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Estimated number of people needing antiretroviral therapy (0-49 years), 2005: Antiretroviral therapy target declared by country: 1. Demographic and socioeconomic data
2. HIV indicators
Adult prevalence of HIV/AIDS (15-49 years) antiretroviral therapy (0-49 years), 2005 antiretroviral therapy (0-49 years), 2005 HIV testing and counselling sites: number of HIV testing and counselling sites: number of Knowledge of HIV prevention methods (15-24 Knowledge of HIV prevention methods (15-24 °= Percentage of young people 15-24 years who correctly identify two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner), who reject the two most common local misconceptions about HIV transmission, and who know that a healthy looking person can transmit Reported condom use at last higher risk sex °°=Percentage of young people 15-24 years reporting the use of a condom during Reported condom use at last higher risk sex sex with a non-regular partner in the last 12 months.
3. Situation analysis
Epidemic level and trend and gender dataCosta Rica’s HIV/AIDS epidemic is especially concentrated in the groups exhibiting sexual risk behaviour and is considered at an incipient stage. Most cases, an estimated 84%, are attributable to sexual transmission. According to the Ministry of Health, sex between men is a major factor in the epidemic in Costa Rica, where more than half of AIDS cases in 1998–2002 were among men who have sex with men, a significant percentage of whom also have sex with women. Bisexuality is therefore a significant channel for HIV transmission into the wider population. Notably, AIDS cases and AIDS mortality have declined in Costa Rica after access to antiretroviral therapy was expanded. The prevalence of HIV infection was estimated to be 0.6% in 2003. The annual incidence has held steady over the past few years at 400–500, a situation that has been characterized as a steady-state epidemic. Factors that negatively impact the progression of the epidemic include: the prevalence of mobile populations, both for transit passage and for migrants (especially from Nicaragua and Colombia); increasing sex tourism, including the commercial sexual exploitation of children; and, since Costa Rican society is considered to be more liberal than other countries in Central America (in the sense that it does not prohibit sexual diversity), men who have sex with men visit or live within Costa Rica more freely.
Major vulnerable and affected groupsVulnerable groups include sex workers and men who have sex with men. Child prostitution and trafficking of women is growing rapidly, and sexually exploited girls and women are also highly vulnerable. The overall adolescent population also represents a high-risk group for HIV/AIDS infection, because access to clear and appropriate information about sexuality and sexual and reproductive health is lacking, which puts adolescents at risk of contracting sexually transmitted infections and HIV/AIDS and increases unwanted pregnancies.
Policy on HIV testing and treatmentCosta Rica is the only country in the Central American subregion with universal access to antiretroviral therapy for people living with HIV/AIDS. Costa Rica passed a general law on HIV/AIDS in 1998. Treatment protocols and guidelines for the clinical management of HIV infection have been developed and/or adapted, based on the adaptation of standards proposed by the Pan American Health Organization/WHO and the United States Centers for Disease Control and Prevention. Between 1998 and 1999, the Legislative Assembly approved legislation aimed at protecting people living with HIV/AIDS against discrimination. This legislation also defined the responsibilities for public institutions with regard to HIV/AIDS prevention, promotion of condom use, testing, registration, treatment and the human rights of prisoners and children living and working in the streets. The social security services have elaborated protocols for the prophylactic treatment of AIDS for health sector workers as well as protocols for triple therapy.
Antiretroviral therapy: first-line drug regimen, cost per person per yearThe first-line drug regimen for adults: zidovudine + lamivudine + efavirenz or nelfinavir. The first-line drug regimen for pregnant women: zidovudine + lamivudine + nelfinavir. The first-line drug regimen for children: zidovudine + lamivudine + lopinavir with a low-dose ritonavir boost. Under the Accelerated Access Initiative, successful price negotiations have led to substantially reduced prices for antiretroviral drugs in Central America. The most common treatment in Central America, zidovudine + lamivudine + efavirenz, now costs between US$ 1000 and US$ 1400 per person per year. Where countries opt to use generic antiretroviral drugs, the cost per person per year for first-line triple therapy will be further reduced to between US$ 800 and US$ 1200. Costa Rica’s cost for the first-line drug regimen for adults in the public system is US$ 1616 to US$ 1879 per person per year.
SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP COSTA RICA
Assessment of overall health sector reponse and capacityAs a result of decades of adequate and efficient investment in education and health and health sector reform over the past decade, the country has been successful in developing a health care system based on the main values of equity, solidarity and universality that covers most of the population at three different levels. Its well-developed publicly funded comprehensive health care system emphasizes the principle of universal coverage and is supported by the World Bank in its Second Health Sector Strengthening and Modernization Project. Political commitment to combat HIV/AIDS is very high, and the efforts of the government and the health care system in recent years have focused on providing universal antiretroviral therapy to all HIV-positive people in need. Costa Rica has been effectively confronting the epidemic for several years through a balanced approach between treatment and prevention. In 1985, the Ministry of Health created the AIDS Control Department for the promotion of voluntary testing and the treatment of people living with HIV/AIDS and a National Commission on HIV/AIDS was established, the predecessor of the current National HIV/AIDS Council. As a result of the health sector reform, the AIDS Control Department was handed over to the Costa Rican Social Security Fund, which is the main health care provider. The four type A social security hospitals have special AIDS clinics with qualified personnel to provide highly specialized health care for all people living with HIV/AIDS. In one of these hospitals, the Association of People Living with HIV/AIDS operates peer counselling consultation to provide more humane attention centred on the person living with HIV/AIDS and his or her family and immediate relatives. Costa Rica has also developed a national strategic plan for integrated HIV/AIDS care.
Critical issues and major challengesKey issues include the need to strengthen drug supply management, quality control, human resource capacity and surveillance. Challenges include the need for infrastructure support, including improving laboratory services, enhancing the capacity of health workers to deliver antiretroviral therapy, improving referral systems, strengthening procurement structures, monitoring drug resistance and delivering general health services. The need for additional trained and qualified human resources has been identified as a limiting factor in scaling up. The US–Central America Free Trade Agreement (CAFTA) could negatively affect the price and availability of generic antiretroviral drugs in the country.
4. Resource requirements and funds committed for scaling up treatment and prevention in 2004–2005
• WHO estimates that US$ 20.9 million was required to support scaling up antiretroviral therapy in Costa Rica during 2004–2005 to meet the WHO “3 by 5” treatment target of 1250 people.
• The country possesses a reasonably high absorption capacity for additional financial resources, due to highly qualified human resources and a network of health care facilities distributed throughout the country. The government currently covers antiretroviral therapy under national health insurance and has been absorbing these costs through the national health budget and World Bank loans. In the year 2000, US$ 8 million was spent on antiretroviral therapy alone. In 2003, total public and private expenditure on HIV/AIDS treatment exceeded US$ 9.0 million. The government has shown strong commitment to HIV/AIDS treatment and has surpassed the WHO “3 by 5” treatment target of 1250 people (based on 50% of estimated need).
• Costa Rica submitted a successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria for total five-year funding of US$ 3.6 million to support HIV awareness efforts and comprehensive care for youth at risk and to improve the quality of life for people living with HIV/AIDS. As of December 2005, US$ 1.9 million has been disbursed.
• Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama submitted a successful proposal to the Global Fund in Round 4 (the Mesoamerican Project in Integral Care for Mobile Populations: Reducing Vulnerability of Mobile Populations in Central America to HIV/AIDS), with a total five-year budget of US$ 4.7 million and two-year approved funding of US$ 2.1 million. The grant agreement was signed in August 2005, and as of December 2005, about US$ 500 000 has been disbursed.
5. Treatment and prevention coverage
• Grassroots advocacy and the resulting legal actions by people living with HIV/AIDS in 1997 were largely responsible for the decision of the Costa Rican Social Security Fund to start providing antiretroviral therapy. Mandated by a Supreme Court decision in 1997, Costa Rica is now the only country in Central America to provide triple combination antiretroviral therapy to all people living with HIV/AIDS in need through the Costa Rican Social Security Fund, which provides universal health care in Costa Rica. The procurement of antiretroviral drugs represents a heavy burden for the overall national budget for medicines.
