Epidemiology Team PEPFAR-DR COP 2015 Epidemiology Team PEPFAR-DR

Table 1.1.1 (a) HIV Prevalence in 15-49 years is 0.8 by DHS-2013 More than 15 k difference between Spectrum and DHS DHS looks to be the most accurate source Deaths and new cases are GAPS

Table 1.1.1 (b) GAP in available data about TB-HIV in HIV Program (including FAPPS) Important difference in MSM & TRANS Size Estimation and accuracy of HIV prevalence in TRANS (~GAP)

Table 1.1.1 (c) Haitians are the largest Priority Population, ~ 500 thousands across the country (4.5% of Persons living in DR) GAP in HIV prevalence among Haitians living in DR. A secondary analysis of DHS and Bateyes survey is necessary HIV prevalence in Militaries looks similar (or less) than General Population

Table 1.1.2 (a) According to Care Cascade, main gaps are between diagnosed and enrolled in HIV clinics, and those in viral suppression If we consider a estimation of PLWHIV based in DHS and FAPPS, gap in diagnosed will be deeper Cascade among Haitians has wider gaps

Comparison of care cascade using SPECTRUM Estimates Versus DHS/FAPPS Estimates Wider gap between PLWHIV and individuals in care when compare SPECTRUM and DHS/FAPS

Comparison of care cascade using SPECTRUM Estimates vs Comparison of care cascade using SPECTRUM Estimates vs. DHS/FAPPS Estimates

Care cascade among 15-49 years (DHS & FAPPS) Wider gaps are in recruitment in care (56% of PLWHIV) and viral suppression (38% of retained)

Comparison between Care Cascade among Dominicans and Haitians (FAPPS 2014) Care Cascade among Haitians shows wider gaps than Dominicans

Table 1.1.2 (b) In 2014, more than 650k HIV test were performed GAP in system to collect individual level data of persons tested for HIV. Current system collects number of tests Regardless of duplicates, 10% of HIV tests performed among Haitians are positives

HIV test in CDC Projects (2013-2014)

Source: CDC Projects (~60,000 pregnant in 15 facilities)

HIV test in Haitians pregnant 2013

MAP: Estimated HIV Prevalence by province in Dominican Republic using DHS/FAPPS data HIV Prevalence is higher in Dajabón, Montecristi, Valverde, Puerto Plata, Samaná, Duarte, María Trinidad and Barahona.

MAP: PLWHIV receiving care at HIV Clinics Most HIV patients in CARE live in Santo Domingo, San Cristóbal, La Altagracia, La Romana, La Vega, Santiago and Puerto Plata

HIV Prevalence vs PLWHIV in care between 15-49 years Prioritized provinces by PEPFAR: yellow circles and green bars Prioritized provinces by DoD: orange circles ad orange bars Not prioritized provinces: red circles and blue bars

Comparison of Costs Per Individuals reached with HIV Prevention Services by Target Population Cost per Key Population reached in HIV prevention activities are lower for FSW, but are similar to MSM and Haitians

Prevalence vs PLWHIV-CARE (Total) Crossing HIV prevalence and PLWHIV in care (Total) by provinces, suggest that will be more effective to prioritize in: Santiago, Puerto Plata, La Romana, Valverde, La Altagracia, etc. Near green zone. Data source: DHS 2013, FAPPS 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

MSM-TG

MAP: MSM Size Estimation by provinces– Place 2014 Most MSM are concentrated in Santo Domingo, Distrito Nacional, San Cristóbal, Santiago, Santiago , San Pedro de Macorís, La Altagracia and La Romana

MAP: HIV prevalence among MSM by provinces – IBBSS 2012 HIV prevalence looks to be similar across 5 provinces targeted by IBSS 2012

MSM access to medical care 11%-31% MSM-TG reported a HIV test performed in last 12 month (IBBSS-2012) 57%-75% MSM-TG reported access to medical services during last episode of STD (not adjusted data from IBBSS 2012) 4%-48% MSM-TG reported discrimination in health services (IBBSS-2012) 28.9% of health personnel do not prefer to attend MSM (HPP 2014) Range of results of IBBSS-2012 indicates the lower and higher valued found by provinces

