REGIONAL DISPARITIES IN HIV/AIDS IN CHILE: EPIDEMIOLOGICAL PROFILE
OF THE DISEASE IN THE NORTH OF THE COUNTRY
by
Macarena Beatriz Arias Aravena
Bachelor in Physical Anthropology, Chile, 2008
Submitted to the Graduate Faculty of
the Department of Epidemiology
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2013
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Macarena Beatriz Arias Aravena
on
April 20th, 2013
and approved by
Essay Advisor:
Thomas Songer, Ph.D.
Assistant Professor
Department of Epidemiology
Graduate School of Public Health
University of Pittsburgh
______________________________________
Essay Reader:
Ronald Stall, Ph.D., MPH
______________________________________
Professor and Chair
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
ii
Copyright © by Macarena Beatriz Arias Aravena
2013
iii
Thomas Songer, PhD
REGIONAL DISPARITIES IN HIV/AIDS IN CHILE: EPIDEMIOLOGICAL
PROFILE OF THE DISEASE IN THE NORTH OF THE COUNTRY
Macarena Beatriz Arias Aravena, MPH
University of Pittsburgh, 2013
ABSTRACT
According to the Ministry of Health, the HIV/AIDS epidemic remains under control in Chile.
However, when the numbers are broken up by region, important disparities are observed in a
manner where the north of the country presents almost three times higher incidence rates than the
national average. Using data from the HIV/AIDS national surveillance system and the
information reported in several governmental documents, the characteristics of the epidemic in
the north, particularly in the XV Region and the I Region, were described and compared with the
situation observed at the country level over the last decade. In summary, the analysis showed that
individuals from the XV Region and the I Region were at significant higher risk for HIV/AIDS
than an average Chilean person (HIV/AIDS relative risk of 2.9 and 1.6, respectively). The
situation in the north was particularly alarming among women, where women had 12.53 (XV
Region) and 7.20 (I Region) times higher risk for the disease than an average Chilean female.
Coherently, heterosexual exposure to the virus in men was also significantly higher in the
northern regions compared to the country overall where the epidemic remains highly
iv
concentrated among men who have sex with men. Additionally, young people aged 20-29 years
were also at higher risk in the north than at the country level.
When an ecological analysis was performed to explore possible factors affecting the regional
disparities observed in the HIV/AIDS rates across the country, prostitution, drug trafficking and
immigration rates showed a consistent positive association with the incidence of the disease at
the regional level. Also, condom use presented a strong negative correlation.
As a sexually transmitted disease, the HIV/AIDS epidemiological profile varies according to the
cultural norms and sexual practices of each population. Understanding those norms and
practices, and the particularities of an epidemic at the local scale, is key for designing and
implementing effective preventive measures. In this context, the public health significance of this
paper is helping to enrich our understanding about the epidemic in the north of Chile so
interventions can be better tailored to the specific needs of this community.
Keywords: HIV/AIDS, North of Chile, Epidemiology
v
TABLE OF CONTENTS
PREFACE ................................................................................................................................. XIV
1.0
INTRODUCTION ........................................................................................................ 1
2.0
BACKGROUND .......................................................................................................... 4
2.1
CHILE: GENERAL CHARACTERISTICS .................................................... 4
2.1.1
Territorial and Political Administration ....................................................... 4
2.1.2
Demographic Characteristics ......................................................................... 6
2.1.3
Ethnic Composition ......................................................................................... 9
2.1.4. Economy ......................................................................................................... 12
2.1.5. Epidemiological Profile ................................................................................. 18
2.2
HIV/AIDS
IN
CHILE:
HISTORICAL
TRENDS
AND
PRESENT
SITUATION 1984-2010 ..................................................................................................... 20
3.0
4.0
2.2.1
Policy Development on HIV/AIDS ............................................................... 20
2.2.2
Chilean Society and HIV/AIDS .................................................................... 23
2.2.3
Epidemiological Profile of HIV/AIDS.......................................................... 25
RESEARCH QUESTION AND SPECIFIC AIMS................................................. 38
3.1
RESEARCH QUESTION ................................................................................. 38
3.2
SPECIFIC AIMS: .............................................................................................. 38
MATERIALS AND METHODS .............................................................................. 40
vi
4.1
MATERIALS ..................................................................................................... 40
4.2
METHODS ......................................................................................................... 45
5.0
RESULTS ................................................................................................................... 56
5.1
MORBIDITY AND MORTALITY PATTERNS OF THE HIV/AIDS
EPIDEMIC IN THE NORTH OF CHILE ....................................................................... 56
5.2
5.1.1
HIV/AIDS Prevalence in the XV Region and the I Region........................ 56
5.1.2
HIV/AIDS Incidence in the XV Region and I Region ................................ 57
5.1.3
HIV/AIDS Mortality in the XV Region and the I Region .......................... 84
ASSOCIATION
BETWEEN
THE
HIV/AIDS
EPIDEMIC
AND
DIFFERENT DEMOGRAPHIC AND SOCIOECONOMIC FACTORS AT THE
REGIONAL LEVEL .......................................................................................................... 91
6.0
DISCUSION ............................................................................................................... 94
7.0
CONCLUSIONS ...................................................................................................... 102
APPENDIX A: HIV/AIDS SURVEILLANCE SYSTEM IN CHILE .................................. 104
APPENDIX B: CORRELATION ANALYSIS DATASET................................................... 106
BIBLIOGRAPHY ..................................................................................................................... 108
vii
LIST OF TABLES
Table 1. Population of Chile by Region, 2012................................................................................ 7
Table 2. GDP by Region and Economic Activity, 2010 (in million pesos, Chilean currency) .... 16
Table 3. Temporal Trends in Demographic and Health Indicators 1990, 2000, 2010 ................. 18
Table 4. HIV/AIDS by Mode of Transmission among Men, 1986-2000 .................................... 32
Table 5. HIV/AIDS by Mode of Transmission among Women, 1986-2000 ................................ 33
Table 6. AIDS Mortality Rates by Sex, 1990-2009 ...................................................................... 36
Table 7. HIV/AIDS Incidence in the XV Region and the I Region, 2002 - 2012 ........................ 58
Table 8. HIV/AIDS Incidence in the XV Region and the I Region versus HIV/AIDS Incidence at
the Country Level, 2002 – 2012 ................................................................................................... 59
Table 9. Relative Risk of HIV/AIDS in the XV Region and the I Region compared to the
Country Level, 2006 - 2010 .......................................................................................................... 61
Table 10. HIV/AIDS Incidence in the XV Region and the I Region by Sex, 2002 - 2012 .......... 62
Table 11. HIV/AIDS Incidence among Males in the XV Region, the I Region and at the Country
Level, 2002 - 2012 ........................................................................................................................ 63
Table 12. HIV/AIDS Incidence among Females in the XV Region, the I Region and at the
Country Level, 2002 - 2012 .......................................................................................................... 64
viii
Table 13. Relative Risk of HIV/AIDS by Sex in the XV Region, the I Region and at the Country
Level, 2006 - 2010 ........................................................................................................................ 65
Table 14. Relative Risk of HIV/AIDS in Males from the XV Region and the I Region compared
to Males at the Country Level, 2006 – 2010 ................................................................................. 65
Table 15. Relative Risk of HIV/AIDS in Females from the XV Region and the I Region
compared to Females at the Country Level, 2006 - 2010 ............................................................. 66
Table 16. HIV/AIDS in the XV Region and the I Region by Sex and Age Category, 2002 - 2012
....................................................................................................................................................... 67
Table 17. HIV/AIDS Age Distribution among Males and Females from the XV Region and the I
Region compared to the HIV/AIDS Age Distribution observed in Males and Females at the
Country Level, 2006 - 2010 .......................................................................................................... 68
Table 18. HIV/AIDS Incidence in the XV Region and at the Country Level by Age Category,
2006 - 2010 ................................................................................................................................... 70
Table 19. HIV/AIDS Incidence in the I Region and at the Country Level by Age Category,
2006 - 2010 ................................................................................................................................... 70
Table 20. Mode of Transmission of HIV in the XV Region and the I Region, 2002 - 2010........ 72
Table 21. Mode of Transmission of HIV by Sex in the XV Region, the I Region and at the
Country Level, 2006 – 2010 ......................................................................................................... 73
Table 22. Mode of Transmission of HIV among Males from the XV Region and the I Region
compared to Males at the Country Level, 2006 – 2010 ................................................................ 74
Table 23. Mode of Transmission of HIV among Females from the XV Region and the I Region
compared to Females at the Country Level, 2006 – 2010 ............................................................ 74
ix
Table 24. Mode of Transmission of HIV among Males from the XV Region and the I Region by
Age Category, 2006 – 2010 .......................................................................................................... 75
Table 25. Mode of Transmission of HIV among Females from the XV Region and the I Region
by Age Category, 2006 – 2010 ..................................................................................................... 76
Table 26. HIV Incidence versus AIDS Incidence in the XV Region and the I Region, 2002 2012............................................................................................................................................... 78
Table 27. HIV and AIDS Incidence in the XV Region versus HIV and AIDS Incidence in the I
Region, 2002 – 2012 ..................................................................................................................... 79
Table 28. HIV Incidence in the XV Region and the I Region versus HIV Incidence at the
Country Level, 2002 – 2010 ......................................................................................................... 80
Table 29. AIDS Incidence in the XV Region and the I Region versus AIDS Incidence at the
Country Level, 2002 – 2010 ......................................................................................................... 80
Table 30. HIV Incidence versus AIDS Incidence among Males and Females from the XV
