With around 670 000 people, Kingston and St Andrew is the most populous parish in the North-West Caribbean island of Jamaica. It is home to 9900 people living with HIV and accounts for 27% of the national HIV burden. The city also has the highest rate of new HIV infections, the highest HIV prevalence among STI clinic attendees and the second highest rate of deaths from AIDS-related illness of all parishes in the country1.
Jamaica has an HIV prevalence of 1.8%, rising to about 30% among gay men and other men who have sex with men and 51% among transgender women2. The epidemic in Kingston and St Andrew is concentrated among gay men and other men who have sex with men and other key populations, including transgender women, homeless people, inmates and female sex workers. Kingston and St Andrew’s HIV testing and treatment targets in 2019 were estimated at 93–53–663,4.
The mayor of Kingston endorsed the Paris Declaration in 2014. Since then, the Fast-Track city initiative has gained significant momentum. In support of achieving global HIV targets, the Jamaican Ministry of Health and Wellness has embarked on a comprehensive strategy to build the capacity of health-care workers and civil society organizations to scale up HIV services. This is supported by the International Training and Education Centre for Health (I-TECH), IAPAC, UNAIDS and other partners.
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1 Skyers N. Situation at a glance. Kingston: Ministry of Health (Jamaica); March 2019.
2 Jamaica Global AIDS Monitoring Report, 2019. Kingston: Ministry of Health (Jamaica); 2019.
3 Personal communication from UNAIDS country office, Jamaica, August 2019.
4 Personal communication with Nicola Skyers, Jamaica Ministry of Health, August 2019.
Assessing quality of care
A national quality of care survey was conducted in Jamaica in 2017. It included a review of medical records, a self-administered questionnaire for clinicians and a qualitative assessment for patients.
IAPAC is supporting an additional survey that specifically addresses the perceptions of people living with HIV about the quality of care that they receive in health-care facilities. Following Ethics Committee approval, 6000 people living with HIV in 15 cities (400 in each city) will be asked to participate. With support provided though the Joint UNAIDS–IAPAC Fast-Track cities project, the survey will be one of the most comprehensive to explore the perceptions of people living with HIV about the quality of care that they receive in their respective cities, including Kingston.
Customer service policy
The Ministry of Health and Wellness in Jamaica has established a customer service policy to develop and implement customer-oriented services across all of its health services. The objective of the policy is to improve health-care delivery by providing quality health care that uses best practice approaches. As part of the Joint UNAIDS–IAPAC Fast-Track cities project, IAPAC is supporting the formation of a customer service subcommittee that will conduct a review of studies conducted and reports published by all stakeholders to identify the gaps and priorities within HIV service provision, including those related to stigma and discrimination.
Virtual training
In response to a request from the Ministry of Health, I-TECH has been providing virtual technical support and capacity-building in Jamaica through the ECHO Platform. This platform uses teleconferencing to link specialist teams with primary care clinicians at treatment sites in remote locations (in addition to clinicians, experts include social workers, psychologists and adherence
counsellors). Weekly teaching sessions provide an opportunity for mentorship, as staff are able to receive advice on the management of challenging cases (such as unsuppressed viral load). The first ECHO programme in the Caribbean was established in January 2018, with the hub in Kingston.
Online, self-paced learning material complements the existing ECHO mentorship programme. IAPAC has produced a series of eight 30-minute training modules that are narrated and self-paced. These cover the following: HIV testing and linkage to care; antiretroviral therapy initiation; adherence and retention in care; PrEP and post-exposure prophylaxis (PEP); key populations; paediatric diagnosis and care; adolescent health; integrated management of HIV and noncommunicable diseases; and HIV and aging.
Selected modules have been adapted for consistency with the Jamaican HIV treatment guidelines. Two additional modules requested by the Ministry of Health are HIV and the Pharmacist and Quality Improvement: Theories and Methodologies for Jamaica.
IAPAC has also produced a three-module e-learning course on stigma elimination and a facility-level stigma assessment tool. A stigma mitigation workshop for facility managers and administrators will follow the e-learning course. Both sets of e-learning courses will be posted on Jamaica’s ECHO training platform; they also will be accessible on computer tablets and smart TVs.
