Guyana (215,000 square km), a developing country, located on the northeast coast of South America, is bordered by the Atlantic Ocean, Suriname, Brazil and Venezuela. It has a landmass of 215,000 square kilometres and is divided into 10 administrative regions. Guyana is the only english-speaking country in SOuth America and is one of two South American member countires of the Caribbean Community (CARICOM).

Political Context: This former British territory gained independence on 26th May 1966 and became a Republic in February 1970. An Executive President is both the Head of State and Government. There are several levels of elected government ranging from Parliament and Regional Democratic Councils (RDCs) to Neighbourhood Democratic Councils (NDCs) and Community Development Committees (CDCs). Members of Parliament comprise members, representing National Slates and Geographic Regions, elected by a system of proportional representation. The local government system consists of ten RDCs, seven mayoralties and sixty-five NDCs. There are also Amerindian Village Councils that operate under separate legislation. The RDCs are administratively responsible for delivery of services – health, education, etc - to their populations.

Economic Context: Despite an abundance of natural resources, Guyana is a low-income country. In 2006, Guyana was ranked 103 (out of 177 countries) on the Human Development Index (HDI). This ranking is based on a GDP per capita of US$4493 (PPP, rank 102); life expectancy at birth of 63.6 years (rank 120); and a 96.5% adult literacy rate (rank 32) (Human Development Report, 2006). Guyana’s GDP is approximately US$800 million a year (The Economist Intelligence Unit, 2006). Based on GDP per capita, Guyana is the second poorest country in the Caribbean region, behind Haiti.

While 40% of Guyana’s economy is composed of the service sector, Guyana is heavily dependent on agriculture commodities (sugar and rice) and mining in gold, diamond, and bauxite. Guyana continues to receive debt relief from the International Monetary Fund (IMF) and the World Bank (WB) under the Highly
Indebted Poor Countries Initiative (HIPC). To qualify for HIPC, the GoG drafted the country’s first Poverty Reduction Strategy (PRS), which sets out the government’s plan for using money from debt relief to alleviate poverty. First released in 2002, the PRS was updated in 2006 and identified HIV/AIDS as an important focal area in the health sector. Guyana has also recently qualified for the Multi-lateral Debt Relief Initiative (MDRI) from the Group of Eight (G8) nations. In addition, in November 2006 the Governors of the Inter- American Bank (IDB) agreed to provide 100% debt reduction to the poorest countries of Latin America and the Caribbean. In effect this will expand the MDRI to include the IDB debt relief. IDB debt currently represents over half of Guyana’s debt stock and progress in this arena will dramatically reduce Guyana’s risk of debt distress and release funds for poverty reduction.

Social Context: A national population census was conducted in 2002.The census recorded a multi-racial population of 751,223 (up from 723,673 from the 1991 Census). The sex distribution of the population shows that 50.1 % were males and 49.9% were females. Approximately 35.5% of the population was under 15 and 7% over 60 years old. The age group mostly affected by HIV/AIDS (15-49) represents 51.3% of the population. Approximately 28.4% of the population lives in urban areas and 71.6% live in rural areas. The coastal Regions 2 (49,253),3 (103,061),4 (310,320),5 (52,428) and 6 (123,695) account for 85.1% of the population. The rural interior (Regions 1,7,8 and 9) is very sparsely populated with 9.4%. East Indians represent approximately 43.5% of the population, African/Black 30.2% and the Amerindian population 9.2%. Mixed-heritage accounted for 16.7% of the population. Other ethnic groups in the country include 0.26% Portuguese (whites) and 0.2 Chinese. The Christian (various denominations) population is 55.4%, the Hindus make up 28.4% and the Muslims make up 7.2%. Very small groups include the Bahai and the Rastafarians. Adult literacy is estimated as 98%3. The gross enrollment rate at the secondary level is 76% and at the primary level 99%. These represent significant increases from a decade ago. There are also increasing numbers of students at the University of Guyana and in various vocational institutions in the country. For additional information, visit the Bureau of Statistics.