Region, the I Region and at the Country Level, 2006 – 2010 ...................................................... 81
Table 31. AIDS Mortality Rates in the XV Region and the I Region, 2002 - 2012 ..................... 85
Table 32. AIDS Mortality Rates in the XV Region and the I Region compared to AIDS Mortality
Rates at the Country Level, 2002 - 2010 ...................................................................................... 86
Table 33. AIDS Mortality Rates by Sex in the XV Region and the I Region, 2000 - 2010 ......... 87
Table 34. AIDS Mortality Rates among Males in the XV Region and the I Region compared to
AIDS Mortality Rates among Males at the Country Level, 2002 - 2010 ..................................... 88
Table 35. AIDS Mortality Rates among Females in the XV Region and the I Region compared to
AIDS Mortality Rates among Females at the Country Level, 2002 - 2010 .................................. 89
x
Table 36. Relative Risk of HIV/AIDS by Sex in the XV Region, the I Region and at the Country
Level, 2006 - 2010 ........................................................................................................................ 89
Table 37. Relative risk for AIDS- related death among Males from the XV Region and the I
Region compared to Males at the Country Level. ........................................................................ 90
Table 38. Results of the Correlation Analysis between HIV/AIDS Incidence and several
Demographic and Socioeconomic Factors at the Regional Level ................................................ 92
Table 39 ...................................................................................................................................... 104
Table 40. Values registered at the regional level for the different variables considered in the
correlation analysis ..................................................................................................................... 106
xi
LIST OF FIGURES
Figure 1. Evolution of the Age Structure of Chilean Population, 1992-2050 ................................ 8
Figure 2. Geographic Distribution of the Population aged ≥ 65 by Region, 2012 ......................... 9
Figure 3. Geographic Distribution of Indigenous Groups in Chile. ............................................. 11
Figure 4. National Unemployment Rates by Quarter of Year, 2009-2012 ................................... 12
Figure 5. Poverty in Chile 1990-2011........................................................................................... 13
Figure 6. Poverty Rates by Region, 2009 ..................................................................................... 14
Figure 7. Gini coefficient registered in the different OECD members, 2011 ............................... 15
Figure 8. Genaral Mortality by Cause of Death, 1990 and 2009 .................................................. 19
Figure 9. Temporal Trends in HIV/AIDS Incidence, 1984-2010 ................................................. 27
Figure 10. Temporal Trends in HIV/AIDS Incidence by Sex, 1990-2010 ................................... 28
Figure 11. Temporal Trends in HIV/AID Incidence by Age Group among Men, 1986-2010 ..... 29
Figure 12. Temporal Trends in HIV/AID Incidence by Age Group among Women, 1986-2010 30
Figure 13. Temporal Trends in HIV and AIDS Incidence by Sex, 1990-2010 ............................ 31
Figure 14. HIV and AIDS Cumulative Incidence Rates by Region, 2006-2010 .......................... 35
Figure 15. Temporal Trends in HIV/AIDS Incidence in the XV Region, the I Region and at the
Country Level, 2002 - 2012 .......................................................................................................... 60
xii
Figure 16. Mean Age of Individuals Diagnosed with HIV/AIDS in the XV Region and the I
Region, by Sex. 2002 - 2012 ......................................................................................................... 67
Figure 17. HIV/AIDS by Sex and Age Category in the XV Region, the I Region and at the
Country Level, 2006 - 2010 .......................................................................................................... 69
Figure 18. HIV Incidence versus AIDS Incidence among Males and Females from the XV
Region, the I Region and at the Country Level, 2006 - 2010 ....................................................... 82
Figure 19. HIV and AIDS Incidence in the XV Region, the I Region an at the Country Level by
Age Category, 2006 – 2010 .......................................................................................................... 84
xiii
PREFACE
I would like to thank the Ministry of Health (MINSAL) and the National Institute of Youth of
Chile (INJUV), especially Mrs. Patricia Rojo Cárdenas, Administrative Coordinator-DIPLAS,
MINSAL, and Mrs. Macarena Hernandez, CEDOC Manager, INJUV, for their kind and timely
help with completing the process to access the data needed for the present research.
Also, my deepest gratitude goes to my Essay Committee, Dr. Thomas Songer and Dr. Ronald
Stall, for their expert and constructive feedback on the interpretation of my findings. Particularly,
I would like to thank Dr. Thomas Songer, who accompanied the essay process from the
beginning, providing me with thoughtful and wisdom advice about the methodology as well as
with accurate and relevant suggestions to improve the quality of my work. He truly honored his
advisor title; his support was a key element for me to successfully complete this important step in
my life.
Last but not least, I would like to thank my parents, Ana and Claudio, for their endless love and
support, and for teaching me and my siblings to dream big about our own lives and the society
that we can help to build.
xiv
1.0
INTRODUCTION
In the last two decades, Chile has shown important achievements in relation to the health status
of its population regarding medical technology and infrastructure, access to treatment,
vaccination coverage, significant decline in the infant and general mortality rates, as well as an
increase in the life expectancy of men and women. This progress has also been evident in the
national policies related to the HIV/AIDS epidemic in terms of implementing several education
campaigns, developing an intense protocol to prevent the vertical transmission of the disease,
improving surveillance of the disease and providing opportune and timely treatment to HIV
positive people. In fact, Chile has significant lower HIV rates compared to other countries in the
region, and according to the Chilean Ministry of Health, the epidemic remains “under control”
[1].
Unfortunately, since more than 40% of the total population of the country is concentrated
in the Metropolitan region, home of the capital city: Santiago, the statistics reported for the
“Chilean population” regarding this topic and other matters tend to be representative of this
geographic area and do not necessarily reflect the situation experienced by the other regions. In
fact, when the HIV/AIDS numbers are broken up by region, it can be observed that the evolution
of the epidemic has been different in the different areas of the country, with regions that have
1
maintained lower rates, while others have shown an important increase in the incidence of the
disease over the last 5 years. For example, for the period 2006-2010, the HIV/AIDS cumulative
incidence rate registered at the national level was 47.2 per 100,000. In contrast, over the same
period, the northernmost region of the country, the XV Region, showed a HIV/AIDS cumulative
incidence of 139.3 per 100,000 while other regions registered a rate as low as 21.4 per 100,000
population (the regions of the country are presented in Table 1) [2].
Therefore, the present study is aimed at describing the morbidity and mortality patterns of
HIV/AIDS in the extreme north of the country, exactly in the XV Region and I Region, where
the rates of the disease have been steadily increasing in the last decade in order to enrich the
knowledge about the HIV epidemic at a more local scale, rather than at the national scale, and
thus help to develop a more comprehensive approach to the study of the disease.
In this context, the subsequent pages present a general description of the social, cultural,
and economic characteristics of Chile and its population as well as an overview of the evolution
and present situation of the HIV/AIDS epidemic at the country level. Later, the paper analyzes
the data obtained through the HIV/AIDS surveillance system for the XV Region and the I
Region over the period 2002-2012, as well as the information about the disease registered in
different governmental documents in order to describe the morbidity and mortality patterns of
the disease in the north OF Chile. Lastly, the paper compares HIV patterns in the northern
regions to the pattern seen nationally and examines the correlation between HIV and several
social and economic factors. Finally, the implications of these results are discussed in the context
2
of the approaches that the Chilean government has used to face the epidemic, the actual policies
about the disease and future perspectives to maintain the epidemic stabilized.
All in all, we hope the results of this investigation will contribute to improve the
knowledge on HIV/AIDS in Chile as well as help in developing a more comprehensive
perspective at the time of designing HIV national health policies so interventions can be better
tailored to the particular characteristics and needs of the different subpopulations that make up
the population of Chile.
3
2.0
2.1
BACKGROUND
CHILE: GENERAL CHARACTERISTICS
2.1.1 Territorial and Political Administration
Chile is a long and narrow country located in the southern area of the South American continent,
bound by the Pacific Ocean to the west, Peru and Bolivia to the north, the Andes Mountains and
Argentina to the east, and the Drake Passage or Sea of Hoces in the far south. Chilean territory
also includes the Pacific islands of Juan Fernández, Salas y Gómez, Desventuradas and Easter
Island.
The country is divided into 15 regions, which are its first-level administrative division.
Each region is designated by a Roman numeral, followed by a name. The Metropolitan Region,
located in the center of the country and home to the country's capital; Santiago, received the
numeral XIII as well as the initials RM1
1
By 2006, there were only 13 regions and the roman numerals were organized in ascending order from
north to south, with the northernmost region designated as I (first) and the southernmost region as XII (twelfth).
4
Since Chile is defined by its political constitution as a unitary state, regional
administration is subordinated to the central government, which is headed by the President. Thus,
each region is ruled by a direct representative of the President: the Intendant; and by
decentralized agencies of the Ministries: the Ministerial Regional Secretariats (SEREMIs).
Additionally, regions are further divided into provinces and communes. Like regions,
provinces are also part of the central government so they are administrated by authorities who
are appointed by the President of the Republic. In contrast, the communes, which are the lowest
level administrative subdivision, are decentralized political entities that operate at the local level.
Each commune is governed by the Mayor and a Municipal Council consisting of 6 to 10
councilors, all of them voted in popular elections. The communal civil service administration is
known as the municipality and these are the entities that are finally responsible for the
decentralized implementation and budget execution of national programs. In fact, the public
branch of the health and education systems are administrated and regulated by the municipalities.
Regarding the Legislative Branch of Chile, it is represented by the National Congress
which consists of two Houses: The Chamber of Deputies and the Senate. Deputies and Senators
However, that year the congress passed a bill to create regions XIV in the south and XV in the north, so then the
north-south Roman numeral order was broken.
5
are elected by the different electoral districts2 through popular vote every four and eight years,
respectively [4,5].
2.1.2 Demographic Characteristics
According to the results from the 2012 Census [6], Chile has a total population of 16,634,603
inhabitants; 46.8% males (n=8,101,890) and 51.4% females (n=8,532,713). The population is