MSM Risk Behaviors (IBBSS - 2012) Differences in reported auto-identification between Santo Domingo and Santiago vs other provinces (~18% vs ~6% for gay) 35%-52% reported use of cocaine in last 6 months 14%-30% reported more than 4 sexual couples in last 6 months 70% -94% reported sex for benefits 42%-71% reported used condom in last anal sex intercourse (passive) 21%-39% reported used condom in last anal sex intercourse (active) 41%-80% reported used condom in last anal sex intercourse for benefits (with other man) Range of results of IBBSS-2012 indicates the lower and higher valued found by provinces

MSM reached in HIV prevention activities versus costs by provinces In Santo Domingo, MSM Prevention costs are high, reached is average and is the largest province where MSM live. In Puerto Plata, MSM Prevention costs are high, reached and size estimation are low La Romana, Santiago, and Barahona reached more MSM than expected according size estimation

MSM reached in HIV prevention activities and costs by provinces MSM Prevention Activities in Santo Domingo, Santiago, La Romana and Barahona reached many MSM and costs per MSM reached are low. Conversely, in Puerto Plata, Montecristi, Elias Piña, Monte Plata y Valverde, cost are high and MSM reaches are low

Cumulative MSM reached and cumulative prevention interventions costs by province Main increase in MSM according to increase expenditure is observed in first 5 provinces (Santo Domingo, La Romana, Santiago, Barahona and San Cristóbal). After the first yellow arrow, the increase of MSM reached is not as significant. After orange arrow the reach is minimum in remaining of provinces and cost increase significantly.

SUMMARY MAPS: EA among MSM

Reached vs cost per MSM reached in HIV prevention activities Crossing Cost per MSM reached in Prevention Activities vs number of reached, suggest that will be less effective prioritize in: Elias Piña,Montec risti, Valverde, etc. Near red zone. Data source: APR 2014, EA 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

Unmet MSM vs cost per MSM reached in HIV prevention activities Crossing Cost per FSW reached in HIV Prevention Activities vs unmet FSW, suggest that will be more effective to prioritize in: Monte Plata, San Pedro de Macorís, etc. Near green zone. Data source: APR 2014, EA 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

HAITIANS

MAP: Haitians living in Dominican Republic by provinces– ENI 2012 Most Haitians live in Santo Domingo, Santiago, Puerto Plata, Valverde, Montecristi and East Region a(La Altagracia and La Romana).

MAP: Haitians in HIV care by provinces of residence– FAPPS 2014 Haitians in care live mainly in Santo Domingo, Santiago, Puerto Plata, Valverde, La Altagracia, San Pedro de Macoris and La Romana.

Haitians access to medical care 52.6% Haitians reported access to public hospitals when they need (ENI 2012) 35.3% Haitians FSW reported HIV tested in last 12 months 48.8% Haitians FSW reported regular medical care (IBBSS- 2013) 13.1% Haitians construction worker reported HIV tested in last 12 months 18.5% Haitians construction workers reported regular medical care (IBBSS-2013)

Haitians Risk Behaviors (IBBSS - 2013) 5.4% Haitians construction workers reported use of cocaine in last 6 months 24.6% Haitians FSW reported in last commercial sex intercourse 12.5% Haitians FSW reported sexual abuse 18.5%Haitians FSW reported use of cocaine in last 6 months Range of results of IBBSS-2012 indicates the lower and higher valued found by provinces

Haitians living in Dominican Republic and total expenditure by provinces High number of Haitians live in Santo Domingo, Santiago and Distrito Nacional, but there is no investment in Santiago Santo Domingo presents highest investment. Independencia, Dajabon, Pedernales and Barauco present high cost but size of population is low.

Haitians living in Dominican Republic and reached by HIV prevention activities by provinces PEPFAR is reaching in HIV prevention activities (sponsored by PEPFAR) only 3% of Haitians living in Dominican Republic.