Sector Financing: Health care services in the public sector are free. Total public sector expenditure is estimated at US$ 33m or about $US48.5 per capita for 2003. It is believed that public sector expenditure accounts for more than 80%, with out-of-pocket and insurance contributions (private sector expenditure) accounting for less than 20% of the total health care cost in the country. In 2002, health expenditure amounted to 8.4% of total government expenditure (10.1% if debt payments are excluded). While it is obvious that the health sector requires a greater injection of financial resources, it must also be obvious that the ability of Government to do so in the foreseeable future is restricted. Note that the Government already commits more than 37% of its total expenditure on the social services and that with debt servicing, more than 50% of public sector expenditure is accounted for. In addition, the country’s revenues are usually significantly below budget projections (>-15%). The country receives significant technical cooperation support for the health sector and in 1999, donors accounted for 5.22% of government health spending (compared with 11% in 1997). All the funds are grants. The principal sources of external financing in 1999 and 2000 were the Inter American Development Bank, UN agencies, PAHO, USAID and GTZ. Guyana’s immunization program benefits significantly from GAVI.

The first reported HIV case for Guyana was reported in 1987. Today, UNAIDS estimates that Guyana has an adult prevalence of 2.4% (range:1.0%–4.9%). Between 1987 and the end of 2006, a cumulative total of 7,831 AIDS cases have been officially reported to the Ministry of Health. In 1987, there were 1.3cases/100,000 population, but this increased to 56.2 cases per 100,000 population by 2003. Cases have been reported in all ten geographical regions of the country. The majority of the cases are among persons 20-44 age group. AIDS is currently the leading cause of death among the 20-49 age group. Overall, about 28% of the cases are female, but in the age group under 24, females account for the majority of cases. The overwhelming evidence is that the transmission of HIV is primarily through heterosexual exposure.

Guyana is described as having a generalized epidemic. There are geographical variations as shown in the Table below:

Before 2001, several small studies among pregnant women showed prevalence rates between 4 and 7%. Since 2001, when PMTCT was introduced, prevalence studies have shown reduced prevalence rates. In 2002, the reported rate was 4.1%. In 2003, the rate was reported as 2.9%, in 2004 as 2.5% and in 2006 as 2.4%.

The most recent concluded ANC HIV Seroprevalence Survey of 2006, showed that the overall prevalence of HIV is low in pregnant women attending ANC services in Guyana with an overall prevalence of 1.55%, a further reduction from the results of the 2004 survey. In the youngest agegroup (15-19years) the HIV prevalence is less than 1%, however, for those age 20-24 the prevalence is slightly higher at 1.34% and combined the prevalence for the 15-24 agegroup the prevalence is 1.0%. The survey yielded the highest HIV prevalence in the agegroup 30-34 years – 2.46%. and a higher prevalence in urban versus rural population ( 2.18 versus 1.22%).
Additionally to HIV the survey low prevalence of syphilis with only 0.66% of the RPR samples reactive and with no significant difference between HIV positive and HIV negative women.

Studies done among commercial sex workers prior to 2001 showed a prevalence rate of approximately 46%. But in a recent study done in 2004, the reported prevalence was 26.6%. A study was conducted among MSM in Region 4 in 2004. This study showed a rate of 21.2%. Among STI patients, HIV prevalence rate among males was reported to be 13.2% in 2002 and 15.1% in 2002 and among females, the prevalence rate for HIV was reported to be 6.5% in 1993 and 12.0% in 2002. Among miners, previous studies had shown rates of between 6.9 and 11%, but a new study in 2004 showed an HIV prevalence rate among miners to be 3.9%.

Guyana completed its first formal Behavioral Surveillance Survey in 2004/2005 among In- and Out-of-school youths, employees of the sugar industry, members of the uniformed services, female commercial sex workers, and MSM. Overall knowledge of HIV transmission was found to be high, but there were also a number of misconceptions prevails still. For example, 30% of the out-of-school youths believe that mosquitoes can transmit HIV and 25% thought that HIV could be transmitted through the sharing of a meal with an infected person. The survey showed that a number of perceptions that may contribute to stigma and discrimination. For example, 25% of the respondents reported that they would not purchase from an HIV+ shopkeeper and more than 33% would want to keep it a secret if a family member were to become infected. The survey showed that condom use with non-regular partner was higher than with regular partners. The survey showed that only a small % of the respondents had been tested for HIV.