heavily concentrated in the central area of the country, with three central regions making up
62.5% of the total population (Metropolitan Region=40.3%; VIII Region of Bio Bio = 11.86%;
V Region of Valparaiso = 10.4%). This settlement pattern has been associated with the livable
Mediterranean climate in the middle areas compared to the extreme weather conditions in the
northern and southern regions of the country, as well as with the highly centralized economic and
political administration in Santiago, the capital of the country [7]
In relation to the population growth, data from the 2012 Census showed that the Chilean
population increased by 9.9% in the last 10 years, with a consequent average annual growth rate
of 0.99%, which is lower than the rates observed between 1982-1992 and 1992-2002 (1.6% and
1.27%, respectively). However, it is important to point out that the growth rate for the period
2002-2012 presents a significant variability across the country, with all the northern regions
2
To elect the members of the National Congress, Chile is divided into several electoral divisions called
electoral districts. Each district is made of groups of communes.
6
showing higher rates than the national average (I Region of Tarapacá = 23.8%; IV Region of
Coquimbo = 15.9%; III Region of Atacama = 14.2%; XV Region of Arica y Parinacota = 12.5%;
II Region of Antofagasta = 12.5%) (see Table 1) [6].
Table 1. Population of Chile by Region
REGIONS OF
CHILE
Region
Name
Population
% Total
population
% Increase
2002-2012
XV
Region of Arica y
Parinacota
213,816
1.29
12.5
I
Region of Tarapacá
300,021
1.8
23.8
101:100
II
Region of Antofagasta
547,463
3.27
12.5
99:100
III
Region of Atacama
292,054
1.75
14.2
101:100
IV
Region of Coquimbo
707,654
4.25
15.9
0.95:1
V
Region of Valparaiso
1,734,917
10.4
12.4
0.93:1
RM
Region Metropolitana
6,685,685
40.33
10.0
0.94:1
VI
Region Del Libertador
General Bernardo
O'Higgins
877,784
5.26
12.2
0.98:1
VII
Region Del Maule
968,336
5.81
6.7
0.96:1
VIII
Region Del Bio Bio
1,971,998
11.86
5.8
0.94:1
IX
Region of La Araucania
913,065
5.47
5.1
94:1
XIV
Region of Los Rios
364,592
2.2
2.8
96:1
X
Region of Los Lagos
798,141
4.74
11.3
97:1
99,609
0.59
10.1
102:1
159,468
0.96
7.7
101:1
16,634,603
100
9.9
95:100
XI
XII
Total
Region of Aysén del
General Carlos Ibáñez
del Campo
Región of Magallanes y
la Antártica Chilena
Total Country
Sex Ratio
97:100
Data Source: 2012 National Census [6]
Regarding the population age structure, improvements in the mortality rate (5.7 per 1,000
in 2010) as well as a reduction in the birth and the fertility rate (14.6 per 1,000 and 1.87 per
7
woman, respectively), have had a significant impact on the age distribution of the population. In
fact, by 2010, according to the National Institute of Statistics (INE) 68.5% of the population was
between 15 and 64 years old and 9.2% was 65 years old or more (see Figure 1) [8]. Furthermore,
it has been projected that by 2030, the Chilean population will have almost the same proportion
of persons between 0-14 as over 64 years old, becoming the second most aged country in South
America, after Uruguay [9].
64.0%
29.0%
66.2%
25.7%
0.1
1992
68.50%
22.3%
8.1%
2002
<15 yrs
64.5%
18.6%
61.8%
16.9% 16.6%
21.6%
9.2%
2010
2030
15 yrs ≤ x ≤ 64 yrs
2050
> 65 yrs
Figure 1. Evolution of the Age Structure of Chilean Population, 1992-2050
Data Source: ECLAC 2007 [9]
On the other hand, with respect to the age distribution of the population by region, almost
40% from all people older than 65 live in the capital, Santiago. However, in relative terms, the
“oldest” regions are the V, XIV, X and IV regions since all of them present more than 10% of
their population inside that age cohort. On the other hand, the “youngest” regions are those in the
further north, with the II Region of Antofagasta showing as little as 0.01% of its total population
above 65 years old [8] (see Figure 2).
8
Figure 2. Geographic Distribution of the Population aged ≥ 65 by Region, 2012
Data Source: INE, 2012 [8]
2.1.3 Ethnic Composition
In Chile, an estimated of 88.9% of the population are whites or mestizos (N = 14,791,996), while
11.1% identify themselves as members of an indigenous group (N =1,842,607) [6].
Similarly to what occurred in other Latin American countries, during the Spanish
conquest and colonization, indigenous groups were subjugated and converted into workforce or
9
slavery. However, in the case of Chile, most of them died either in the war or from different “old
world” diseases [10]. Accordingly, most of the Chilean population correspond to whites or
mestizos, population originated from the admixture between those indigenous who survived
(mostly women) and the Spanish settlers (mostly men), as well as from several immigrant groups
who arrived to the country over the 19th and 20th centuries like Germans, British/Irish, Spanish,
and Middle East people [11].
Regarding the 11.1% of indigenous people, 84.1% are Mapuche (N= 1,508,722),
Amerindian group characterized for being the only one in the region who managed to keep their
independence first from the Inca Empire and later from the Spanish settlers. They were only
defeated in the late 19th century when the authorities of the new Chilean State were trying to
secure the boundaries of the country after the independence process. By then, Mapuche people
were forced to cede their lands rights (the present IX Region), and these territories were offered
to several Chilean and immigrant families. This historic fact represents the origin of a conflict
that persists until today between certain sectors of Mapuche people who still vindicate their
rights over those lands, and Chilean State [10].
On the other hand, besides Mapuche people, there are other eight Pre-Hispanic groups
officially recognized by the Chilean Law. These groups are the following: 0.62% Aymara (N =
114,523); 0.74% Quechua (N = 13,667); 0.33% Atacameño (N = 6,101); 0.74% Colla (N =
13,678); 0.24% Diaguita (N = 45,314); 0.46% Rapanui (N = 8,406), 0.1% Alacalufe (N = 1,784);
and 0.09% Yamana (N = 1,235). Most of them inhabit relatively isolated areas like the Andean
highlands in the northern area of the country or the fjords in the far south, with the exception of
10
the Mapuches who are highly concentrated in the Metropolitan Region and the IX Region [6]
(see Figure 3).
More
recently,
because
of
the
exponential growth of Chilean economy, an
important number of immigrants have
arrived to the country, particularly from
other Latin American Countries. In fact,
according to the last Census, by 2012 there
were 339,536 foreign born people living in
Chile, and 50% of them reported arriving to
the country over the last 5 years (N=
167,729). He largest immigrant groups are
Peruvians (23.61%), Colombians (11.3%),
Argentineans (9.33%), Americans (8.26%),
and Spaniards (8.23%), and they are highly
concentrated in the capital of the country
(more than 50%). However, the regions with
the highest proportion of immigrants among
their population are the I Region and the XV
Region with 6.1% and 6.6%, respectively
Figure 3. Geographic Distribution of Indigenous
Groups in Chile.
Data Source: 2012 National Census [6]
[6].
11
2.1.4. Economy
Over the last two decades, Chile’s economy has shown a remarkable progress, boasting a 6%
increase per year in its Gross Domestic Product [12], and making important improvements
regarding employment rates and reduction of poverty. In relation to the unemployment rate,
Chile presented a value of 6.1% during the last quarter of 2012, the lowest level in almost 5 years
[13 - 16] (see Figure 4). On the other hand, regarding the poverty level of the country, the results
published in the 2009 National Survey of Socioeconomic Characterization (CASEN 2009)
showed that the percentage of people living under the poverty line, including those living under
extreme poverty conditions, decreased from 38.6% in 1990 to 15.1% in 2009 (see Figure 5) [17].
As a consequence of its sustained economic growth, in January 2010, Chile was invited to
become the 31st member of the Organization for Economic Cooperation and Development [12].
11.5%
11.2%
10.0%
9.0%
10.6%
8.5%
7.2%
8.0%
7.4%
6.6%
7.1%
I
II
III
2009
IV
I
II
III
IV
6.1%
7.3%
6.6% 6.6%
I
2010
II
III
2011
IV
I
6.5%
II
2012
Figure 4. National Unemployment Rates by Quarter of Year, 2009-2012
Data Source: INE, 2009, 2010, 2011, 2012 [13 -16]
12
III
IV
Figure 5. Poverty in Chile 1990-2011
Data Source: CASEN 2009 [17]
However, the officially published poverty rates have been questioned by different
national and international organizations since the instrument used by the government to measure
it uses a poverty line that is based on an outdated household consumption survey from 1987,
instead of more recent surveys from 1997 or 2007. Furthermore, in 2008, the economist and
actual Minister of Economy, Felipe Larrain, developed a new instrument based on consumption
information from 1997. After applying this new poverty line to the original sample considered in
the 2009 National Survey of Socioeconomic Characterization, the national poverty rate increased
from the official 15.1% to 24.5% (see Figure 6), In spite of this evidence, the government reports
current poverty numbers based on the old rather than the new instrument [18].
13
Figure 6. Poverty Rates by Region, 2009
Official poverty rates (red) versus poverty rates based on updated consumption data (pink).
Regardless considerable economic growth in the last 20 years, Chile still stands as one of
the countries with the worst income distribution between rich and poor. For example, even when
the gap between the richest 20% of households and the poorest 20% decreased from 13 times in
1990 to 10.9 times in 2011, in absolute terms, this value remains significantly higher than the
average registered among the OECD members [19]. In fact, according to the data published by
the OECD in their report Society at a Glance 2011: OECD Social Indicators [20], Chile presents
a Gini coefficient for the distribution of household per capita income above 50%, representing
the highest value registered among the OECD countries that in average show a Gini coefficient
of 31% (see Figure 7). The same report also describes inequality problems in relation to other
socioeconomic variables besides income, like access to health and education.
14
Figure 7. Gini coefficient registered in the different OECD members, 2011
Data Source: OECD, 2011 [20]
Since the economy is highly dependent on the natural resources, the economic profile of
the different regions will vary according to their geographic and climatic conditions. Mining
activity is concentrated in the northern areas of the country, while fishing activities are more
intense in the south, and farming in the central regions. The Metropolitan Region is largely
focused on services and manufacturing (see Table 2) [21, 22].
15
XV
Table 2. GDP by Region and Economic Activity, 2010 (in million pesos, Chilean currency)
The blue numbers represent the % contribution of the region to the total income produced by each economic sector (column percent). The red numbers represent
the % contribution of each economic activity to the total GDP of the Region (row percent).
Farming &
Livestock
Fishing
Mining
Manufactu
- ring
Electriciy
Gas &
Water
20,054
3,349
5
83,023
17,394
0.8
3.6
0.6
26,165
I
1,810
0.9
0.1
0.1
0.9
14,854
0.2
0
12.
4
0.1
9,806
17
2.1
51
5.2
4.8
0.5
18,426
8.5
0.6
10,784
RM
9.0
3.3
3.0
322,894
12.
2
0.8
0.1
775
0.2
51.
8
1,109,922
8.4
38.
6
1,098,137
V
238,797
5.2
66.
0
1,119,488
IV
136,998
2.8
53.
9
6,706,929
III
44,858
0.2
0
1,639,097
II
4,326
7.4
0
8.3
15.
1
175,755
0
1.3
0.1
0.8
14.
9
75,148
0.7
2.5
443,269
4.3
4.4
15,635
0.2
0.7
107,845
1.0
3.8
1,207,958
11.
6
16.
6
4,993,027
48.
0
11.
6
0.6
3.1
82,437
2.6
2.7
217,627
6.9
2.1
86,934
2.8
4.0
45,666
1.5
1.6
1,683
0.1
Transpor
-tation
&
Communi
-cation
Financier
Services
Housing
Services
Personal
Services
Public
Adm.
GDP
24,057
92,076
52,522
19,288
44,486
106,842
95,493
558,589
0.4
4.3
200,884
3.0
6.6
1,027,117
15.
5
10.
1
364,190
5.5
16.
9
261,529
3.9
9.1
659,369
0
782,368
24.
9
Construc
-tion
Commerce
Restaurant
&
Hotels
1.8
9.9
9.1
0.9
16.5
389,625
3.9
12.8
336,616
3.4
3.3
112,146
1.1
5.2
256,918
2.6
8.9
565,556
5.6
7.8
0.8
9.9
178,844
2.7
5.9
481,710
7.4
4.7
101,568
1.6
4.7
186,669
2.9
6.5
1,017,799
15.
6
14.
1
0.1
3.5
7,618
0.5
0.3
228,453
1.3
2.2
59,641
0.3
2.6
134,766
0.8
4.7
526,873
3.0
7.2
0.9
8
73,806
1.5
2.4
194,784
4.1
1.9
54,600
1.1
2.5
140,208
