testing among sex workers is roughly 70% for the entire region while condom use during last sexual intercourse ranges between 78% and 96%.15
People who inject drugs in Latin America
There are over two million people who inject drugs (PWID) in Latin America, with the largest proportion of these in Brazil (540,000). HIV prevalence among this group varies significantly between countries with up to 6% of PWID in Brazil living with HIV, compared to 1% in Peru.16
However, the popularity of injecting drugs has declined across Latin America and has been replaced by people who favour smoking or inhaling drugs.17 It is now widely acknowledged that drug use in the region is mainly the non-injecting of cocaine and its derivatives.18
One systematic review of key affected populations in Brazil detected an HIV prevalence of 23.1% among people who use drugs.19 Another study from Montevideo in Uruguay found an increase in HIV risk among cocaine smokers, with an estimated 6.3% HIV prevalence rate.20 This is due mainly to the fact that any form drug use impairs a person’s ability to engage in safer sex behaviours.
HIV testing and counselling in Latin America
Data on HIV testing coverage is very limited for Latin America, however, it is estimated that 50% of people living with HIV in the region do not know their HIV status. In 2012, an estimated 36 per 1000 people were tested across Latin America and the Caribbean (LAC), second only to sub-Saharan Africa.21
Furthermore, provider-initiated HIV testing strategies targeting patients with tuberculosis (TB) have high coverage figures in some countries but figures for the LAC region as a whole continue to be low and progress is slow - from 39% in 2006, to 52% in 2011.22
Late HIV diagnosis is a serious issue in Latin America. In at least half of the countries in this region, 38% of people when tested for the first time, had a CD4 count under 200.23
Antiretroviral treatment in Latin America
Access to antiretroviral treatment (ART) across Latin America is relatively high. In 2012, an estimated 75% of people in need of treatment were receiving it - the highest percentage for a low- and middle-income region.24 However, the introduction of the World Health Organisation's 2013 treatment guidelines which made people with CD4 counts under 500 (rather than 350) eligible for treatment, meant that ART coverage fell to 45% in 2013. Of those on treatment, 66% had achieved viral suppression.25
El Salvador, Guatemala, Uruguay and Venezuela have now adopted these new guidelines, while Bolivia, Colombia, Mexico, Nicaragua and Peru are also about to implement the same criteria. By contrast Brazil and Panama modified their guidelines to offer treatment to all people living with HIV regardless of CD4 count.26
Moreover, treatment coverage varies greatly by country. For example, over half of all people living with HIV are accessing ART in Argentina (61%), Chile (60%), Costa Rica (56%), Guyana (52%) and Mexico (51%). By contrast, treatment coverage is just 20% in Bolivia.27
Stock-outs of antiretroviral drugs are a major obstacle to treatment in this region. While efforts have been made to decrease the likelihood of this happening, in 2012, 10 countries reported at least one stock-out in the previous 12 months.28
Retention on treatment after one year in Latin America is high (80%). However, because many begin taking treatment with a very low CD4 count, mortality in the first six months following treatment initiation is still too high.29
HIV prevention programmes in Latin America
Some HIV prevention interventions in Latin America have been enormously successful, and have helped to reduce HIV incidence among certain groups in particular areas.
Reducing HIV-related stigma and discrimination
Some Latin American countries have taken steps to address the problem of HIV-related stigma and discrimination. For example, Peru, Columbia, Brazil and Mexico have recently launched new actions plans to raise awareness among health providers and government officials of the importance of non-discrimination on the basis of sex, race, religion, sexual orientation and HIV status.30
At a community level, one study from Chile showed how peer education can improve HIV-related knowledge, attitudes and behaviours among community clinic health workers. Three months after the intervention, healthcare workers had higher knowledge of HIV transmission and were more accepting of people living with HIV. They were also more likely to engage in safer sex themselves.31
Another study from Peru has shown how engaging community leaders with HIV interventions can reduce community-level HIV stigma. Intervention participants reported lower levels of stigma after two years. This suggests that normalising HIV prevention behaviours and HIV communications can reduce HIV-related stigma and change community norms.32
Prevention of mother-to-child transmission (PMTCT)
In Latin America, the Regional Elimination Strategy has had a direct impact on accelerating progress in reducing new infections among children by improving surveillance systems and access to HIV prevention services for women. Between 2009 and 2013, the number of children who acquired HIV declined by 28%.33
However, coverage of antiretroviral treatment to prevent the mother-to-child transmission of HIV (PMTCT) varies greatly by country. For example over 70% of pregnant mothers living with HIV access PMTCT services in Ecuador, Mexico, Nicaragua, Panama and Peru. Costa Rica and Nicaragua are close to eliminating MTCT.34
By comparison, PMTCT coverage is less than 30% in countries like Bolivia, Guatemala and Venezuela, due to difficulties in reaching those belonging to key affected populations such as indigenous people, sex workers and young women.35 There are still approximately 35,000 children below the age of 15 living with HIV across the region.36
Access to harm reduction programmes across Latin America is extremely limited.
