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Objective: To delineate changes in the epidemiology of HIV including morbidity and mortality patterns based on three key time points in Jamaica's HIV response., Method: Surveillance data from Jamaica's HIV/AIDS Tracking system (HATS) were analysed and distribution of cases by age, gender sexual practice, risk factors and clinical features were determined for three time periods (1988-1994: formal establishment of HIV surveillance at the national level, 1995-2003: introduction of HAART globally; 2004-June 2008: introduction of HAART and HIV rapid testing in Jamaica). Factors that predicted late stage diagnosis (AIDS or AIDS death) were also determined, Results: 22 603 persons with HIV were reported to the Ministry of Health, Jamaica, between 1988 and June 2008. Between the first and last time blocks, the modal age category remained constant (25-49 years) and the proportion of women reported with HIV non-AIDS increased from 32.5% to 61.4% (p < 0.001). However the male:female ratio for persons reported with AIDS remained at 1.3:1 between 1995 and 2008. Although heterosexual transmission was the most frequent mode of transmission in each time period, sexual behaviour was consistently under-reported (4769 persons or 21% of all cases ever reported). Late stage diagnosis (AIDS or AIDS death) decreased significantly between the first and last time blocks (16% decline, p < 0.0001) with men, older persons and persons with unknown risk history being more likely to be diagnosed at AIDS or AIDS death., Conclusion: HIV testing and treatment programmes have improved timely diagnosis and reduced morbidity associated with HIV infection in Jamaica. However new strategies must be developed to target men and older persons who are often diagnosed at a late stage of disease. Surveillance systems must be strengthened to improve understanding of persons reported with unknown risk behaviours and unknown sexual practices.

The subtypes of the human immunodeficiency virus - type 1 (HIV-1) strains from 54 HIV-1 - infected persons including 44 strains which were typed previously by heteroduplex mobility assay (HMA) were determined by DNA sequencing and phylogenetic analysis. Of 54 HIV- infected persons, 92.5% were infected with HIV-1 subtype B and 7.5% with other HIV-1 subtypes including subtypes D (3.7%), A (1.9%) and J (1.9%). In the phylogenetic analysis, the subtype A virus found in the sample clustered with subtype A reference strains and a circulating recombinant form (CRF) reference strain which originates in Central Africa and is circulating in Cuba indicating a close relationship between these viruses. There was 86% concordance between HMA and DNA sequencing in assigning subtype B viruses. For the non-B subtype viruses, there was less concordance between the two methods (67%). The results confirm the predominance of HIV-1 subtype B strains and the high genetic diversity of HIV-1 strains in circulation in Jamaica. The efficacies and some limitations of the HMA as a method of HIV-1 subtyping also were noted. It is important that the HIV/AIDS epidemic in Jamaica be monitored meticulously for possible expansions in non-B subtypes and the emergence of inter-subtype recombinant forms. We recommend that the more expensive DNA sequencing and phylogenetic analysis, including HIV-1 genotyping for antiretroviral drug resistance testing, be used as an adjunct to the more cost-effective HMA to track the HIV/AIDS epidemic in Jamaica.

Background: The Ministry of Health, Jamaica, is scaling-up programmes to improve the health of HIV-positive pregnant women according to the modified WHO recommended preventative mother to child transmission (pMTCT) regimens of therapy based upon the mother's clinical and immunological status. Highly-active antiretroviral drugs (HAART) can result in successful pMTCT to < 1%. We report the clinical and immunological characteristics of HIV/AIDS in an era of evolving treatment and care of HIV-infected pregnant Jamaican women., Subjects and Method: Clinical records were reviewed of patients registered in antenatal clinics in Greater Kingston and St. Catherine, Jamaica (annual birth cohort--20,000) between September 2002 and August 2006. Disease status was determined using the Centers for Disease Control and Prevention (CDC) classification system for adult HIV/AIDS. Demographic, clinical and laboratory data were documented and analyzed., Results: During the four-year period, 571 HIV-infected women were enrolled; 62% from Victoria Jubilee Hospital, 25% from Spanish Town Hospital and 13% from the University Hospital of the West Indies. Mean age was 27-29 (range 15-41) years, median parity was 2 (range 0-9) and 68-70% were unemployed. Ninety-five per cent had live births. CDC categories of illnesses were A--mild disease in 82% (n=473), B--moderate disease in 4.4% (n=24) and C--severe disease in 1.4% (n=8) while 12% (n=66) had insufficient data. During the first three years, CD4+ cell counts were evaluated in only 2.5% (10 of 406) of patients with median of 344 cells/microL, compared to CD4 evaluation in 50% (83 of 165 women) in the last year with median of573 cells/uL. Antiretroviral (ARV) medications primarily for pMTCT were given to 89% (n=506) ofwomen. Of these, uptake of HAART increased during years 1-3 from 2-3% to 62% in year four Within two years post-partum, 24 women died, 92% (n=22)from the direct complications of HIV/AIDS., Conclusion: A comprehensive system of care of HIV in the peripartum period has been developed in Jamaica. Detailed medical evaluation during pregnancy is performed with modern guidelines and increasing laboratory availability of CD4+ cell counts and viral loads. We believe declining HIV infection rates in Jamaican infants and healthier mothers are a direct consequence of increased testing in pregnancy with early diagnosis and initiation of HAART-based pMTCT regimens in pregnant women.

