TEMAS DE ACTUALIDAD / CURRENT TOPICS

Countries of Central America need to invest more in HIV/AIDS prevention1

Los países de Centroamérica necesitan invertir más en la prevención de la infección por el VIH y el sida

Key words: acquired immunodeficiency syndrome, HIV infections, health expenditures, cost-benefit analysis, Central America.

SINOPSIS

Cuatro de los seis países latinoamericanos con la mayor prevalencia de infección por el virus de la inmunodeficiencia humana (VIH) en adultos se encuentran en Centroamérica, subregión donde la epidemia amenaza con volverse incontrolable si no se intensifican las medidas dirigidas a combatirla, afirma un informe emitido por el Banco Mundial en octubre de 2003. La prevalencia de la infección por VIH en adultos es mayor en Belice (2,0%), Honduras (1,6%), Panamá (1,5%) y Guatemala (1,0%) que en El Salvador (0,6%), Costa Rica (0,6%) y Nicaragua (0,2%). A pesar de que en estos últimos tres países la prevalencia de la infección por VIH es relativamente baja en estos momentos, podría aproximarse a 2,0% para el año 2010 si continúa la tendencia actual. La transmisión del VIH en Centroamérica ocurre fundamentalmente por la vía sexual entre personas heterosexuales, un patrón más parecido al observado en el Caribe que en América del Sur. Debido a esa tendencia, se está cerrando la brecha existente actualmente en Centroamérica entre el número de hombres y de mujeres con sida, todavía caracterizada por una mayor proporción de hombres infectados. Se podría lograr un gran impacto en el control de la epidemia de infección por VIH y sida en Centroamérica, incluso con recursos limitados, si los fondos se encauzaran hacia intervenciones más eficaces en función del costo. Entre las intervenciones que podrían tener mayor impacto se encuentran la comercialización social del condón; la distribución gratuita de condones entre personas pertenecientes a grupos en alto riesgo; la información, la educación y la comunicación dirigidas a los grupos en mayor peligro, incluidos los hombres que tienen relaciones sexuales con otros hombres, los trabajadores sexuales y los presidiarios; y el acceso a asesoramiento y a pruebas de detección voluntarias.

Four of the six countries in Latin America with the highest HIV prevalence rates among adults are in Central America, where the epidemic threatens to run out of control unless prevention efforts are intensified, according to report issued in October 2003 by the World Bank. The report was produced in conjunction with the Third Central American Congress on Sexually Transmitted Diseases/HIV/ AIDS, which was held 1317 October in Panama. Among the countries of Latin America, Belize, Honduras, Panama, and Guatemala were four of the six nations with the highest HIV prevalence levels as of the end of 2001.

''The HIV/AIDS epidemic in Central America is increasingly serious, and although the epidemic continues to be concentrated in high-risk populations, it is becoming generalized in some countries,'' said Jane Armitage, the World Bank's Director for Central America. ''Fortunately, we are still on time. Prevention is the key.''

TRANSMISSION PATTERNS IN CENTRAL AMERICA

The new World Bank report is entitled HIV/ AIDS in Central America: An Overview of the Epidemic and Priorities for Prevention. According to the report, HIV adult prevalence rates in Central America are highest in Belize (2.0%), Honduras (1.6%), Panama (1.5%), and Guatemala (1.0%). The two other countries in Latin America with similarly high rates are Guyana (2.7%) and Suriname (1.2%).

The rates in the other countries of Central America are: El Salvador (0.6%), Costa Rica (0.6%), and Nicaragua (0.2%). Despite the relatively low levels that those three countries now have, if current trends continue, the epidemic could reach prevalence levels of close to 2% in those nations by the year 2010.

HIV transmission in Central America is primarily due to heterosexual sex, a pattern that is more similar to what is seen in the Caribbean than in South America (see the sidebar entitled ''Latin America must deal with a range of problems in combating the HIV/AIDS epidemic''). Because of that tendency in Central America, although there are now more men than women with AIDS in the area, the gender gap is closing, according to the World Bank report.

The HIV/AIDS epidemic in Central America is generally concentrated in high-risk populations such as commercial sex workers, men who have sex with men, prisoners, street children, and police and military forces. In Honduras another high-risk group are the Garifuna, a population of Afro-Caribbean heritage. Two exceptions to these typical patterns for Central America are Belize, where the disease is becoming generalized in some areas of the country, and Nicaragua, where the epidemic is still nascent.

Commercial sex workers in Central America are at high risk of HIV infection because their customers frequently do not uses condoms. Sex workers often do not insist on the use of condoms since they underestimate the risk of infection, they do not have access to condoms, or they earn more money by providing unprotected sex. Clients of sex workers act as a bridge between high-risk groups and the general population.

COST-EFFECTIVENESS MODEL FOR ALLOCATING LIMITED FUNDS

A substantial impact on the HIV/AIDS epidemic in Central America can be achieved even with limited resources, provided they are channeled to the most cost-effective interventions. That is according to a decision-making tool, called the Allocation by Cost-Effectiveness (ABC) Model, that the World Bank developed in 2002 in order to help officials determine the resource allocation that would prevent the highest number of new infections for any given budget level. The model can also be used to simulate the effect of alternative budget decisions and to generate consensus on the HIV prevention interventions that could have the greatest impact.

The ABC Model focuses only on prevention programs and does not consider tradeoffs between paying for prevention rather than treatment and care. The model analyzes alternative resource allocations differentiated by strategy and target population group, as defined by risk behavior, sexual orientation, gender, and other characteristics.

The ABC Model was applied in country-level workshops in Guatemala, Honduras, and Panama between May 2002 and August 2003. During those workshops, initial estimates made with the model were reviewed by national and international experts in order to reach broader consensus and to produce ''ownership'' of the final results.

From the workshops it became clear that even limited but well-spent resources could slow the spread of HIV/AIDS. In the three countries the most cost-effective interventions were identified as: condom social marketing; free condom distribution targeted to high-risk groups; information, education, and communication for high-risk groups, including men who have sex with men, commercial sex workers, and prisoners; and voluntary counseling and testing.

Using that optimal allocation of funds, US$1 million would prevent between 5 100 and 12 000 infections. The corresponding cost per infection prevented would be between US$ 84 and US$196. A second key finding of the workshops was that with a budget of US$ 10 million, only about 25% of all primary and secondary HIV infections can be prevented. That is because it is hard to reach the population groups that have the highest risk. For example, the workshop participants in the three countries estimated that any given intervention can only reach between 40% and 70% of commercial sex workers and only some 25% of men who have sex with men. That finding leads to the conclusion that after a certain budget level, the government should not only fund traditional prevention interventions but also develop strategies to reach a higher proportion of high-risk groups. This could be done, for example, through such efforts as decriminalization, reduction of stigma, and increased service coverage.

The results from the workshops indicate that spending for HIV prevention in Central America has been far from adequate. In 2000 the total of public and private funding for HIV-related public health and prevention activities was US$2.8 million in Guatemala, US$ 6 million in Honduras, and US\$ 900 000 in Panama. However, these resources were not well targeted towards the high-impact prevention activities identified in the workshops.

Nevertheless, the modeling exercise should help officials in Central American countries to work more productively in the future with the Global Fund for AIDS, TB and Malaria; the United States' Agency for International Development; and other external donors.

The complete report from the World Bank can be viewed and downloaded for free from the Web site of the World Bank at http://www.worldbank.org.