2.9
4.9
538,563
11.
3
7.4
1
19.
1
175,694
1.7
5.8
372,598
3.6
3.7
115,632
1.1
5.4
330,775
3.2
11.
5
931,843
9
12.
8
2.3
17.
1
112,529
2.7
3.7
127,133
3.1
1.3
75,386
1.8
3.5
142,563
3.5
5.0
467,401
11.
4
6.4
0.6
-
3,043,657
3.4
-
10,155,416
11.3
-
2,159,884
2.4
-
2,872,285
3.2
-
7,264,763
8.1
-
2,205,371
6,501,919
3,025,322
15,011052
2,735,815
5,588,585
1,642,743
42,985,626
33.
2
64.
8
46.
5
84.
7
57.
3
54.
2
40.
1
47.9
5.1
15.1
16
7.0
35
6.4
13
3.8
Table 2 continued
VI
Farming &
Livestock
Fishing
Mining
Manufactu
- ring
Electriciy
Gas &
Water
498,019
586
1,127,724
499,504
151,105
18.
8
12.
2
0.2
381,877
VII
14.
4
12.
4
436,191
VIII
16.
4
6.1
0.9
8.6
11.
5
139,437
0.1
6,942
0.1
87,654
24.
7
1.2
0.3
0.2
0
22 m
15,159
5.0
16.
4
13
179,618
X
6.8
8.1
7,330
XI
0.3
1.8
13,609
4.3
1.4
0
0m
0
107,413
30.
3
4.8
37,452
10.
5
9.1
10,622
1.5
Tot
al
1.7
2,654,400
3
1.3
355,068
1.2
8.0
2.1
20.
0
240,421
0
3.7
164,192
XII
0.5
0
15,370
0.1
24.
0
214,776
0m
0
16.
7
158,549
XIV
5.3
12.
3
1,704,185
0
0
4.8
515,359
5,509
5,680
1.6
27.
7
8.6
3,343
228,582
IX
0
20.
6
13,169,092
2.3
10.
8
4.8
625,159
19.
9
4.4
29.
1
15.
4
10,399,196
12.
9
44,196
1.4
2.2
48,523
1.5
4.5
123,030
3.9
5.5
3,647
0.1
122,501
1.2
20.
3
916,834
17,996
0.2
3.7
Transpor tation
&
Communication
Financier
Services
Housing
Services
Personal
Services
Public
Adm.
GDP
361,207
243,747
202,173
350,199
141,743
338,843
152,503
4,067,353
5.4
8.9
249,429
3.8
8.0
704,370
10.
6
9.9
207,411
3.1
10.
4
42,492
0.6
3.9
185,408
2.8
8.3
86,846
0.9
125
0
Construc
-tion
Commerce
Restaurant
&
Hotels
1.3
21.
2
55,989
0
3,146,728
0.8
7.0
6,635,669
2.4
6.0
252,138
2.5
8.2
590,779
5.9
0.8
216,740
2.2
10.
9
137,682
1.4
12.
8
221,311
2.2
9.9
30,619
0.3
7.5
81,578
0.8
10.
2
10,029,450
Data Source: Central Bank of Chile, 2010 [22]
17
3.1
5.0
217,123
3.3
7.0
467,675
7.2
6.6
194,697
3.0
9.8
85,348
1.3
7.9
220,961
3.3
9.9
24,538
0.4
6.0
54,816
0.8
6.9
6,511,765
2.0
8.6
163,510
0.9
5.3
560,303
3.2
7.9
187,651
1.1
9.4
72,836
0.4
6.8
261,261
1.5
11.
7
11,232
0.1
2.7
42,844
0.2
5.4
17,717,527
3.0
3.5
108,785
2.3
3.5
323,307
6.8
4.5
153,508
3.2
7.7
60,445
1.3
5.6
130,900
2.7
5.9
21,807
0.5
5.3
54,865
1.1
6.9
4,777,622
3.3
8.3
373,056
3.6
12.
1
889,534
8.6
12.
5
409,796
4.0
20.
6
170,051
1.7
15.
8
369,645
3.6
16.
6
55,306
0.5
13.
5
76,263
0.7
9.6
10,304,463
3.7
3.7
188,429
4.6
6.1
421,520
10.
3
5.9
179,907
4.4
9.1
89,657
2.2
8.3
185,382
4.5
8.3
98,093
2.4
23.
9
119,353
2.9
15.
0
4,098,092
4.5
-
3,085,150
3.4
-
7,107,861
7.9
-
1,986,739
2.2
-
1,076,406
1.2
-
2,225,350
2.5
-
410,236
0.5
-
796,757
0.9
-
89,799,072
2.1.5. Epidemiological Profile
The demographic transformation described previously, as well as the important improvements in
the healthcare system over the last two decades in terms of public policy and infrastructure, have
had a deep impact in the epidemiological profile of the country. Explicitly, there have been
improvements in the vaccination rates and medical technology, a considerable decline in infant
and general mortality, lower fertility rates (even below the “replacement level”), as well as a
longer life expectancy for men and women (see Table 3) [9, 23 - 27].
Table 3. Temporal Trends in Demographic and Health Indicators 1990, 2000, 2010
Data Source: Multiple Sources [9, 23 - 27]
Year
Indicator
1990
2000
2010
Birth Rate [9, 23]
(Annual number of births per 1,000 pop)
23.3
17.0
14.7
Fertility Rate [9, 24]
(Average number of children per women aged 15-49 yrs)
2.55
2.21
1.89
Infant Mortality Rate [9, 24]
(Number of infant deaths before age 1 per 1000 live births)
16.0
8.1
7.9
6.0
5.5
5.4
95%
95%
96.9%
-
97.2%
94%
84%
94%
94.4%
7%
8.1%
9.2%
Women
77.4 yrs
80.8 yrs
74.9 yrs
Men
71.5 yrs
74.8 yrs
80.6 yrs
Mortality Rate [9, 24]
BCG (newborn)
Vaccination Rates
[25, 26, 27]
Quintuple Vaccine (3rd dosis)
MMR vaccine (12 months)
% population ≥ 65 yrs old [9]
Life Expectancy [9, 23]
18
Consequently, the number of people among the older age groups has increased, affecting
the morbidity and mortality patterns of the country now characterized by a significant burden of
chronic diseases, particularly cardiovascular diseases (see Figure 8). For example, for the year
2009, cancer and cardiovascular diseases accounted for 53% of all deaths, while only 1.9% of the
total number of deaths was attributed to infectious diseases [25].
2009
14.3%
4.7%
2.6%
27%
8.9%
7.3%
9.7%
25.6%
Figure 8. Genaral Mortality by Cause of Death, 1990 and 2009
Data Source: National Institute of Health, 2011 [25]
19
2.2
HIV/AIDS IN CHILE: HISTORICAL TRENDS AND PRESENT SITUATION
1984-2010
2.2.1 Policy Development on HIV/AIDS
In 1984, the first AIDS case was registered in the country. Because of the rapid increase in the
number of cases between 1985 and 1990, the Chilean government created the AIDS National
Commission (CONASIDA) in 1990. CONASIDA is a governmental agency aimed at
developing, implementing and evaluating public policies oriented to promote safe sexual
behaviors and improve access to and the quality of health care for people living with HIV/AIDS
[28].
Therefore, since 1990 and until 2011 when CONASIDA became the National Program
for Prevention and Control of HIV/AIDS and other STD’s, this was the institution responsible
for setting national policies in relation to the HIV/AIDS epidemic. Some of the most significant
achievements made by Chilean State through this institution were the implementation of several
HIV prevention campaigns oriented to improve sexual health, increase condom use and build
community awareness about the disease among the general population, as well as the
promulgation of two important laws: the law 19,776, also known as the “AIDS Law”, and the
inclusion of HIV/AIDS as a public health priority in the AUGE Health Plan [28].
Specifically, the AIDS Law was developed in 2001 to protect the privacy and civil rights
of HIV positive people and to establish the obligations of the Chilean State regarding the
20
HIV/AIDS epidemic prevention and control. Accordingly, for people living with the disease, the
law guarantees access to care, treatment and health services, and the right to education and work.
Also, it ensures access to HIV testing on a volunteer and informed basis, as well as the
confidentiality of the results. On the other hand, it defines the Chilean State as the main
responsible for providing education on HIV prevention among the general population as well as
the one in charge of ensuring the protection of the previously mentioned civil and privacy rights
for HIV positive individuals [29].
Regarding the second law, it refers to the official recognition of HIV/AIDS as a public
health priority for the country by being listed as one of the diseases included in the AUGE Plan,
a new health legislation implemented in 2005 which defines a regime of explicit guarantees for
people affected by certain health conditions, including HIV. The explicit guarantees include:
access, timeliness (opportunity), quality and financial protection. In this context, this law ensures
that every Chilean has full healthcare coverage and access to Anti-Retroviral Therapy (ART) and
100% access to the treatment protocol to prevent mother-child transmission [28, 30].
Other important achievements of Chilean State in relation to HIV/AIDS policy
development have been:
-
In 2004, the implementation of a new online surveillance system so every new case of
HIV/AIDS must be reported to the health authority on a daily basis. Also, the notification
protocol defined that every reactive sample must be retested by the Public Health
Institute (ISP) to confirm the diagnosis.
21
-
In 2007, the surveillance system protocol was amended to also collect information on any
change in the patients’ disease status (from HIV to AIDS).
-
In 2008, the Ministry of Health conducted an audit to revise the information about all the
HIV/AIDS cases that were diagnosed from 1984 until the date [1].
More recently, in 2010, the Government incorporated the design of a new HIV
prevention plan as part of the goals of the National Health Strategy 2011-2020, which includes
other related objectives like: sexual health promotion, reduction of the number of unplanned
pregnancies, and primary prevention of other STD’s. In this context, helped by interventions like
ASAP (AIDS Strategy and Action Plan) and the National Consultation on Universal Access, the
health authority started designing the HIV/AIDS national response for the period 2012-2016 in
October 2011 [31].
According to several recommendations from technical advisory agencies like UNAIDS,
the political and ethical principles that guide the new strategy are equity, decentralization,
intersectoral action, and participation, and it responds to the following practical objectives:
health promotion and prevention of HIV and other STD’s, integral health care for HIV positive
people, improvement of the epidemiological surveillance of the disease, and reduction of the
social stigma and discriminatory behaviors towards people living with HIV/AIDS.
22
2.2.2 Chilean Society and HIV/AIDS
Sociocultural concepts and practices in relation to sex in general and the HIV epidemic in
particular, have been strongly linked with the incidence rates of the virus. In fact, lack of
appropriate knowledge about the disease and unsafe sex represent the main barriers to prevent
the disease to spread [32]
In Chile, according to the results from the 6th National Youth Survey conducted in 2009,
Chileans have sex for the first time at the age of 17 (total population = 16.7 yrs; men = 16.4 yrs;
women = 17.1 yrs), and during their first sexual intercourse, only 49% used some type of
contraceptive method. Among them, 86.7% preferred condom. In their last sexual intercourse,
74.3% reported using a contraceptive method, and 44% preferred condom. Now, the main reason
for using condoms was to prevent pregnancy (90.6% of the answers) and only 39.7% of the
respondents pointed out protection against HIV and other STD’s as the primary reason to explain
condom use. The main reasons for non-use were: irresponsibility (23.4%), less pleasure (15.3%),
wanted pregnancy (10.6%), access difficulties (9.6%), and partner disapproval (9.1%). Important
differences in condom use were observed by socioeconomic status, where condom use was
higher in the rich compared to the poor [33].
Regarding men who have sex with men (MSM), a study conducted in 2008 among the
MSM population from the Metropolitan Region established that 55.8% of the participants
declared the use of condom during their last anal intercourse with male partners [34]. In research
performed in 2006 on HIV prevalence, AIDS knowledge, and condom use among female sex
23
workers in Santiago, 93.4% of the women responded that they always used condoms with their
clients [35]
The results from the 6th National Youth Survey also show that there are still important
misconceptions and prejudices about HIV/AIDS among the general population. For example,
when participants were asked about the means of transmission of HIV/AIDS, 98.5% of
respondents selected unsafe sex as a means of exposure. However, about 51.5% of participants
believed that sharing personal hygiene objects with infected people is a risk factor for HIV, and
22.7% considered that sharing the toilet with a homosexual person or someone living with the
disease can also transmit the virus [34].
Furthermore, two different studies conducted to explore the beliefs and attitudes of health
workers towards HIV positive individuals concluded that inaccurate fears regarding HIV
transmission and societal prejudices against homosexuals are important barriers that cause
stigmatization and discriminatory attitudes/behaviors inside the healthcare system. These
attitudes and behaviors include heightened precautions to treat HIV infected people and
difficulties in maintaining the confidentiality of the serostatus of the patient [38, 39]
24
2.2.3 Epidemiological Profile of HIV/AIDS
a)
HIV/AIDS Prevalence
Since the first case of AIDS was registered in the country, the epidemic has been under
surveillance by the Ministry of Health of Chile. According to the surveillance system data, a total
of 24,014 HIV/AIDS cases have been diagnosed in the country between 1984 and 2010 (69%
males and 31% females), and 6,929 people have died from AIDS between 1990 and 2010 [2].
However, CONASIDA together with UNAIDS estimates that there would be an additional
20,000 more persons infected with HIV/AIDS who do not know it [30].