Background and Purpose: Highly active antiretroviral therapy (HAART) has improved morbidity and mortality and quality of life, revitalized communities and transformed the perception of HIV/AIDS from being a "death sentence" to a chronic illness. Strict and sustained adherence to medication is essential long-term viral suppression. In April 2005, an Adherence Support Programme was introduced to Jamaica's HIV Programme, whereby Persons Living with HIV/AIDS (PLWHA) who had achieved high levels of adherence were trained to provide support to other PLWHA in order to increase their adherence to HAART regimens., Methods: A cross-sectional survey of 116 individuals with advanced HIV and on HAART was performed in June and July 2006., Results: Many participants were unemployed, poor persons with limited education. Based on self-report of seven-day adherence, 54.8% of persons were 95-100% adherent, 37.5% were 80-94% adherent and 7.7% were < 80% adherent. Having interacted with an adherence counsellor was not associated with adherence levels. Factors associated with nonadherence were: being away from home (38%), sleeping through dose-time (37%), forgetfulness (37%) and running out of pills (31%). Having no food (26.9%), not wanting to be seen taking medication (200%) and intolerable side effects (18.8%) were also reasons given. Only 44% of persons used aids to remind them of dose times., Conclusion: Adherence in this study group is low and may have worsened since 2005. More emphasis must be placed on preparing adults to start HAART The use of pillboxes and other reminders such as alarm clocks and cell phones must be reinforced.

The subtypes of 141 isolates of human immunodeficiency virus type-1 (HIV-1) from Jamaica were determined by a combination of env and gag heteroduplex mobility analysis (HMA) genotyping. The majority of HIV-1 isolates were subtype B (131/141, 93.0%); one (0.8%) isolate each of subtypes C, D and E was found and 7 (4.9%) were indeterminate. These results and the failure of the sets of primers used to amplify some of the HIV-1 isolates provide strong evidence of genetic diversity of the HIV/AIDS epidemic in Jamaica. Surveillance of the circulating HIV-1 genetic subtypes is a pre-requisite for developing regional vaccine strategies and understanding the transmission patterns of the virus. This is the first study of its kind in Jamaica and the findings complement data from other Caribbean countries. This work supports the view of colleagues from the French and Spanish-speaking Caribbean that an epidemiological network supported by regional laboratories will help track this epidemic accurately with positive outcomes for the public.

Background: The seroprevalence of HIV among pregnant women in the Caribbean is 2-3% and increasing. The Kingston Paediatric and Perinatal HIV Programme is developing and implementing a unified programme to eliminate mother-to-child transmission (MTCT) of HIV in Kingston, Jamaica., Methods: Pregnant women presenting to Kingston Metropolitan Antenatal Clinics, Victoria Jubilee Hospital, Spanish Town Hospital and the University Hospital of the West Indies had HIV serology performed by ELISA, or by the new Determine Rapid Test after receiving group counselling. HIV-positive women were referred to High Risk Antenatal Clinics. Antiretroviral prophylaxis with zidovudine (AZT), or nevirapine was given. Care was administered using a standard protocol by a multi-disciplinary team of public and academic healthcare personnel., Results: In year one, 19,414 women delivered Among 14,054 women who started antenatal care for this period, 5,558 (40%) received group counselling and 7,383 (53%) received HIV-testing. During the fourth quarter of follow-up, these comparative rates were 66% (2049/3 118) and 72% (2260/3118) respectively. HIV seroprevalence overall was 2.1% (152/7 383). One hundred and seven HIV+ women at varying gestational ages were identified in the programme, 72 had so far received AZT and nine nevirapine (76%). 0f 84 deliveries, birth outcomes were 75 live births (89%), six neonatal deaths and four maternal deaths (all from HIV/AIDS). Major challenges include repeat pregnancies of 36% despite prior knowledge of HIV seropositivity and poor partner notification with only 30% (32) having a HIV-test. Although rates of HIV testing in pregnant women in Greater Kingston are increasing, rates of testing overall remain sub-optimal. On the labour ward, there was sub-optimal identification of the HIV+ pregnant woman and administration of AZT chemoprophylaxis, along with issues of patient confidentiality and stigma., Conclusion: This programme needs strengthening in order to reduce maternal-fetal transmission of HIV in Greater Kingston, Jamaica "pMTCT-PLUS, or comprehensive family-centred care, is the next step".

Objectives: This study aims to determine the number and age distribution of pregnant women testing positive for HIV at 16 selected clinics in Jamaica between 2001 and 2002; the utilization of therapeutic interventions to minimize the risk of mother-to-child transmission (MTCT) and the current status of the HIV-exposed infants and, finally, the number of children who received testing for detection of HIV and to calculate the incidence of MTCT in these children., Methods: A retrospective study was carried out at sixteen pilot clinic sites by examining the patient records for all confirmed HIV-positive pregnant mothers and the resultant infants at these facilities for the period January 2001 to December 2002., Results: One hundred and twenty-three of 8116 pregnant women newly tested positive during the period January 2001 to December 2002; however, 176 HIV+ women delivered. Fifty-three (30%) knew their HIV status prior to participating in the programme. Sixty-two (1.4%) and 61 (1.6%) tested positive in 2001 and 2002, respectively. One hundred and ten (77%) and 113 (83%) mothers and infants, respectively, received ARV therapy, (92% - nevirapine, 8% - zidovudine). Twenty-three per cent of pregnant women received no ARV Forty-four (25.0%) of the 176 infants had a documented ELISA HIV test before eighteen months of age, none had a PCR test. The health status of 40 (23%) of these children was known: 30 (75%) were alive and well, five of whom did not receive any ARV, one (2.5%) was alive and ill and nine (22.5%) were reported dead, five of whom received ARV; 28.6% of infants who did not receive ARV were reported as either dead or ill compared to 13.8% of those receiving ARV CONCLUSION: Though the majority of pregnant women discovered their HIV status during pregnancy, a significant number got pregnant knowing that they were HIV+. The majority of mothers and infants received ARV but the follow-up and testing of infants was limited. Nevirapine is clearly protective in the prevention of MTCT of HIV and should be made universally accessible. All infants delivered to HIV+ mothers should be identified and tested for HIV.