An AIDS Indicator Survey (AIS) conducted in 2005 found that the overall knowledge of HIV Transmission was high with 98% of the population having heard of HIV and AIDS and 75% of the adults knowing that having only one uninfected faithful partner can reduce the chance of contracting HIV. Knowledge of other means of avoiding HIV transmission such as using condoms and limiting sex to one uninfected partner who has no other partners is relatively high with 76% of women and 81% of men citing both methods Correct knowledge of mother to child transmission i.e. HIV can be transmitted by breastfeeding and that the risk of MTCT can be reduced by the mother taking drugs during pregnancy is relatively low ( 39% for women and 28% for men).

In relation to attitudes the AIS revealed that attitudes toward teaching children about condom use to avoid HIV are generally positive with 81% of women and 84% of men supporting teaching children age12-14 about using a condom.

In relation to behaviour- the survey revealed that the median age of the first sexual intercourse for women is 18.4 years and for men 18 years. The proportion of all women age 15-49 who report having sex with two or more partners in t he 12 months preceding the survey is relatively low (1%) but reaches 9% among men. A larger proportion of men reported having high risk sex at home at some time in the past 12 months. 50% of women and 66% of men reported condom use the last time they had sex with a nonmarital, noncohabiting partner in the last 12 months.

If this epidemic remains unchecked, Guyana could face the day-to-day experience of declining standards of living, reduced capacities for personal and social achievement, an increasingly uncertain future, with important consequences for what can be achieved today, and a diminished capacity to maintain what has been secured over the past decade in terms of social and economic development. HIV/AIDS has the potential to distort the very fabric of everyday life in Guyana, with profound implications for both social and economic development.

HIV/AIDS poses a significant socio-economic challenge for Guyana. It is a developmental issue and since Guyana is recovering from decades of under-development, HIV/AIDS represent a major barrier to overcoming under-development and, further, HIV/AIDS can lead to regression from gains made in the last decade. As in other countries, HIV/AIDS affects the most productive age groups (20-49) in the society. This makes Guyana very vulnerable to the devastating impact of HIV/AIDS. HIV/AIDS is already the leading cause of death among these age groups in Guyana. Since many of these persons may either be the sole breadwinner for their family or an important contributor to the family’s income, HIV/AIDS is likely contributing to driving families into poverty and making them very vulnerable.

The effects of debilitating illnesses caused by HIV/AIDS and increasing numbers of deaths due to AIDS are:

• Fall in productivity arising from illnesses and deaths

• Increased absenteeism by PLWHA and their caregivers

• Increased numbers of parentless children and, thus, an increase in the population of orphans and vulnerable children (OVC)

• Increased health expenditure by the Government

• Diversion of resources from savings, resulting in lower incomes
  

Guyana’s Poverty Reduction Strategy paper (PRSP), endorsed by the World Bank and the IMF, recognized the potential of HIV/AIDS in leading to further poverty for Guyana and, thus, made the fight against HIV/AIDS a major priority in the strategy to reduce poverty in Guyana.

According to a UNICEF Report (2004), there are currently an estimated 4,200 children (children under 18) who might be classified as OVC being one or both of their parents have died or are ill (PLWHA). These children face an uncertain future and the threat of exploitation, violence and abuse. Further studies are urgently needed to establish the exact number of children affected by HIV/AIDS, but it is evident that this has become a major challenge for Guyana. A recent assessment by UNICEF among 165 OVCs showed that 37% of them were missing one or both parent because of HIV/AIDS.

VCT is an entry point to care and treatment in Guyana. Prior to 2003, there was only limited access to VCT in Guyana, being only available at a limited number of public health institutions and at only one NGO-operated site. The introduction of PMTCT in 2001 at eight public sector sites provided added capacity for VCT in the public sector, but did not improve significantly access to VCT in Guyana. Testing was available in about five private sector operated sites also, but while these services may have offered voluntary testing, it is believed that most of these testing services were without counseling. With the addition of partners such as PEPFAR, World Bank and Global Fund, a dramatic improvement in access to VCT has occurred.