In 2009-2010, the National Health Survey included a HIV test for all the participants as
one component of its assessment. Results from this survey established a disease prevalence of
0.21% (95% CI: 0.06% – 0.72%) among the population aged 18-64 [35]. Based on the results
from the 2012 National Census, this would be equivalent to 34,802 individuals. However, the
most concerning situation is related with the magnitude of the epidemic among the MSM
population. In fact, the study mentioned above conducted on the MSM population of the
Metropolitan Region established a HIV/AIDS prevalence of 21.1% for this group (95% CI:
12.8% - 30.0%) [34].
The Health National Survey 2009-2010 also questions respondents about the use of HOV
test in the past. The results showed that 27.3% of the adult sample was tested for HIV/AIDS at
least one time in their lives; a value that goes up to 44% when the analysis considered only those
25
respondents between 15 and 49 years old who were sexually initiated. Also, there were important
differences by sex in these estimates, where women reported being tested more than men (55.1%
versus 27.3%). This situation has been associated with the inclusion of the HIV test as part of the
pre-natal care national protocol. The 5th and 6th National Youth Surveys (conducted in 2005 and
2009, respectively) showed that the percentage of people aged 15 to 29 years old who have been
screened for HIV at least one time in their lives increase from 28.4 to 30.1% in the period.
With respect to the testing prevalence among the higher risk populations, the previously
mentioned study conducted on the MSM community from the Metropolitan Region estimated
that 25% of the group had been tested on over the last 12 months [34]. Regarding the females sex
workers, a study conducted in 2005 about the perception on the female condom showed that 85%
of the participants were tested for HIV at least one time in their lives [37].
b)
HIV/AIDS Incidence
Since the first case of HIV/AIDS was reported in 1984, the incidence of the disease has
increased steadily, especially between 2005 and 2010. In fact, according to the Ministry of
Health’s records, more than one third of the total number of cases registered between 1984 and
2010 (N= 24,014) correspond to the period 2005-2010 (N= 9,288). Additionally, the annual
incidence rates have been growing considerably after 2006 with a peak of 12.54 per 100,000
inhabitants in 2009 (see Figure 9) [2].
26
Figure 9. Temporal Trends in HIV/AIDS Incidence, 1984-2010
Data Source: Rates were calculated based on the number of HIV and AIDS cases registered per year by the
Ministry of Health [2] and the mid-year population estimations made by the National Institute of Statistics [39].
HIV/AIDS Incidence by Sex
In relation to the distribution of the disease by sex, between 1990 and 2010, 83.6% of the total
number of newly diagnosed cases were males (N=19,586) and 16.4% females (N=3,832).
Nevertheless, the number of females infected with HIV/AIDS has been slowly increasing since
2005, the year in which HIV/AIDS testing started to be offered on an optional basis to pregnant
women as part of the national protocol for prenatal care (see Figure 10) [1, 2].
27
Figure 10. Temporal Trends in HIV/AIDS Incidence by Sex, 1990-2010
Data Source: Ministry of Health, 2011 [2]
HIV/AIDS Incidence by Age
Historically, the HIV/AIDS in Chile has been primarily concentrated among people aged 20 to
49 years old. Particularly, the 30-39 age cohort has had a higher cumulative incidence rates over
the last 15 years, showing a stabilization trend over the last 10 years. In contrast, increasing
incidence rates have been reported for the 20-29 and 40-49 age cohorts during the same period.
Also, even though the number of cases seems to be relatively low among people aged 10-19
years old when they are compared to the number of cases registered among other age groups, the
28
cohort has shown the highest percentage increase in the HIV/AIDS incidence over the last 15
years [2].
Regarding the age distribution of HIV/AIDS by sex, as it was mentioned above, since the
infection is considerably more frequent among men; the same trends described previously for the
general population apply for them (see Figure 11) [2].
Figure 11. Temporal Trends in HIV/AID Incidence by Age Group among Men, 1986-2010
Data Source: Ministry of Health, 2011 [2]
Women have historically presented the higher HIV/AIDS incidence rates among the 2029 age cohort. However, in the last 10 years, there seems to be a stabilization of the rates for this
age group at the same time that the incidence of the virus has been progressively increasing
among people aged 30-39 years old. The 10-19 and 60-69 cohorts have also shown increasing
rates during this period (See Figure 12) [2].
29
Figure 12. Temporal Trends in HIV/AID Incidence by Age Group among Women, 1986-2010
Data Source: Ministry of Health, 2011 [2]
HIV/AIDS Incidence by Disease Status at Diagnosis
From the total number of cases registered between 1984 and 2010, and excluding those
notifications without information either about sex (N=10) or disease status (N=129), 54.8% (N=
13,086) of the cases have been identified in the HIV stage of the disease while 45.2%
(N=10,789) of them have been diagnosed during the AIDS phase based on to the CD4 cells
count at the time of diagnosis [2].
30
Following a historical trend seen worldwide, diagnosis during the AIDS phase was
predominant from 1984 to 1998. After 1998, surveillance largely identifies individuals who were
diagnosed with HIV (Table 4 and Figure 13). The increasing number of cases detected in the
early stages of the infection has been associated with improvements in access and effectiveness
of HIV testing [2].
Figure 13. Temporal Trends in HIV and AIDS Incidence by Sex, 1990-2010
Data Source: Ministry of Health, 2011 [2]
HIV/AIDS by Mode of Transmission
In Chile, sexual contact is by far the most common mode of transmission of HIV, representing
around 96% of the total infections registered between 2006 and 2010. Specifically, 45.3% were
31
men who have sex with men (MSM), and 10.1% and 41% reported a bisexual and heterosexual
exposure, respectively. On the other hand, 1.9% of the newly diagnosed cases were due to blood
transfusion, 0.9% to drug use, and 0.8% to vertical transmission [2].
Regarding men, the prevalence of homosexual exposure has remained close to 55% since
the beginning of the epidemic. At the same time, the most significant changes have been related
with a steadily decreasing proportion of bisexual transmission from 26.1% in the first
quinquennium (1986-1990) to 12.4% in the last one (2006-2010), with an equivalent increase in
the percentage of heterosexual exposure from 11% to 28.9% during the same time period. The
major mode of transmission among women has consistently been heterosexual contact
throughout this assessment from 1986 to 2010. Finally, the frequency of other type of exposures
to HIV has remained small in both males and females since 1986 (see Table 4 and Table 5) [2].
Table 4. HIV/AIDS by Mode of Transmission among Men, 1986-2000
1986-1990
1991-1995
1996-2000
2001-2005
2006-2010
N
%
N
%
N
%
N
%
N
%
Homosexual
404
56.35
1,458
55.33
2,343
55.50
2,970
55.52
3,178
55.72
Bisexual
187
26.10
501
19,01
668
15.82
797
14.90
709
12.43
Heterosexual
79
11.02
499
18.94
1,054
24.96
1,495
27.95
1,653
28.98
Drug users
24
3.35
151
5,73
116
2,75
32
0.60
55
0.96
Blood Transfusion
18
2.51
11
0.42
10
0.24
8
0.15
92
1.61
Vertical
5
0.7
15
0.57
31
0.73
47
0.88
17
0.3
717
100
2,635
100
4,222
100
5,349
100
5,704
100
Total
Data Source: Ministry of Health [2]
32
Table 5. HIV/AIDS by Mode of Transmission among Women, 1986-2000
1986-1990
1991-1995
1996-2000
2001-2005
2006-2010
N
%
N
%
N
%
N
%
N
%
Heterosexual
65
82.28
315
82.89
786
90.45
1,020
92.90
1,224
93.65
Drug users
3
3.80
27
7.11
25
2.88
12
1.09
8
0.61
Blood Transfusion
7
8.86
10
2.63
6
0.69
4
0.36
39
2.98
Vertical
4
5.06
28
7.37
52
5.98
62
5.65
36
2.75
Total
79
100
380
100
869
100
1098
100
1307
100
Data Source: Ministry of Health [2]
HIV/AIDS Incidence by Region
In terms of crude numbers; 50.4% of the total number of newly diagnosed cases registered over
the last 10 years are from the Metropolitan Region (N= 7,413), followed by the V (N= 1,725)
and VIII (N=1,426) regions with 11.73% and 7.84%, respectively (see Figure 14). However,
regarding the incidence rates of the disease, the northern regions of the country have higher
incidence rates and shown a higher increase in the disease rates over the last decade [41].
For the period 2006-2010, the XV Region of Arica y Parinacota, showed the highest HIV
and AIDS incidence rates in the entire country. Specifically, it presented an HIV incidence rate
of 83.8 and an AIDS incidence rate of 55.5 per 100,000 inhabitants, which are considerably
higher than the corresponding national rates of 27.5 and 19.6 for the same period. Additionally,
the I and II regions also exhibited higher rates compared to the country total, showing HIV
33
incidence rates of 45.6 and 36.9, and AIDS incidence rates of 28.0 and 18.7, respectively (see
Figure 14) [2].
34
Figure 14. HIV and AIDS Cumulative Incidence Rates by Region, 2006-2010
Data Source: Ministry of Health [2]
35
c)
HIV/AIDS Mortality Rates
Between 1990 and 2009, 6,929 persons died from AIDS in Chile. From the total number of
AIDS deaths, 87.3% were men (N= 6,052). The highest AIDS mortality rate was observed in
2001 with 3.6 persons per 100,000 population dying from the disease. However, since 2004 there
has been a stabilization tendency with a constant mortality rate close to 2.5 per 100,000. Now, in
relation to the trends by sex, men have shown a reduction in the AIDS mortality rate from 6.2 to
4.4 per 100,000 between 2001 and 2009. At the same time, women have shown an unchanged
mortality rate of around 0.8 per 100,000 over the same period (see Table 6) [2].
Table 6. AIDS Mortality Rates by Sex, 1990-2009
Year
Men
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
N
66
75
101
163
227
278
317
360
343
424
402
Rate*
1.0
1.1
1.5
2.4
3.2
3.9
4.4
5.0
4.6
5.6
5.3
N
6
2
13
11
26
24
45
50
40
50
56
Rate*
0.1
0.0
0.2
0.2
0.4
0.3
0.6
0.7
0.5
0.7
0.7
N
72
77
114
174
253
302
362
410
383
474
458
Rate*
0.5
0.6
0.8
1.3
1.8
2.1
2.5
2.8
2.6
3.1
3.0
2001
2002
2003
2004
2005
2006
2007
2008
2009**
2010
2011
N
479
380
357
356
333
357
341
328
365
-
-
Rate*
6.2
4.9
4.5
4.5
4.1
4.4
4.2
4.0
4.4
-
-
N
73
60
66
43
62
65
51
64
70
-
-
Rate*
0.9
0.8
0.8
0.5
0.8
0.8
0.6
0.8
0.8
-
-
N
552
440
423
399
395
422
392
392
435
-
-
Rate*
3.6
2.8
2.7
2.5
2.4
2.6
2.4
2.3
2.6
-
-
Women
Total
Year
Men
Women
Total
Data Source: Ministry of Health [2]
* Mortality Rate per 100,000 population.
** Number of cases registered until October 31st, 2009.
36
Regarding mortality rates by region, the highest AIDS mortality rates registered in the
north of Chile, particularly in the XV Region Arica y Parinacota. In fact, in 2009, the XV Region
was the only region that showed an AIDS mortality rate above 10 while all the other regions
presented rates below 4 per 100,000 population. On the other hand, for the year 2009, the lowest
AIDS mortality numbers were observed for the IX and XII regions, with AIDS rates of 0.6 per
100,000 [2].
37
3.0
RESEARCH QUESTION AND SPECIFIC AIMS
3.1
RESEARCH QUESTION
What are the specific characteristics of the HIV/AIDS epidemic in the north of Chile,
particularly in the XV Region and the I Region, and what are the possible factors associated with
the recent higher incidence rates registered in the area?
3.2
SPECIFIC AIMS:
1) Describe the morbidity and mortality patterns of the HIV/AIDS epidemic in the XV
Region and the I Region of Chile.
2) Compare the HIV/AIDS morbidity and mortality patterns observed in the XV and I
regions of Chile with the information described about the epidemic at the country level.
3) Evaluate the relationship between the HIV/AIDS rates and several social and economic
factors at the regional level (birth rate, general mortality rate, age structure of the
population, percentage of immigrants, gender inequality, poverty rate, unemployment
rate, average income per capita, income inequality, contribution of the region to the
38
national GDP, drug trafficking, prostitution, alcohol consumption, smoking, condom use
and prevalence of misconceptions about HIV/AIDS.
39
4.0
MATERIALS AND METHODS
4.1
MATERIALS
The morbidity and mortality patterns of the HIV/AIDS epidemic in the north of Chile were
described using the following sources of information:
a) Prevalence:

Data collected through the HIV/AIDS online surveillance system between 2002 and
2012 provided by the Department of Epidemiology, Health Promotion Subdivision, of
Ministry of Health of Chile to the author by personal communication. The
characteristics of this database are described in detail in the document “Appendix A”.

Ministry of Health of Chile, Department of Epidemiology (2010). Epidemiological
Report on HIV/AIDS: Region of Arica and Parinacota, 1990-2009 [41].

Ministry of Health of Chile, Department of Epidemiology (2007). Evolution of the
HIV/AIDS Epidemic: Region of Tarapacá, 1987-2006 [42].

National Institute of Statistics (2013). 2012 National Census Report [6].
40
b) Incidence:

Data collected through the HIV/AIDS online surveillance system between 2002 and
2012, provided by the Department of Epidemiology, Health Promotion Subdivision,
of the Ministry of Health of Chile to the author by personal communication. The
characteristics of this database are described in detail in the document “Appendix A”.

National Institute of Statistics (2013). 2012 National Census Report [6].

National Institute of Statistics (2005). CHILE: Population Projections and
Estimations. Country and Regions, 1990–2020 [40].

National Institute of Statistics of Arica y Parinacota (2006). Population Estimations
by June 30th, by Sex and Age Group, 2005-2010 [43].

National Institute of Statistics of Tarapacá (2003). Population Estimations by June
30th, by Sex and Age Group, 2005-2010 [44].
c) Mortality:

Ministry of Health of Chile, Department of Statistics and Information on Health
(2011). Mortality by Cause of Death, by Region. 2000-2010 [45]

National Institute of Statistics (2013). 2012 National Census Report [6].

National Institute of Statistics (2005). CHILE: Population Projections and
Estimations. Country and Regions, 1990–2020 [40].

National Institute of Statistics of Arica y Parinacota (2008). Population Estimations
by June 30th, by Sex and Age Group, 2005-2010 [43
41

National Institute of Statistics of Tarapacá (2003). Population Estimations by June
30th, by Sex and Age Group, 2005-2010 [44]
The characteristics of the epidemic at the regional level were compared with the
information described for the disease at the country scale. In this context, the data for the country
was obtained from the following documents:

Ministry of Health of Chile, Department of Epidemiology (2011). Evolution of the
HIV/AIDS epidemic in Chile, 1984-2010 [2].

Ministry of Health, Department of Epidemiology (2013). HIV/AIDS Cases: Chile,
2010-2012 [46].

National Institute of Statistics (2005). CHILE: Population Projections and
Estimations. Country and Regions, 1990–2020 [40].
On the other hand, to analyze the association between the HIV/AIDS incidence rates and
different demographic, economic and social indicators at the regional level, data was obtained
from the following sources
a) HIV/AIDS rates: Ministry of Health of Chile, Department of Epidemiology (2011).
Evolution of the HIV/AIDS epidemic in Chile, 1984-2010 [2].
b) Demographic Factors

Birth Rate: Ministry of Health of Chile, Department of Statistics and Information on
Health (2009). Basic Indicators of Health: Chile, 2009 [47].

General Mortality Rate: Ministry of Health of Chile, Department of Statistics and
Information on Health (2009). Basic Indicators of Health: Chile, 2009 [47].
42

Age Structure of the Population: Ministry of Health of Chile, Department of Statistics
and Information on Health (2009). Basic Indicators of Health: Chile, 2009 [47].

Percentage of Immigrants: Ministry of Internal Affairs and Public Security, Migration
Department (2010). Annual Report of the Migration Department, 2010 [48]
c) Economic Factors

Poverty Rate: Ministry of Social Development of Chile (2011) Interactive
Platform, 2009 National Survey of Socioeconomic Characterization [49].

Unemployment Rate: Ministry of Social Development of Chile (2011). Interactive
Platform, 2009 National Survey of Socioeconomic Characterization [49].

Average Income per Capita: Ministry of Social Development of Chile (2011).
Interactive Platform, 2009 National Survey of Socioeconomic Characterization
[49].

Gini Coefficient: Ministry of Health of Chile, Department of Epidemiology
(2010). Regional Diagnosis based on the Social Determinants of Health Approach
[50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64]

Contribution of the Region to the National GDP: Central Bank of Chile (2011).
National Accounts of Chile: Regional GDP 2011 [22].
d) Social Factors

Gender inequality: Ministry of Planning of Chile (presently, Ministry of Social
Development) (2010). Index of Gender Inequality [65]
43

Prevalence of Smoking: Ministry of Health of Chile (2010) National Health Survey
2009-2010 [36].

