Using Estimation and Projection Package and Spectrum for Jamaica's national HIV estimates and targets

The HIV epidemic in Jamaica has features of both a generalised and concentrated epidemic. The adult HIV prevalence was estimated at 1.6% in 2007 and 27 000 person were living with HIV.1 However, higher HIV prevalence has been found in the most at-risk populations such as sex workers (9%), men who have sex with men (MSM; 32%), crack/cocaine users (5%), inmates (3.3%) and sexually transmitted infection (STI) clinic attendees (3.6%).2 3 Several behavioural factors such as early sexual debut, high levels of multiple partnership, transactional sex and limited condom use increase HIV transmission in Jamaica. These factors coupled with gender disparities, poverty and homophobia provide fertile ground for the growth of the HIV epidemic and reinforce the need for a multisectoral response.2 Jamaica's national HIV/STI programme (NHP) has identified four priority areas in order to halt and reverse the spread of HIV: prevention; treatment care and support; enabling environment and empowerment and governance.4 Key indicators and targets are used to monitor progress towards universal access. However, the quantity of services required for achieving access to all those who need services and, hence target-setting, are hindered by insufficient data on populations in need of services. Currently, the HIV surveillance system and national surveys provide information on the HIV epidemic in Jamaica and identify populations in need of services such as treatment. The surveillance system is a name-based confidential reporting system that began in 1982. Between 1982 and 2008, 23 972 persons living with HIV, including 13 445 persons with AIDS and 7394 AIDS deaths, were reported to the Ministry of Health.3 The number of persons reported with HIV per year doubled between 1996 (971 cases) and 2008 (1868 cases). This is due to new HIV infections as well as increased access to testing, improved surveillance and increased awareness about HIV/AIDS among healthcare workers and the general population. Public access to antiretroviral therapy (ART) in 2004 coupled with improved laboratory capacity and support services resulted in a 40% decrease in AIDS deaths between 2004 and 2008.3 Despite improvements in HIV surveillance, many gaps persist and hamper accurate generation of estimates. For example, inclusion in the surveillance system relies on persons being tested and diagnosed, but nearly half of people living with HIV are unaware of their status.2 A previous survey of Jamaican physicians revealed as much as 30–40% underreporting of people living with HIV accessing care.5 In addition, case report forms are often incomplete, limiting the understanding of the contribution of the most at-risk populations in Jamaica's HIV epidemic. For example, although HIV transmission is primarily through heterosexual transmission, the sexual practice of 43% of men reported with HIV is unknown. Similarly, the risk history is unknown for at least 20% of persons reported with AIDS.3 In addition, limited data are available on the progression of HIV and the impact of interventions, including ART availability, in Jamaica. These limitations can have a negative impact on programme planning and accurate target-setting, and further limit the ability of the NHP to measure efforts to halt the transmission of HIV reliably. Surveillance of high-risk groups such as sex workers and MSM have been challenging, partly due to stigma and discrimination, which makes accessing these populations difficult. Despite these challenges, the NHP completed second-generation behavioural surveillance activities with these groups between 2001 and 2008, along with smaller studies. In 2009, the NHP sought to strengthen its understanding of Jamaica's HIV epidemic and populations in need of services by participating in the UNAIDS estimates process using the estimation and projection package (EPP) and Spectrum.