An increase in the number of public sector sites has occurred and VCT through the public sector is now available in all ten geographical regions of the country. VCT is offered through fixed sites at health center and through NOGs, and through mobile teams. There are 43 fixed sites in eight of the ten geographical regions and the two mobile teams serve the hinterland regions. The number of persons tested through VCT has increased over the years, with 16064, 25063 in 2005 and 2006 respectively.  VCT is also available at all PMTCT sites and more than 100 such sites are operating in seven regions of the country. The STI and TB clinics and the malaria clinics in the public sector also serve as an entry point for VCT.

NAPS and the Maternal Child Health (MCH) Department of the Ministry of Health launched the PMTCT Program in Guyana in November 2001 at eight sites in Regions 4 and 6. UNICEF and PAHO were major partners in the initial launch of the program in 2001. There are now (end of 2006) more than 100 public sector PMTCT sites in eight Regions. These sites provide access to PMTCT for almost 80%  of pregnant women in Guyana. PEPFAR, through its GHARP Program coordinates the PMTCT efforts at 42 of the PMTCT sites. The World Bank supports the Ministry of health’s PMTCT program at the other sites. Major expansion of the PMTCT program is planned for 2007 and it is expected that the World Bank  and UNICEF would also fund part of Guyana’s PMTCT program. 

Most of the sites operating in Guyana have demonstrated greater than 90% uptake of testing for HIV and the number of women receiving treatment with Nevirapine is very high (>80%) in most sites. More than 85% of the babies born to HIV+ pregnant women receive nevirapine treatment after birth. 
Prior to 2001, studies showed about 7% prevalence of HIV among pregnant women. In 2002, the PMTCT sites revealed a prevalence of about 4%. In 2004, the prevalence rate among pregnant women as assesses at the PMTCT sites was 2.5%. There was a further reduction revealed in the ANC Seroprevalence Survey of 2006 of 1.55%.

Treatment is essential to reducing the risk of transmission, prolonging useful life, and improving quality of life. By the end of September 2007 1949 patients were receiving anti-retro viral therapy (ARV). The estimated number of adults (aged 15-49) needing ARV treatment at the end of 2007 is 3240 (Source:Projection estimates from the 2006 ANC Seroprevalence Survey using the Estimation and Projection Package (EPP), a UNAIDS Epidemiological Modeling Software and Spectrum (a Constellation Futures Projection Package ). The Guyana Guidelines has undergone its first revison and the CD4 threshold for initialting ARVs has been increased from 200 to 350. It is expected that this will result in a larger number of persons being placed on ARV treatment at an earlier time.

Guyana’s programme has moved from one treatment site in 2001 to 12 fixed treatment sites at the end of September 2007 and one roving medical team that serves the hinterland regions of 1, 7, 8 and 9.

Treatment for STIs is available in both the public and private sector. National guidelines for the syndromic management of STIs exist and training of health personnel in the public sector in most of the regions has been carried out using the approach. There is a need to bring the health personnel in the private sector up to speed with the public sector.

In a Behavioral Surveillance Survey (BSS) assessing subgroups undertaken in 2004, the out-of-school youth aged, 15-24, indicated that there continues to be a high level of HIV/AIDS knowledge. 89.5% of respondents understand that HIV can be transmitted from mother- to- child, but 23% of the respondents report having the misconception that transmission occurs via mosquito bites. The average age at first sexual encounter in this sub-group was 16.1 years.

It appears that although general knowledge about HIV is relatively high, so is the level of stigma and discrimination. When asked, 48% of respondents replied that they would keep their HIV status from their family if they found out they were HIV+; 23.7% reported they would not buy goods from an HIV-positive shop owner, 65.3% were of the opinion that an HIV-positive teacher should not be allowed to teach. Only 19.8% reported that they would share a meal with an HIV infected person. While 81% reported that they would care for a relative with HIV/AIDS, it is alarming that 28.8% believe HIV infected persons should be quarantined.