Prevalence of Alcohol Consumption: Ministry of Health of Chile (2007). 2nd Survey
about Quality of Life and Health, Chile 2006. Regional Results by Rural/Urban
population [66]

Prostitution: Ministry of Health of Chile (2007). 2nd Survey about Quality of Life and
Health, Chile 2006. Regional Results by Rural/Urban population [66]

Rate of Drug Trafficking: National Institute of Statistics (2010). Annual Report of the
National Police, 2010 [67]

Prevalence of Condom Use: Ministry of Health of Chile (2007). 2nd Survey about
Quality of Life and Health, Chile 2006. Regional Results by Rural/Urban population
[66]. Database of the 6th National Youth Survey that was conducted by the National
Institute of Youth in 2009 INJUV. The database was facilitated by the National
Institute of Youth to the author by personal communication.

Prevalence of Misconceptions about HIV/AIDS: Database of the 6th National Youth
Survey that was conducted by the National Institute of Youth in 2009 INJUV. The
database was facilitated by the National Institute of Youth to the author by personal
communication.
44
4.2
METHODS
Morbidity and mortality patterns of the HIV/AIDS epidemic in the north of Chile were described
for each region and compared between regions and also with the data registered at the country
level.
a) Prevalence
Prevalence was estimated by calculating the number of new HIV/AIDS cases diagnosed
since the beginning of the epidemic until 2010 and subtracting the number of AIDS deaths until
20103 [2, 41, 42]. Prevalence rates were calculated using data on the total population estimated
by the 2012 National Census [6]. The calculations were made for the country as a whole and for
the north, with no distinction regarding region or sex, since there was not information available
about the number of deaths registered in each region before the year 2005 (Before 2006, the XV
Region was part of the I Region). Besides the point estimation of prevalence, the correspondent
95% confidence interval was estimated using the binomial probability. The HIV/AIDS
prevalence observed in the north and at the country level were compared using a two-tailed test
of two proportions at an alpha level of 0.05.
b) Incidence
In relation to the HIV/AIDS incidence, it was analyzed as following:

3
General Incidence
Information on AIDS mortality is available only until 2010.
45

Incidence by Sex

Incidence by Age

Incidence by Mode of Transmission

Incidence by Disease Status
General Incidence
The general incidence of the disease was evaluated by calculating the annual incidence
rate per 100,000 population for the XV and I regions for each year between 2002 and 2012. The
estimations were based on the number of cases registered in the online surveillance system and
the mid-year population estimations provided by the National Institute of Statistics [2, 40, 41, 42,
43, 44]. Besides the point estimation, a 95% confidence interval was calculated based on the
Poisson distribution. The differences between the two regions were compared with a two-tailed
test of two proportions at an alpha level of 0.05.
The results observed in both northern regions (Region XV and Region I) were compared
with the data at the country level using data from the HIV/AIDS National Report 1984-2010 [2]
and a document published by the Department of Epidemiology of the Ministry of Health that
contains the number of HIV/AIDS registered in 2011 and 2012 by region [46]. The denominators
for the annual incidence rates at the country level were obtained from the mid-year population
estimations reported by the National Institute of Statistics [40, 43, 44]. First, the differences
between the two northern regions and the country were evaluated with a two-tailed test of two
proportions at a significance level of 0.05. Secondly, a relative risk analysis was performed to
46
compare the risk for HIV/AIDS observed in the XV Region, the I Region and in the country by
using their 2006-2010 cumulative incidence rates.
Incidence by Sex
The HIV/AIDS incidence by sex was analyzed by estimating the annual incidence rates
per 100,000 population observed in each region for men and women. Incidence rate information
was obtained from the online Chilean surveillance system and the mid-year population
estimations made by the regional subdivisions of the National Institute of Statistics [43, 44]. The
incidence rates were compared between males and females from the same region in order to
evaluate possible difference in the incidence of the disease by sex using a two-tailed test of two
proportions at a confidence level of 0.05.
In addition, the data on HIV/AIDS incidence observed in the XV and I regions was
compared with the data on HIV/AIDS incidence observed at the country level [2]. The analysis
was performed using the annual incidence rates registered for men and women in each group
between 2002 and 2010. No information was available by sex for the years 2011 and 2012 at the
national scale. The rates observed for males in both regions were compared with the rates
observed for males at the country level. Later, the same analysis was performed for women. A
two-tailed test of two proportions was applied at a significant level of 0.05.
Finally, it was estimated the relative risk of HIV/AIDS by sex in each region and at the
country level. Additionally, the risk for HIV/AIDS was compared between men from the XV
47
Region and the I Region and for males at the national scale. Same-sex risk comparisons were
also performed for women.
Incidence by Age
The HIV/AIDS incidence by age was also studied for men and women form both
northern regions. Four groups were used in this assessment: males-XV Region, females-XV
Region, males-I Region, and females-I Region. The mean age and standard deviation was
calculated for each group. The mean ages were compared between males and females from the
same region and by conducting same-sex comparisons between regions using a two sample t test,
two-tailed, at an alpha level of 0.05. Later, the cases observed in each of the four groups between
2002 and 2012 were organized in the following age categories: 0-9 yrs; 10-19 yrs; 20-29 yrs; 3039 yrs; 40-49 yrs; 50-59 yrs; 60-69 yrs; >70 yrs. The age distribution of the HIV/AIDS new
cases was compared between groups using a fisher exact test at a significance level of 0.05.
The next step was to estimate the 2006-2010 cumulative incidence rates of HIV/AIDS
with their respective 95% confidence interval observed in each one of these age categories for
men and women from the XV Region, the I Region, and at the country scale. The distribution of
cases by age was compared between men and between women from these three different
geographic levels using a fisher exact test at an alpha level of 0.05.
Finally, the risk of getting infected with the virus was analyzed by comparing the 20062010 cumulative incidence rates of HIV/AIDS observed in each age category between the XV
Region and the country, and between the I Region and the country.
48
Incidence by Mode of Transmission
The HIV/AIDS incidence rate by mode of transmission was analyzed based on the way in
which the information from the HIV/AIDS surveillance system. In this context, since sexual
exposure, blood transfusion, drug use, and presence of HIV positive mother represent different
questions in the database, they were analyzed separately. Therefore, the first step was to estimate
for each question the frequency and percentage of cases identified between 2002 and 2012 who
reported the different possible modes of transmission: 1) sexual exposure: homosexual, bisexual,
heterosexual; 2) blood transfusion: yes/no; 3) drug use: yes/no; and 4) presence of HIV positive
mother: yes/no. Later, the results were compared between regions using a fisher exact test at a
significance level of 0.05. The same analysis was be conducted by sex, and the distribution of the
different types of mode of transmission was compared between men and women from the same
region and between males and females from the different regions.
As a second step, the scenario observed in the northern regions of the country was
compared with the data registered at the country level by analyzing the cases registered for men
and women in the XV Region, the I Region and at the country level between 2006 and 2010. The
proportion of cases observed in each exposure category was compared between males and
between females from the three geographic levels of analysis by using a two-tailed test of two
proportions at an alpha level of 0.05.
Incidence by Disease Status
The HIV and AIDS annual incidence rates were calculated for each region for the period
2002-2012 with their corresponding 95% confidence intervals. Confidence intervals were
49
estimated using the Poisson distribution. The annual HIV rates were compared with the AIDS
rates using a two-tailed test of two proportions at a significance level of 0.05. Also, the HIV and
the AIDS rates were compared by regions applying the same methodology.
The results observed in the north were compared with the situation observed at the
country level for each year between 2002 and 2010 since there was no information available
about the all the new cases registered in the country between 2011 and 2012 by disease status.
The analysis was performed using a two-tailed test of two proportions (α = 0.05).
The rates observed in the XV and I regions were also compared again with the scenario
observed at the country level, this time including distinctions by sex. To perform this analysis,
the 2006-2010 cumulative incidence rates of HIV and AIDS for men and women were estimated
in both northern regions and at the country level. The rates were analyzed using a two-tailed test
of two proportions at an alpha level of 0.05.
Finally, the age distribution of the HIV and AIDS cases was evaluated by calculating the
2006-2010 cumulative incidence rates of HIV and AIDS in the different age categories
mentioned previously for the XV Region, the I Region and at the national scale. Groups were
compared with a fisher exact test at a significance level of 0.05.
50
c) Mortality
Mortality patterns were analyzed by region and sex according to the information provided
for the period 2000-2010 by the Ministry of Health which was recorded based on the ICD-10CM system [45]. No analysis by age was performed since that information was not publically
available.
In this context, the annual mortality rates were estimated for each region in general, and
also for men and women from both regions by using the number of AIDS deaths reported by the
Ministry of Health [45] and the mid-year population estimations made by the regional
subdivisions of the National Institute of Statistics [43, 44]. The corresponding confidence
intervals were calculated using the Poisson distribution and the results were compared between
regions, and between males and females from the same region by using a two-tailed test of two
proportions at a confidence level of 0.05.
Next, the results observed for men and women in the northern regions were compared
with the mortality rates registered by sex at the country level using the same methodology.
Finally, the risk for dying from AIDS was analyzed by sex using the 2006-2010 cumulative
incidence rates observed for men and women from the XV Region, the I Region, and at the
country level. The analysis considered inter and intra-sex comparisons.
51
d) Social and Economic Factors in HIV/AIDS
The association between the HIV/AIDS epidemic and several demographic, economic
and social factors was evaluated by performing a small ecological study using data registered at
the regional level. The correlation between region specific HIV/AIDS rates and the noted factors
was examined in this ecological assessment. The different variables in this analysis were
operationalized as following:

HIV rates: the 2006-2010 cumulative incidence rates of HIV per 100,000 population with
respect to the 2008 mid-year population.

AIDS rates: the 2006-2010 cumulative incidence rates of AIDS per 100,000 population
with respect to the 2008 mid-year population.

HIV/AIDS rates: the 2006-2010 cumulative incidence rates of HIV + AIDS per 100,000
population with respect to the 2008 mid-year population.

Birth rate: the annual number of births per 1,000 population registered in each region in
2009.

General mortality rate: the annual number of deaths from all causes per 100,000
population registered in the region in 2009.

Age structure of the population: the percent of people aged 0-14 years old and the percent
of people older than 64 years old living in the region by 2009.

Percent of immigrants: the proportion of immigrants in the total population of the region
based on the information registered in 2010 by the Migration Department of the Ministry
of Internal Affairs and Public Security.

Poverty rate: the percent of people in the region living under the poverty line according to
the 2009 National Survey of Socioeconomic Characterization.
52

Unemployment rate: the percent of people in the region aged 15-64 yrs who reported the
following three conditions in the 2009 National Survey of Socioeconomic
Characterization: 1) did not work over the last week; 2) are not employed and do not own
a personal business; and 3) attempted to find a paid job over the last two months.

