Abstinence, Fidelity, Condom Abstinence, Fidelity, Condom Use and the Stabilization of Use and the Stabilization of the AIDS Epidemic in Haitithe AIDS Epidemic in Haiti

Antoine Augustin MD, MPHAntoine Augustin MD, MPH

Centre d’Analyse des Politiques de Santé

HIV Prevalence among Pregnant HIV Prevalence among Pregnant Women, Haiti, 1993-2000Women, Haiti, 1993-2000

4.5%

6.0%

6.2%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

1993 1996 2000

Source: IHE/GHESKIO 1993, 1996, 2000

HIV Prevalence among pregnant women, Mirebalais (Central Haiti),

1993-2003

0

1

2

3

4

5

6

7

1993 1996 1999 2003

Year

Pe

rce

nt

HIV

po

sit

ive

Percent ofpregnantwomen whoare HIV-positive,Mirebalais,Haiti

Source: IHE /GHESKIO 1993, 1996, 2000; MARCH 2003

HAITI AND AIDSHAITI AND AIDS

PrΘvalence du VIH

0.02 to 0.28

0.28 to 0.55

0.55 to 0.63

0.63 to 0.99

0.99 to 2.13

2.13 to 5.18

Country contextCountry context

8 million people

10,000 square miles

40% urban

Per capita income: US$450.00

Centre d’Analyse des Politiques de Santé

MIREBALAIS

Trends in per capita GNPTrends in per capita GNPPer capita income 1980-

2000

0

50

100

150

200

250

300

350

400

450

1960 1970 1980 1990 2000

Year

Centre d’Analyse des Politiques de Santé

Source: BRH 2002; CAPS 2003

Trends in infant mortalityTrends in infant mortality

Infant mortality

0

50

100

150

200

1960 1970 1980 1990 2000

Year

Death

s p

er

1000 liv

e b

irth

s

Centre d’Analyse des Politiques de SantéSource: EHF 1978; DHS 1994; DHS 2000

Per capita income and IMRPer capita income and IMRPer capita income and

IMR

0

50

100

150

200

250

300

350

400

450

1960 1970 1980 1990 2000

year

Centre d’Analyse des Politiques de Santé

Source: BRH 2000; CAPS 2003

METHODSMETHODS Secondary data analysis from DHS Secondary data analysis from DHS surveys (1994 and 2000)surveys (1994 and 2000)

Secondary data analysis from sentinel site Secondary data analysis from sentinel site seroprevalence surveys of 1993, 1996 and seroprevalence surveys of 1993, 1996 and 20002000

Population-based data analysis from central Population-based data analysis from central HaitiHaiti

Review of various qualitative surveys Review of various qualitative surveys

Review of the international literature on Review of the international literature on condom data analysis condom data analysis

Factors reviewed for this Factors reviewed for this presentationpresentation

Knowledge of AIDSKnowledge of AIDS

Personal risk perceptionPersonal risk perception

Age at sexual debut Age at sexual debut

Recent sexual activityRecent sexual activity

AbstinenceAbstinence

FidelityFidelity

Condom useCondom use

Behavior to reduce riskBehavior to reduce riskCentre d’Analyse des Politiques de Santé

Knowledge of AIDSKnowledge of AIDS

0102030405060708090

100

1994 2000

women

men

Source: DHS 1994; DHS 2000

Knowledge of Mode of Knowledge of Mode of Transmission of HIVTransmission of HIV

Centre d’Analyse des Politiques de Santé

K n owledge of at least on e mode of t r an smiss ion

0

10

20

30

40

50

60

70

80

90

100

1994 2000

Y ear

women

men

Source: DHS 1994; DHS 2000

Age at Sexual Debut, Women and Age at Sexual Debut, Women and MenMen

A ge at fi r s t sex

0

5

10

15

20

1994 2000

Y ear

women

men

Centre d’Analyse des Politiques de SantéSource: DHS 1994; DHS 2000

Age at first sex, womenAge at first sex, women

FEMALES

17.6

17.8

18

18.2

18.4

1980 1985 1990 1995 2000

FEMALES

Source: DHS 2000

Recent Sexual Activity (Preceding Recent Sexual Activity (Preceding Four Weeks)Four Weeks)