In Guyana , gender issues contribute to the broader social, economic, and political problems. Women carry a disproportionate burden relative to men, in economic and social terms. Gender roles and relations powerfully influence the course and impact of the HIV/AIDS epidemic. Gender-related factors shape the extent to which men, women, boys and girls are vulnerable to HIV infection and the ways in which AIDS affects them. Reversing the spread of HIV therefore necessitates that women are empowered in all spheres of life. Their socially defined roles as care-givers, wives, mothers and grandmothers mean they bear the greatest part of the AIDS-care burden. They also bear the brunt of the epidemic in other ways too, since they are most likely to lose jobs, income and schooling. Given the growing ‘feminization’ of AIDS in Guyana , there is a special need to address the specific factors that contribute to women’s vulnerability and risk. These include insuring that adolescent girls have access to information, services and treatment, that violence against women is not tolerated, and that prevention interventions target vulnerable women.

Institutionally, attention to women’s rights and to gender issues has been bolstered by a nascent women’s movement linked to regional Caribbean organizations, international conventions, and UN conferences. Donor support, particularly from the Canadian International Development Agency (CIDA) Gender Equity Program, has been an important stimulus for improving the legal foundation for gender equality and building programs to deal with gender issues.

However, men and young boys are also vulnerable. In a Gender Assessment report for USAID/Guyana, August 2003, a NGO working to prevent transmission reported that the principal gender issue in dealing with HIV/AIDS is the case of young men, devoid of employment opportunities or achievement and with low self-esteem, who consider themselves to be invincible but also are reluctant to seek information and advice. The recent BSS reported that of the 702 male out-of-school youths surveyed, 47.8% felt that their chances of being infected were low or non-existent.

Between 1988 and 2000, the Government of Guyana was the main source of financial support for HIV/AIDS programs. Since then, external funding has surpassed domestic sources of funding by approximately 50 percent.

Government of Guyana (GOG) : Key elements of the GOG’s current response to the epidemic include:

• Strengthening of the surveillance system to produce information that will inform the design of interventions for HIV/AIDS reduction and planning care for those affected;

• Increase access to appropriate STI diagnosis and management as a key prevention strategy

• A plan to increase access to voluntary counseling and testing (VCT);

• A Plan to increase PMTCT Plus sites.

• AIDS awareness and education training at worksites;

• Rigorous blood screening for HIV and other infectious markers

• To reduce the risk and vulnerability to infection with HIV through targeted public education efforts focused on health care providers, youth, employers, employees, entertainers, commercial sex workers and men who have sex with men , and,

• Provision of free HIV services including antiretroviral therapy for HIV-positive patients

• Early infant diagnosis

• Plan for the expansion of the Laboratory diagnosis and monitoring of HIV and for the diagnosis of opportunistic infections

• Support for persons living with HIV ( nutritional, psychosocial, economic and others)

• Support for orphans and vulnerable children

The GOG has recognised the need of a multi-sectoral approach of addressing the HIV/AIDS epidemic in Guyana. Funding was successfully sought to support sector Ministries developing and implementing programmes for HIV/AIDS. The need for strong leadership, support and coordination of this multi-sectoral response led to President Bharrat Jagdeo establishing the Presidential Commission on HIV/AIDS in June 2004. The Commission is chaired by His Excellency, the President and it includes nine sector Ministers and representatives from the international community. The secretariat of the commission is house at the Health Sector Development Unit (HSDU). Eleven key Ministries have developed programmes and received funding to support the implementation of those programmes. These Ministries included:

• Ministry of Agriculture

• Ministry of Amerindian Affairs

• Ministry of Culture, Youth and Sports

• Ministry of Education

• Ministry of Home Affairs

• Ministry of Human Services and Social Security

• Ministry of Local Government and Regional Development

• Ministry of Housing and Water

• Ministry of Public Service

• Ministry of Labour

• Ministry of Foreign Trade

These Ministries had all developed and are implementing HIV/AIDS workplans targeting their constituencies ( direct beneficiaries and indirect beneficiaries).
Additional to the Ministries, public corporations have also developed and are implementing workplans. These include the Guyana National Newspapers Limited and the Guyana Lands and Surveys Commission. In addition to the Public Sector the Government of Guyana supports over 50 Civil Society, Faith Based and Community Based Organisations to implement HIV/ AIDS Programmes.