- Needle and syringe programmes (NSPs)
Only five countries operate NSP services - Argentina, Brazil, Mexico, Paraguay and Uruguay. Brazil offers the most extensive coverage with between 150 and 450 sites. Both Argentina and Brazil are believed to have scaled back NSP services due to a decline in injecting drug use.38
By comparison, coverage is improving in Mexico due to Global Fund programmes. An estimated 8.1 syringes are now distributed per PWID per year.39 This is still far below the WHOs recommendation of 200 needles per PWID per year.
- Opioid substitution therapy (OST)
OST services in Latin America are only available in Colombia and Mexico. In Mexico, 18.6% of opiate users have access to OST.40
In Colombia, OST sites operate in seven cities - Bogotá, Medellín, Cali, Pereira, Armenia, Cúcuta and Bucaramanga. However, the number of sites in each city is unknown, as is the number of people using them.41
HIV can push people and families into poverty by reducing household capacity and increasing medical costs. In response to this, some countries in Latin America have introduced social protection measures to mitigate against the negative impacts suffered by those affected by HIV.42
For example, the Ecuadorean government has recently implemented a policy where caregivers for children under the age of 14 living with HIV receive a monthly cash transfer. In the first year of the scheme, 500 caregivers were set to receive the cash transfer.43
In Uruguay, the 'Social Card' is a social protection programme targeting transgender women. Cardholders receive $30 a month to buy food and cleaning products. The initiative currently reaches 1000 people, the majority of whom, belong to the transgender community. 44
Barriers to HIV prevention in Latin America
Because HIV prevalence is low in most Latin American countries, the epidemic remains fairly hidden, meaning that many people are ignorant or fearful of HIV and AIDS.
"[His family] fed him in the same plate ever, and like that, he had his own cup, glass, fork, knife, spoon, you get the idea, he was isolated by his own family. His razors where always trashed, and his tooth brush too, also, no one was ever taking care of his pills...One week before he died, in the middle of a discussion because of he having AIDS he was thrown out of his house by his older sister... he died alone." - Lover of an HIV-positive man in Honduras 45
MSM and transgender women face particularly high levels of stigma and discrimination putting them at risk of hate crimes and homicide. Since 2008, 1,200 transgender people have been murdered in Latin America.46
Moreover, 44-70% of transgender women have felt the need to leave, or were thrown out of their homes.47 One study from Mexico indicated that 11.4% of transgender women living with HIV were excluded from family activities.48
Violence is also a barrier to HIV prevention for sex workers. One study of female sex workers in Argentina reported that 24.1% had received sexual abuse; 34.7% reported rejection experiences; 21.9% reported having been beaten; while 45.4% reported having been arrested because of their sex work activity. Higher levels of inconsistent condom use was also reported among those who experienced sexual abuse, rejection and police detention.49
- Punitive laws
Latin America is forward thinking in its drive to decriminalise drug use, with many national drug policy reforms having taken place in the last few years. For example, Colombia has decriminalised the possession of small amounts of cocaine or marijuana.50
However, the majority of these reforms have focused on reducing the supply and trafficking of drugs. As a result, large numbers of PWID are still imprisoned.51
Moreover, most countries in Latin America lack antidiscrimination laws and legislation on gender identity and sexual orientation.52
As a result, transgender people in particular, face very high levels of transphobia. Furthermore, the arbitrary detention of transgender women, including torture and inhumane treatment, is not prosecuted. Transphobia is reported to be widespread among police forces in Guatemala and Honduras.53
- Restrictions on entry, stay and residence
The majority of countries in Latin America have no restrictions on entry, stay and residence for people living with HIV. Belize, Nicaragua and Paraguay do have these restrictions but Paraguay has stated that lifting their ban is a priority and aims to achieve this by 2015.54
HIV funding in Latin America
Latin America has showed significant commitment in investing resources in HIV programming. In 2013, 94% of HIV spending in the region came from domestic sources.55
However, countries such as Bolivia, Guatemala, Honduras and Nicaragua are still heavily dependent on international funding which covers at least 40% of their HIV responses. Moreover, even in countries with high levels of domestic funding, programmes for key affected populations are still mostly funded by donors (two-thirds in 2012).56
Long-term access to treatment is also dependant on lower antiretroviral drug prices. It is estimated that the region could save up to 75% on first- and second-line treatment if countries moved from current price structures to recommended ones.57
The future of HIV and AIDS in Latin America
Latin America has made significant progress in tackling its HIV epidemic, particularly in the provision of treatment. However, the introduction of the new WHO treatment guidelines has since made many more people eligible for treatment requiring a scale-up up in treatment programmes and the negotiation of more affordable drug prices.
Even where treatment is readily available, a number of barriers prevent many groups from accessing the services they need. For example, homophobia and transphobia, which in many cases result in homophobic crimes, need to be addressed by laws and policies that protect the rights of all people.
Sensitisation programmes targeting national uniformed personnel, aimed at reducing stigma and discrimination towards key affected populations and people living with HIV, are also needed in order to reduce hate crimes across the region.
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