P r opor ti on of women and men s exual l y ac ti ve i n

pr ec edi ng 4 weeks

0

20

40

60

1994 2000

Y e a r

women

men

Centre d’Analyse des Politiques de Santé

Source: DHS 1994; DHS 2000

Proportion of young men and Proportion of young men and women who never had sexwomen who never had sex

Proportion of women and men sexually active in preceding 4 weeks

0

10

20

30

40

50

60

1994 2000

Y ear

women

men

Centre d’Analyse des Politiques de Santé

Source: DHS 1994; DHS 2000

Risk perception for HIV, womenRisk perception for HIV, women

Centre d’Analyse des Politiques de Santé

P er son al H I V r isk per cept ion by women

0

20

40

60

80

100

None Low I ntermediate High

Level of per ceived r isk

1994

2000

Source: DHS 1994; DHS 2000

HIV risk perception, menHIV risk perception, men

HIV risk perception by men

0

20

40

60

80

100

None Low Intermediate High

Level of perception

1994

2000

Source: DHS 1994; DHS 2000

Factors linked to levels of risk Factors linked to levels of risk perception, womenperception, women

Source: DHS 1994; DHS 2000

0

10

20

30

40

50

60

70

Abstinence Condom use One partneror partnerreduction

Partnerreduction by

partner

1994

2000

Factors linked to HIV risk Factors linked to HIV risk perception, menperception, men

Source: DHS 1994; DHS 2000

0

10

20

30

40

50

60

70

Abstinence Condom use One partner orpartner reduction

Partner reductionby partner

1994

2000

Behavior to reduce HIV risk, Behavior to reduce HIV risk, womenwomen

C han ge of behavior by women t o r educe H I V r isk

0

20

40

60

80

no change abstinence condom use Fidelity/1 partner

Type of change

1994

2000

Source: DHs 1994; DHS 2000

Behavior change to reduce HIV Behavior change to reduce HIV risk, menrisk, men

B ehavior chan ge by men t o r educe r isk of H I V

0

10

20

30

40

50

no change abstinence condom use Fidelity/1 partner

Behavior change

1994

2000

Source: DHS 1994; DHS 2000

Condom use, women and menCondom use, women and menCondom use, women and men, 1994 and 2000

0

5

10

15

20

25

30

35

1994 2000

Year

women

men

Source: DHS 1994; DHS 2000

Male condom sales, PSI/HaitiMale condom sales, PSI/Haiti0.

78 1.38

3.68

5.03

4.41

7.87

7.27

8.48

11.6

5

12.4

1

15.4

0

2

4

6

8

10

12

14

16

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Million condoms sold

Centre d’Analyse des Politiques de SantéSource: PSI

DISCUSSIONDISCUSSION

Haitians know about HIV/AIDSHaitians know about HIV/AIDS

They do not feel at high risk of contracting They do not feel at high risk of contracting HIV and they feel less at risk than 10 years HIV and they feel less at risk than 10 years agoago

Age at first sex is probably lower than what Age at first sex is probably lower than what was measured via DHSwas measured via DHS

There is no evidence that patterns of There is no evidence that patterns of abstinence have changed abstinence have changed

Not enough data on casual recreational sexNot enough data on casual recreational sex

Discussion (continued)Discussion (continued)

The perception that the partner is more faithful The perception that the partner is more faithful has increasedhas increased

Despite large numbers of condoms reported as Despite large numbers of condoms reported as being sold, there is no evidence that condom use being sold, there is no evidence that condom use has increasedhas increased

The proportion of women and men who cite The proportion of women and men who cite condom use as the reason they feel less at risk condom use as the reason they feel less at risk has remained essentially unchanged between has remained essentially unchanged between 1994 and 2000, at 1.8% and 3.4% respectively for 1994 and 2000, at 1.8% and 3.4% respectively for women , and 13% and 16% for men. women , and 13% and 16% for men.

CONCLUSIONCONCLUSION

The data on condom use and condom sales The data on condom use and condom sales should be interpreted with caution. Several should be interpreted with caution. Several studies have found that it is difficult to studies have found that it is difficult to extrapolate level of use from levels of salesextrapolate level of use from levels of sales

In all likelihood, many factors have acted in In all likelihood, many factors have acted in a synergistic manner to stabilize the AIDS a synergistic manner to stabilize the AIDS epidemic in Haitiepidemic in Haiti