Community capacity-building
In collaboration with local and international community partners, IAPAC plans to implement a community capacity-building workshop. The curriculum for this workshop will include HIV treatment literacy, adherence, primary and secondary prevention, viral load testing and differentiated care. A second community capacity-building activity involves a stigma conversation map intervention that is centred around self-stigma and U = U.
Conclusion
The ECHO learning platform will be handed over to the Ministry of Health and Wellness to ensure its sustainability. Health-care workers will be motivated to make use of the training provided through the platform, as it will be linked to the requirement for Continued Medical Education (CME).
Kingston is responding to the grave challenge of stigma and discrimination, creating safe stigma-free spaces to reduce the barriers that prevent people from seeking HIV testing, undertaking treatment and accessing HIV services – thereby protecting themselves and others.
Analyzing the epidemic
Kingston and St Andrew (Kingston) undertook a situation analysis in 2021, with UNAIDS’ support, to assess the epidemic and response. The analysis showed that the city hosts nearly a quarter (24.6%) of Jamaica’s population – and over a third (34.3%) of its diagnosed people living with HIV1. It also has Jamaica’s highest rate of new infections, highest HIV prevalence among people with sexually transmitted infections, and highest rates of AIDS-related deaths. While some progress has been made in the city’s HIV response – 82% of the estimated population of people living with HIV have been diagnosed – only 76% of those diagnosed in 2019 were receiving treatment, of whom 84% were virally suppressed. The city has some way to go to achieve all three new 95-95-95 treatment targets.
The analysis also showed that, as elsewhere in Jamaica, HIV-related stigma and discrimination are among the city’s greatest challenges and continue to affect HIV prevention and treatment efforts. National studies and reports reveal that people living with HIV experience feelings of shame and guilt about their positive status, as well as discrimination from healthcare providers and auxiliary workers and fear of marginalization. This undermines efforts to increase HIV testing, while many of those who are diagnosed do not disclose their HIV status, even to family members or sexual partners.
Some populations – notably sex workers, men who have sex with men and transgender persons – remain particularly vulnerable and are often not reached with HIV services, resulting in higher HIV infection rates. Despite some reform, key legislative protections are still lacking, particularly to prohibit discrimination based on health status (including HIV status), gender identity or sexual orientation. In addition, same sex intimacy, sex work, and some elements of drug possession and use are criminalized.
Stigma and discrimination may be related to HIV status and transmission, or to the stigmatization of sex work, gender, and same-sex relationships. Stigma-related rejection and shame can lead people into higher-risk situations, such as unprotected or transactional sex, which carry a higher risk of HIV transmission. Stigma can also contribute to a reluctance among people living with HIV and those at risk of infection to use HIV services, including testing and treatment services. Men who have sex with men may conduct simultaneous sexual relationships with women and men to conceal the latter, increasing the risk of sexual transmission of HIV. Among young people, negative and inaccurate perceptions of HIV also contribute to a lack of safe sex practices, with many mistakenly assuming that they are at low risk of contracting HIV.
Stigma-Free Spaces
To address these complex challenges, the Mayor of Kingston, Senator Councillor Delroy Williams, and the municipal corporation are working with the Jamaican Network of Seropositives (JN+) and UNAIDS to create stigma-free spaces in the city. Since 1996, JN+ has supported the national HIV response to assist people living with HIV, promoting the GIPA Principle (Greater Involvement of People Living with HIV) and community empowerment and engagement. The stigma-free spaces project will engage a wider audience and establish new partnerships that will serve all populations affected by and living with HIV. It also addresses intersectional aspects of stigma and discrimination, beyond HIV, including those related to gender, sex, identity, race, disability, occupation, place of residence, age, socioeconomic status, academic background, workplace – among others. The project steering committee includes the Private Sector Organisation of Jamaica (PSOJ), Jamaica AIDS Support for Life (JASL), J-FLAG, TransWave, Eve for Life, Kingston & St Andrew Municipal Corporation (KSAMC), Jamaica Manufacturers & Exporters Association (JMEA), Human Resources Management Association of Jamaica (HRMAJ), the Ministry of Health and Wellness (MOHW) and UNAIDS.
The “Stigma-Free Spaces” project covers public spaces such as businesses and workplaces, educational establishments, government offices, places of worship, and sports, social and entertainment venues. In the initial phase, six private- and public-sector organizations in Kingston have committed to ensuring they are free from HIV-related stigma and discrimination and are taking steps to become certified as “Stigma-Free Spaces”.
