Khamal Clayton, Alison Decker, Angela Mazimba, and Savannah Newman are second-year International Development students who traveled to Antigua and Barbuda, Saint Lucia, Grenada, and Trinidad and Tobago in January 2019 to better understand the cost drivers for scaling up treatment of HIV/AIDS across the Caribbean. The team was working with PANCAP, the Pan Caribbean Partnership Against HIV/AIDS, a regional partnership of governments, regional civil society organizations, bilateral and multilateral agencies, and contributing donor partners.

The IDEV Practicum allows students to work directly with public, private and non-governmental organizations as a capstone to their graduate studies. The IDEV Practicum Blog chronicles the travels of IDEV students who take on client projects over winter break.

Our Practicum team worked with the Pan Caribbean Partnership Against HIV/AIDS (PANCAP) and the Pan American Health Organization (PAHO), to develop a cost-benefit analysis of the World Health Organization’s (WHO) Treat All policy in the Caribbean. Under the Treat All policy, all populations and age groups are eligible for anti-retroviral treatment—acknowledging that early use of ART keeps people living with HIV healthier, and reduces the risk of transmitting the virus. Thus, adhering to Treat All guidelines could mean scaling up treatment, which has budgetary implications. Our fieldwork research supported the creation of a standardized tool for Ministries of Health across the Caribbean that can estimate the increased costs and impacts of scaling up HIV testing and treatment to support informed decisions in health finance planning, budgeting, and sustainability.

To prepare for our fieldwork, our team spent a semester researching the historical context of the Treat All policy, different health finance methodologies, HIV/AIDS treatment options and treatment costs in the Caribbean, as well as other factors that might influence scale-up costs. In our fieldwork, two members of our team traveled to Antigua and Barbuda and Saint Lucia (smaller, (Organization of Eastern Caribbean States) islands) and two members traveled to Grenada and Trinidad. Data we collected in the field helped triangulate and confirm our desk research as well as provide new information which helped us construct our tool. Doing this research in the sunny atmosphere of the Caribbean was an added bonus. 

Antigua and Barbuda/Saint Lucia

Across the two islands, we conducted interviews with personnel within the Ministries of Health, including each country’s Permanent Secretary, Chief Medical Officer ,and HIV/AIDS liaison to learn about the cost drivers of HIV/AIDS treatment. To understand the financing details, we met with pharmaceutical experts, procurement officers, and government budgetary specialists on both islands. And to gain context about the state of HIV/AIDS treatment, we met with Antigua and Barbuda and Saint Lucia’s clinical care coordinators, nurses, NGOs working with vulnerable groups, and public health strategists for an on-the-ground perspective on access to and quality of HIV/AIDS treatment.

Comparing the state of HIV/AIDS in each country led to some interesting conclusions about what might be critical to financing a scale-up of HIV/AIDS treatment at the country level in the Caribbean. Antigua and Barbuda, for example, use a Medical Benefits Scheme, financed by a payroll tax, to finance its health expenditures. Its Prime Minister is also heavily invested in HIV/AIDS treatment and is willing to advocate for additional funds as necessary. In Antigua, government budgetary specialists see financing is seen as sustainable--the challenge is in battling the stigma and discrimination to ensure that people in vulnerable groups seek testing.

In Saint Lucia, however, financing is less sustainable. Although the country budgets and forecasts for HIV/AIDS treatment, the lack of a comprehensive medical benefits scheme means for additional financing, the Ministry must submit an ad-hoc request--which can be challenging. In addition to uncertain financing, there is stigma and discrimination around HIV/AIDS issues in Saint Lucia which create barriers to care for members of the LGBTQ community, commercial sex workers, and young people. With the cost estimation tool we developed through our data and research, we hope to concretize the available data, and help to create budgetary forecasts for a variety of scale-up scenarios.

Grenada/Trinidad and Tobago 

Grenada’s centrally managed HIV response system seemingly aligns with the goals of Treat All – the expanded coverage of locally funded testing and treatment for all Grenadians. However, the Grenadian system, like others in the Caribbean region, has to contend with persistent barriers to access including adherence, stigma, and a range of socio-economic factors. Given these barriers, Grenada has sought to decentralize the HIV response system, in the interest of expanding access. For full and effective implementation of Treat All, decentralization will have to occur alongside responses that address supply chain management, lab/quality assurance, and patient compliance.

On the other hand, Trinidad and Tobago have multiple stakeholders organized under the National AIDS Coordinating Committee (NACC). Therefore, no specific department or organization has sole responsibility for evaluating and coordinating the HIV/AIDS response for the country. Unfortunately, this means that itis difficult to pinpoint who is responsible for providing specific data as there are multiple layers. Nonetheless, despite recent fiscal challenges, Trinidad and Tobago remains one of the region’s wealthiest countries and is able to support a free healthcare program for all its citizens, including those affected by HIV/AIDS.

Looking Forward

Overall, both teams had positive experiences conducting our field research. The challenge moving forward is to create a customizable tool which can fit the needs of the different islands in the Caribbean. We hope to use the knowledge we gained to create different cost-benefit sample scenarios. All of us believe the lessons we have learned and the skills we have gained through working on this project will be relevant in whichever paths our respective careers take, whether we are creating a project budget or analyzing a country context. Beyond that, we will also take with us the new friendships and memories which have been forged by this unforgettable experience.

To read about the work that other IDEV Practicum teams did this year, visit this page.

The team with project stakeholders.

The team with project stakeholders.

PHOTO CREDITS: Khamal Clayton, Alison Decker, Angela Mazimba, and Savannah Newman