International Labor Organization (ILO) HIV/AIDS Workplace Education Program :

In October 2003, The ILO HIV/AIDS Workplace Education Program commenced operation in Guyana , with funding of approximately US$ 396,762 from the United States Department of Labor (USDOL) over a three-year period. The program is being implemented in close consultation with the Ministry of Labor, Human Services and Social Security, employers and workers, to implement HIV/AIDS programs in the world of work, enhance workplace protection and reduce the adverse consequences of social, labor and economic development. To date, sixteen (16) enterprises in the Service Sector, two (2) in the manufacturing Sector, one (1) in Forestry, and three (3) in Mining, are actively collaborating in the program. Thirteen (13) of the twenty-two enterprises have completed their draft HIV/AIDS policies which is currently being reviewed by the ILO. Over the next three months, managers, workers and workers representatives will be trained as HIV/AIDS educators.

A draft policy and action plan for the Guyana Trades Union Congress (GTUC) has been formulated, revised and is presently with the executive council of the GTUC for approval.

Donors working in HIV/AIDS and/or the Health Sector include UNAIDS, UNFPA,UNICEF, USG, Global Fund, PAHO, the World Bank, the IDB, and bilateral donors. The IDB is supporting health sector reform and decentralization.

The World Bank will support institutional capacity strengthening, monitoring, evaluation and research, scale up the HIV/AIDS response by line ministries, civil society organizations and the private sector, and expand health sector prevention and treatment and care services for HIV/AIDS. The Global Fund program will expand existing efforts under National Strategic Plan (2002-2006) to improve and expand HIV prevention activities, increase access to care and treatment for people living with HIV/AIDS. The United States Government (USG) Agencies, such as USAID and CDC have a close working relationship with the MOH and continue to be one of the largest sources of financial and technical assistance to the national program. The Canadian International Development Agency (CIDA) and its implementing partner, the Canadian Society for International Health (CSIH), recently launched a program focusing on health information systems and laboratory strengthening for TB and STIs in three regions. UNICEF is supporting the development of a curriculum on Family Life Education for Levels 1 – 3 in-school students, through the Ministry of Education, and is evaluating the needs of orphans and others affected by HIV/AIDS. UNFPA is supporting a project that is focused on reducing incidence of HIV/AIDS in youths in especially difficult circumstances.

German Agency for Technical Cooperation (GTZ) is supporting a project targeting commercial sex workers, including a condom social marketing campaign. The World Bank will support institutional capacity strengthening, monitoring, evaluation and research, scale up the HIV/AIDS response by line ministries, civil society organizations and the private sector, and expand health sector prevention and treatment and care services for HIV/AIDS. PAHO and CAREC will continue to provide resources for gaps in laboratory strengthening and surveillance. UNDP supports national efforts by offering knowledge, resources and best practices from around the world.

In Guyana , youth, women of childbearing age, commercial sex workers, mobile populations such miners and loggers, and men-who-have-sex with men have been identified as among those most at risk for HIV infection. What began as an epidemic concentrated among groups engaging in high-risk behaviors, such as commercial sex work, is now characterized as a generalized epidemic since the prevalence rate is above one percent in the general population (based on public sector AIDS case reporting estimates are between 3.5% and 5.5%), though there is an acknowledged paucity of supporting data. Efforts are underway to collect data that will aid in the understanding of the Guyanese epidemic and ensure that programming is targeted at those most likely to transmit the disease.

General heterosexual transmission includes sexual transmission that occurs in marital, regular, and casual partnerships and accounts for about 80% of those infected. Additionally, transmission through men-who-have-sex-with-men (MSM) is estimated to be about 18%. Rates of HIV among those considered most-at-risk are significantly higher than those of the general population.

As such, while the Guyana epidemic is considered to be generalized, it is not the same type of generalized epidemic as those found in sub-Saharan Africa where prevalence in the general population may be as high as 30%. Consequently, the most effective programming must continue to have significant focus on populations at greatest risk of serving as vehicles of transmission and targeted behaviour change communication strategy. Additionally, programming must also seek to prevent new HIV infections among those in the general population who may not identify with any of the high-risk groups, may engage in multiple or concurrent relationships, and who do not perceive their behavior to be especially risky, as they may emerge as a bridge from Most at Risk Populations (MARPS) to the general population. This is particularly true of men who have sex with men and also have sex with women but do not self-identify as gay/homosexual or bisexual.