These organizations receive targeted sensitization training conducted by JN+ to strengthen the capacity of staff, volunteers and users to create and use stigma and discrimination reduction strategies. The training includes information on rights and complaints channels. Each organization also produces a staff charter encouraging non-stigmatizing and non-discriminatory behaviours towards both clients and fellow workers.
Where possible, they are then assessed using a “mystery shopping” approach – anonymous clients access and use each organization’s services and report on them – and a staff survey. These reports provide the basis for certification as “stigma-free”. Once they are certified, stigma-free spaces can display a plaque or trophy provided by the programme.
Once the initial stage is completed, the certification programme will be assessed to determine uptake and interest from other entities. Further training will be provided by JN+ to interested organizations.
To amplify the programme, partners are working together to create traditional and social media campaigns, including a launch event and branded give-aways such as cups and pop sockets. To bring the message to as broad an audience as possible, an anti-stigma mural has been completed on a wall next to a major commuter highway in Kingston.
Mayor Delroy Williams is extremely supportive of the initiative and has publicly committed to the creation of stigma-free spaces across the city. He has stated that he wants his office – the municipal corporation (@ksamcorp) – to be Kingston’s first stigma-free space, and that the ultimate objective is for the whole city to be free of stigma.
In November 2021, Kingston’s municipal corporation unanimously passed a resolution declaring World AIDS Day (1 December) a commemorative day of public interest for the city and committing to a range of activities to help end AIDS as a public health and development concern. In 2021, the municipality worked with private and public sector entities to light buildings and monuments across the city in red and unveiled the mural on Pechon Street. It also developed communications materials shared through both social and traditional media, and engaged social media influencers to amplify World AIDS Day messages. Mayor Williams has strongly committed to speaking publicly on HIV and the broader issues of stigma and discrimination in his activities in 2022, including at different forums and through public addresses.
1 Patricia Watson, R. Situational Analysis: Data Analysis and Web Page Development – Kingston Fast-Track City Programme. 2021.
10 NOVEMBER 2021
A resolution calling on the Kingston and Saint Andrew Municipal Corporation to declare World AIDS Day as a commemorative day for the City of Kingston, received unanimous approval by the City’s Councilors today.
The resolution, which reaffirms Jamaica’s commitment with the Sustainable Development Goals, the Fast Track City Initiative, and the 2021 Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030, resolves that on December 1st of every year, the City of Kingston, in partnership with the public and private sector and affected communities, will commemorate World AIDS Day.
The Mayor of Kingston, Senator Councilor Delroy Williams lauded the resolution as an important step towards transforming Kingston into a stigma-free city. “This resolution stems from a commitment by the Municipality to keep contributing to the end of AIDS, which will only be possible if we effectively tackle the root causes, including stigma, discrimination, and violence that put Jamaicans at risk of acquiring HIV and not adhering to their medications”, stated Mayor Williams.
Acknowledging that “ending discrimination, stigma and marginalization will result in more persons getting tested, accessing treatment and reducing HIV in the municipality”, the resolution further resolves that “events be held each year within the Municipality of Kingston and St Andrew to raise awareness and to end discrimination, stigma, and HIV related violence”.
According to Jamaica’s latest People Living with HIV Stigma Index, launched in 2020, a third of people living with HIV have experienced at least one form of stigma and/or discrimination due to their HIV status in the last 12 months. Furthermore, more than half of the participants reported experiencing self-stigma, and the majority expressed that they find it difficult to tell others about their HIV status.
“Strong partnerships and commitments from local governments are critical to enhance our efforts to end discrimination. As we continue to work towards an equitable and enabling Jamaica for our brothers and sisters living with HIV who continue to be marginalized, I am heartened and welcome this move by the Municipality, led by the Mayor. The passing of this declaration brings awareness and local buy-in,” stated Jumoke Patrick, Executive Director of JN+.
Manoela Manova, UNAIDS Country Director, highlighted these commitments are a step in the right direction. “We have a lot of work to do to end inequalities, discrimination, and AIDS. The commitment shown by the Municipality and the Councilors, through the passing of this resolution, are both a gesture of solidarity and leadership that must be nurtured and replicated across all levels of government.”