Haitians reached in HIV prevention activities and costs by provinces Cost per Haitians reached in Valverde and Distrito Nacional are high and coverage is low Barahona was excluded because it was defined as outlier (~590 USD per Haitians reached)

Haitians reached in HIV prevention activities and costs Increase of expenditure is proportional to increase of Haitians reached

SUMMARY MAPS: EA among Haitians

Reached vs cost per Haitians reached in HIV prevention activities Crossing Cost per Haitians reached in Prevention Activities vs number of reached, suggest that will be more effective prioritize in: Santo Domingo, La Altagracia and Pedernales. Barahona and Distrito Nacional were considered outlier and were excluded Data source: APR 2014, EA 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

Unmet Haitians vs cost per Haitians reached in HIV prevention activities (AE 2014) Crossing Cost per Haitians reached in HIV Prevention Activities vs unmet Haitians, suggest that will be more effective to prioritize in: Santo Domingo, La Altagracia, Valverde and Montecristi. Near green zone. Data source: APR 2014, EA 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

FSW

MAP: FSW Size Estimation by provinces– Place 2014 Most FSW are concentrated in Santo Domingo, Distrito Nacional, San Cristóbal, Santiago, San Pedro de Macorís, La Altagracia, La Romana and Monte Plata

MAP: HIV prevalence in FSW by provinces – IBBSS 2012 HIV prevalence looks to be similar across 4 provinces targeted by IBSS 2012 but lower in Santo Domingo (1.7%)

FSW access to medical care 21%-52% FSW reported a HIV test performed in last 12 month (IBBSS-2012) 56%-100% FSW reported access to medical services during last episode of STD (not adjusted for RDS - IBBSS 2012) 48%-79% FSW reported regular medical care (not adjusted data from IBBSS 2012) 86%-95% FSW reported discrimination in health services (IBBSS-2012) 24.8% of health personnel do not prefer to attend MSM (HPP 2014) Range of results of IBBSS-2102 indicates the lower and higher valued found by provinces

FSW Risk Behaviors (IBBSS - 2012) 30%-57% reported use of cocaine in last 6 months 9%-31% reported sexual abuse 61%-92% reported used condom in last commercial sex intercourse 6%-23% reported used condom in last non commercial sex intercourse The average sex worker began between 18-20 years (not adjusted by RDS) Range of results of IBBSS-2012 indicates the lower and higher valued found by provinces

FSW reached in HIV prevention activities versus costs by provinces In Santo Domingo and Distrito Nacional, FSW Prevention costs are high, reached is low, but are the largest provinces where FSW live In Puerto Plata, FSW Prevention costs are high, and reached are higher than size estimation San Cristóbal, Elias Piña, Montecristi, La Vega, Duarte, Azua, Monseñor Noel, San Juan and Dajabón reached more FSW than expected according to size estimation

FSW reached in HIV prevention activities and costs by provinces FSW Prevention programs in Puerto Plata and San Cristóbal reached many FSW and cost is average. Santiago interventions seems effective as costs per FSW reached is low. Cost are high among Elias Piña and low in La Romana, Santo Domingo, La Altagracia Monseñor Noel, San Pedro de Macorís and Distrito Nacional

FSW reached in HIV prevention activities and costs There is no clear efficiency point. As investment increase, the number of FSW reached also increases. Expenditure looks to be directly proportional to reached FSW by Prevention Activities

Reached vs cost per FSW reached in HIV prevention activities Crossing Cost per FSW reached in Prevention Activities vs number of reached, suggest that will be less effective to prioritize in: Distrito Nacional , Monseñor Noel, Hato Mayor. Near red zone. Data source: APR 2014, EA 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

SUMMARY MAPS: EA among FSW

Unmet FSW vs cost per FSW reached in HIV prevention activities Crossing Cost per MSM reached in HIV Prevention Activities vs unmeet MSM, suggest that will be more effective to prioritize in: Distrito Nacional, Santo Domingo, etc. Near green zone. Data source: APR 2014, EA 2014 Provinces in green quadrant have better values for 2 indicators, in red quadrant have worse values for 2 indicators, and in yellow quadrants have only one good indicator.

Cost and Geographical Analysis by KP and PP MSM FSW Haitians