The historical records consulted indicated that, at the beginning of the AIDS epidemic, men were five times more likely to be living with AIDS than women. Men living in the red zone district of Port‐au‐Prince, where two thirds of female commercial sex workers with HIV live, were three times more likely to have an opportunistic infection than men living in other areas of Port‐au‐Prince. Risk factors, particularly bisexuality/homosexuality and blood transfusion, were present among most patients with AIDS in Haiti. Thus, the epidemic was concentrated among the more at risk population.
Since 1970, blood transfusions were provided by two centres, the “Hôpital de l'Université d'Etat d'Haiti” (HUEH), where donors were remunerated, and the “Centre de Transfusion Sanguine de la Croix‐Rouge”, where donors were not remunerated.16
To stop the spread of HIV, the government closed down the blood bank at HUEH in 1986. Since then, a behavioural screening policy for blood donors has been instituted, and the Red Cross is the only organisation authorised to provide blood transfusions. Donors are recruited from among a patient's family members, and screened and tested for HIV. Donors are not remunerated.16
This policy eliminated blood transfusion as a mode of transmission by limiting exposure to infected blood, therefore reducing the incidence of HIV infection.18
The natural history of HIV in Haiti shows that the disease progressed rapidly from initial infection to AIDS and death, with people dying twice as fast as in developed countries. As the epidemic in the early to mid‐1980s was concentrated among the more at risk groups, it can be inferred that with high mortality among people with HIV/AIDS (due to a shorter duration of infectivity) and with the early intervention efforts in securing the blood supply, prevalence among commercial sex workers and among blood donors peaked in the late 1980 and then declined.
Evidence of decline of HIV prevalence
As the epidemic spread from more at risk groups living in urban areas to women and rural areas, incidence in the general population doubled every other year and reached a peak in the early 1990s (see table 1). With a shorter duration of infectivity and a secured blood supply, incidence, as calculated by Spectrum, declined and was followed by a decrease in prevalence in the mid‐1990s.
The observed decline of HIV prevalence among pregnant women, as well as the decline of national estimates fitted by EPP, was confirmed after controlling for confounding variables.
Key indicators of behaviour change
Has the high mortality among female commercial sex workers contributed to a change of behaviour among their peers, such as increased condom use? Recent studies indicate that 9 out of 10 commercial sex workers in Port‐au‐Prince used a condom at the last contact.
The DHS, BSS, and others studies from the last five years indicate that Haitians are well informed about HIV/AIDS. Three out of four people can cite three main methods of HIV prevention. One out of three of men who have sex with men, commercial sex workers, public transportation drivers, and street youth, and about half of the general population, have complete and correct knowledge of HIV.
In spite of this increased knowledge and provision for condoms, a third of female sex workers continue to accept more money for unprotected sex and half of discordant couples continue to have unprotected sex. Approximately half of men who have sex with men and street youth, and one out of four public transportation drivers have exchanged sex for money. Two out of three of the most at risk and of the general population have not used a condom at the last contact and more than two out of 10 people have a history of STI. In spite of this, the epidemic is being fuelled at a lower pace among these groups than it was in the 1980s.
Nevertheless in the general population, there is an increase in condom use with occasional partners at last contact, an increase in abstinence and fidelity, and a decrease in the number of occasional partners. However, the age of sexual onset has gone down and the proportion of sexually active youth has increased.
Other positive elements that have acted in synergy24
include: the leadership role of the National AIDS Control Program; sustained advocacy efforts in improving the policy environment; engagement of past and current governments; improved capacity at all levels; public/private sector partnerships; transparency and accountability of programmes; scientific research within the country; mobilisation of financial resources; implications of the press, faith based organisations, communities, and people living with AIDS; commitments of key stakeholders; improved STI case management; better access to services, voluntary counseling, testing, care, and treatment; and indications of behaviour change in recent years.2
Limitations of the study
There are several limitations of this analysis. Firstly, total fertility rates, life expectancy at birth, and all other demographic variables required for the demographic projections and incidence calculations are only available nationwide. Therefore Spectrum analysis for Port‐au‐Prince or for urban and rural areas was not possible. Secondly, HIV prevalence reproduced by the EPP and incidence modelled by Spectrum are nationwide estimates. Most trends of behavioural data are available for Port‐au‐Prince or other major urban areas and are only documented for the last five years, many years after incidence declined. Thirdly, there are unexplained variations of prevalence in some sentinel sites and a lack of comparability of indicators in behavioural studies over time. Fourthly, not all confounding factors are considered in the logistic regression. Lastly, the analysis may be clouded due to the following:
- the small sample size of some surveys
- most studies were done in Port‐au‐Prince and in major urban areas only
- no incidence data were available from studies
- the impact of political instability and violence on internally displaced people was not known
- there is no instrument to quantify and test if blood safety practices and mortality are sufficient to justify the rapid decline of HIV prevalence.
- After more than 20 years of a generalised epidemic in Haiti, there is evidence of decline of HIV prevalence among all pregnant women, pregnant women living in urban areas and pregnant women 25 years and older, but there is no evidence of decline among pregnant women living in rural areas or pregnant women 24 years and younger.
- There is evidence of behaviour change in recent years, mostly in Port‐au‐Prince. However, the timeframe of this change does not match the earlier decline in HIV incidence.
- The reasons for decline seem to point to mortality and blood safety intervention efforts in the early stages of the epidemic.