• Costa Rica leads the Central American subregion and has achieved 100% antiretroviral therapy coverage. As of July 2004, the reported total number of people receiving antiretroviral therapy in Costa Rica was 1850. By March 2005, this number had increased to an estimated 2000 people on antiretroviral therapy, and by July 2005, 2564 people were receiving treatment in Costa Rica.
• In 2003, WHO and UNAIDS estimated Costa Rica’s total antiretroviral therapy need to be about 2500 people, and the WHO “3 by 5” treatment target for 2005 was set at 1250 people (based on 50% of estimated need). With estimated coverage by March 2005 of 2000 people, Costa Rica surpassed the WHO “3 by 5” treatment target. However, WHO estimates of need as of the end of 2005 increased to 3400.
6. Implementation partners involved in scaling up treatment and prevention
Leadership and managementThe Ministry of Health plays a leading role within the framework of sectoral reform, with strategic management, leadership and regulatory functions. The national response to HIV/AIDS is led by the Ministry of Health through the National AIDS Commission, which was established in 1999. The National HIV/AIDS Council provides strategic and policy guidance for Global Fund grant operations, through the Technical Secretariat. Other coordination mechanisms include the Country Coordinating Mechanism of the Global Fund and the United Nations Theme Group on HIV/AIDS in Costa Rica.
Service deliveryThe Ministry of Health provides leadership in policy and programming and overall management of antiretroviral therapy service delivery. The Costa Rican Social Security Fund has overall operational responsibility for service delivery. Implementing partners include both government institutions and nongovernmental organizations. UNAIDS provides support for prevention activities in the uniformed services.
Community mobilizationA range of nongovernmental organizations, United Nations agencies (such as UNDP and WHO) and bilateral donors (such as the United States Agency for International Development) work alongside the government in mobilizing communities and supporting people living with HIV/AIDS. Local nongovernmental organizations such as FUNDESIDA work with vulnerable populations, especially sex workers, street children and sexually exploited girls, supporting the Department of AIDS of the Ministry of Health. The Programme for Integral Attention to Adolescents of the Costa Rican Social Security Fund and nongovernmental organizations such as the Asociación Demográfica Costarricense and Paniamor specialize in sexual and reproductive health, work with adolescents and provide training to health care workers. The Association of People Living with HIV/AIDS operates peer counselling services and supports people living with HIV/AIDS. The Ministry of Education and Ministry of Justice are also highly involved in information, education and communication as well as training activities. The OPEC Fund for International Development and the United Nations Population Fund support HIV prevention activities among youth.
Strategic informationThe Ministry of Health and the Costa Rican Social Security Fund have overall responsibility for surveillance and data collection. The Ministry of Health is responsible for controlling and validating the data provided by the Costa Rican Social Security Fund. The Department of Epidemiological Vigilance of the Ministry of Health together with the Department of Epidemiological Vigilance of the Social Security System conduct sentinel research. The National Institute of Statistics and Census and the Center for Population Studies of the University of Costa Rica provide support for demographic surveys.
7. Staffing input for scaling up HIV treatment and prevention
WHO's response so far• Hosting a meeting in August 2005 for countries of Central America to assess progress towards “3 by 5” and to identify gaps and areas of cooperation• Developing a subregional plan for HIV/AIDS surveillance in Central America• Implementing the “3 by 5” strategy and developing national and subregional strategic plans• Holding training workshops in the subregion on prevention and counselling among youth and vulnerable groups, delivering antiretroviral therapy, preventing sexually transmitted infections and training health workers in the treatment of injecting drug users• Establishing the Regional Revolving Fund for Strategic Public Health Supplies (including antiretroviral therapy), with 12 countries in the subregion signing the agreement and purchases worth more than US$ 12 million being made in 2003 Key areas for WHO support in the future• Supporting the development of human resources capacity and training• Providing support for drug procurement and supply management Staffing input for scaling up HIV treatment and prevention• A National Programme Officer is in place as well as a Subregional HIV/AIDS Officer (Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama).
For further information please contact: WHO HIV helpdesk, Email: [email protected], Tel: +41 22 791 1565, Fax: +41 22 791 1575, This country profile was developed in collaboration with national authorities, the WHO Country Office for Costa Rica and the Pan American Health Organization.
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