Average income per capita: the average of the proportion of total income per household
divided by the number of individuals per household, based on the data from the 2009
National Survey of Socioeconomic Characterization.

Contribution of the region to the national GDP: the percentage of the total GDP generated
by each region according to the Central Bank of Chile.

Income inequality: the Gini coefficient, index used globally to measure income inequality
within a population estimated for each region based on the results of the 2006 National
Survey of Socioeconomic Characterization.

Gender inequality: the gender inequality index developed by the Ministry of Planning. It
includes information about 5 social dimensions that was obtained from the 2006 National
Survey of Socioeconomic Characterization: Family, Education, Health, Work, and
Poverty and Income. It ranges from “0” to “1” where a value of “0” represents a situation
of total inequality that is unfavorable to women, and a value of “1” means that men and
women are theoretically equal.

Prevalence of smoking: the percent of people in the region who reported smoking in the
2009 National Survey of Socioeconomic Characterization.

Prevalence of alcohol consumption: the percent of men and percent of women in the
region who reported experiencing more than two problematic episodes because of alcohol
53
consumption over the last month in the 2nd Survey about Quality of Life and Health
(2006).

Prostitution: the percent of people in the region who reported problems of prostitution in
their neighborhoods in the 2nd Survey about Quality of Life and Health (2006).

Rate of drug trafficking: the number of people arrested for minor drug trafficking and
number of people arrested for major drug trafficking in each region per 10,000
inhabitants (definition of the offense based on Jurisprudence). The number of arrests was
obtained from the annual report of the national police and the denominator was the midyear population estimations made by the regional subdivisions of the National Institute of
Statistics for 2010

Prevalence of condom use: the percent of youth (14 - 30 years old) who reported using
condom during their last sexual intercourse in the 6th National Youth Survey (2010) and
percentage of people from each region who reported always using condoms in their
sexual intercourses over the last 12 months in the 2nd Survey about Quality of Life and
Health (2006).

Prevalence of misconceptions about HIV/AIDS: the percent of youth in each region who
responded “yes” to the question: “do you believe that HIV can be transmitted by sharing
the bathroom with a homosexual person or someone infected with the virus?” in the 6th
National Youth Survey (2010).
The analysis for these ecological assessments was performed conducting a bivariate
correlation analysis between the HIV rates, the AIDS rates and the HIV/AIDS with the different
factors previously described. The correlation was evaluated by estimating the corresponding
54
spearman correlation coefficient. The significance of the estimation was evaluated at an alpha
level of 0.05 (two-tailed). All calculations were performed in Microsoft Excel 2010 and/or
Stata/IC 12.0 for Windows.
55
5.0
5.1
RESULTS
MORBIDITY AND MORTALITY PATTERNS OF THE HIV/AIDS EPIDEMIC
IN THE NORTH OF CHILE
5.1.1 HIV/AIDS Prevalence in the XV Region and the I Region
In the extreme north, the first cases of HIV/AIDS were registered in 1987, three years after the
first case was identified in the country. Between 1987 and 2010, there were 1,152 newly
diagnosed cases. On the other side, until 2010, a total of 309 people died from HIV/AIDS related
causes in the area. Therefore, considering the information from the 2012 National Census which
defines a population of 213,565 and 298,257 for the XV and I regions respectively (total
=511,822), the prevalence of the disease in the north of the country is estimated to be close to
0.16% (95% CI: 0.15 – 0.18%)
At the same time, between 1984 and 2010, 24,014 cases were diagnosed in the country,
and until 2010, 364 people had died from AIDS-related causes in Chile. Therefore, based on the
results from the 2012 National Census that describes a total population of 16,572,475
inhabitants, the prevalence of HIV/AIDS at the country level would be close to 0.14% (95% CI:
0.14 – 0.15%)
56
The difference in the HIV/AIDS prevalence between the northern regions and the country
as a whole (0.16 vs. 0.14) was statistically significant (p < 0,001).
5.1.2 HIV/AIDS Incidence in the XV Region and I Region
Regarding the incidence of the disease, according to the HIV/AIDS surveillance system, 1,046
new cases of HIV/AIDS were identified in the XV and I regions between 2002 and 2012.
Therefore, based on the information described in the previous section, it is possible to estimate
that 74.5%% of the total number of cases registered in the extreme north have been diagnosed
over the last 10 years of the epidemic.
In terms of the burden of the disease for each region, 555 out of the 1,046 cases were
identified in the XV Region (53.1%) and 491 (46.9%) in the I Region. The largest number of
cases for the XV Region was registered in 2012, with a total of 77 cases, while the largest
number of new cases for the I Region was identified in 2011, with a total of 64. The differences
observed in the incidence of the disease between regions for the period 2002-2012 were
statistically significant every year since 2007, with a higher HIV/AIDS incidence in the XV
Region (see Table 7).
57
Table 7. HIV/AIDS Incidence in the XV Region and the I Region, 2002 - 2012
XV Region
Year
I Region
Rate** and
Total
N
95% CI
Population*
53
27.55
34
258,530
2002
(20.64 – 36.03)
36
191,874
18.76
25
265,358
2003
(13.14 – 25.97)
43
191,368
22.47
32
272,191
2004
(16.26 – 30.27)
28
190,859
14.67
53
279,011
2005
(9.75 – 21.20)
47
189,692
24.78
51
286,105
2006
(18.21 – 32.95)
39
188,524
20.69
20
293,205
2007
(14.71 – 28.28)
68
187,348
36.30
59
300,301
2008
(28.19 – 46.01)
59
186,147
31.70
50
307,426
2009
(24.13 – 40.88)
49
184,957
26.49
48
314,534
2010
(19.60 – 35.02)
56
183,190
30.57
64
321,726
2011
(23.09 – 39.70)
77
181,402
42.45
55
328,921
2012
(33.50 - 53.05)
* Mid-year population estimated by the National Institute of Statistics
** Incidence Rate per 100,000 population
N
Total
Population*
192,392
Rate** and
95% CI
13.15
(9.11 – 18.38)
9.42
(6.10 – 13.91)
11.76
(8.04 – 16.60)
19.00
(14.23 – 24.85)
17.83
(13.27 – 23.44)
6.82
(4.17 – 10.53)
19.65
(14.96 – 25.34)
16.26
(12.07 – 21.44)
15.26
(11.25 – 20.23)
19.89
(15.32 – 25.40)
16.72
(12.60 – 21.76)
p value
0,006
0,007
0,000
0,266
0,480
0,000
0,001
0,000
0,006
0,018
0,000
When the HIV/AIDS annual incidence rates registered in the northern regions were
compared to the incidence of the disease at the country level, the XV Region showed statistically
significant higher rates compared to the numbers presented at the national level across all the
period 2002-2012 (see Table 8). In contrast, the I Region presented more variable results since in
some years of the interval the HIV/AIDS rates were significantly higher than the national
average while in other years the I Region and the country exhibited similar results (see Table 8).
58
Table 8. HIV/AIDS Incidence in the XV Region and the I Region versus HIV/AIDS Incidence at the
Country Level, 2002 – 2012
Year
XV Region
Country
2002
N
53
Rate*
27.55
N
1408
Rate*
9.14
2003
36
18.76
1478
2004
43
22.47
2005
28
2006
p value
I Region
Country
p value
0,000
N
34
Rate*
13.15
N
1408
Rate*
9.14
9.49
0,000
25
9.42
1478
9.49
0,970
1397
8.87
0,000
32
11.76
1397
8.87
0,114
14.67
1360
8.54
0,004
53
19.00
1360
8.54
0,000
47
24.78
1183
7.35
0,000
51
17.83
1183
7.35
0,000
2007
39
20.69
1314
8.08
0,000
20
6.82
1314
8.08
0,452
2008
68
36.30
1574
9.58
0,000
59
19.65
1574
9.58
0,000
2009
59
31.70
2123
13.61
0,000
50
16.26
2123
13.61
0,213
2010
49
26.49
1734
10.34
0,000
48
15.26
1734
10.34
0,007
2011
56
30.57
2,713
16.03
0,000
64
19.89
2,713
16.03
0,086
2012
77
42.45
1,710
10.00
0,000
55
16.72
1,710
10.00
0,000
0,035
*Incidence rate per 100,000 population
The predominance of the disease in the north becomes evident when the annual incidence
rates for both regions and those registered at the country level between 2002 and 2012 are plotted
into a graph. Specifically, Figure 15 shows that across the entire time interval under
consideration the HIV/AIDS rates registered in the north of Chile has been higher than the
national rates with exception of the year 2007 when the I Region presented the lower incidence
of the disease among the three groups.
59
Figure 15. Temporal Trends in HIV/AIDS Incidence in the XV Region, the I Region and at the Country
Level, 2002 - 2012
Additionally, the figure shows that before 2007 the HIV/AIDS rates in both northern
regions exhibited a highly irregular trend with abrupt ups and downs. In contrast, from 2007 until
2011, the rates registered in the XV Region, the I Region and the country level started to follow a
similar pattern, with the rates of the XV Region being on top and the rates registered at the
country scale being on the bottom of the figure.
To answer the question about how much different the HIV/AIDS rates are between the
XV Region, the I Region and the numbers registered at the country level, the relative risk for
HIV/AIDS was compared between the three groups. Overall, people in the XV Region have the
highest risk for the disease. Specifically, the risk for the disease in the XV Region is 1.84 times
60
higher than the risk among people from the I Region, and 2.9 times higher compared to an
average Chilean person. On the other hand, the I Region is at 1.57 times higher risk for HIV than
an average individual in the country. All of the differences identified were statistically significant
(see Table 9).
Table 9. Relative Risk of HIV/AIDS in the XV Region and the I Region compared to the Country Level,
2006 - 2010
HIV/AIDS Cumulative
XV Region
Incidence 2006-2010 *
139.85
XV Region
1
139.85
I Region
75.92
Country
48.25
*Incidence rate per 100,000 population
I Region
75.92
1.84 (1.54 - 2.20)
p < 0,001
1
-
Country
48.25
2.90 (2.56 - 3.27)
p < 0,001
1.57 (1.38 - 1.80)
p < 0,001
1
HIV/AIDS Incidence by sex
From the total number of new cases of HIV/AIDS registered between 2002 and 2012 in the north
of Chile, 789 were males (75.4%) and 257 females (24.6%). Specifically, 411 out of the 789 men
were diagnosed in the XV Region and 378 in the I Region. At the same time, among women, 144
new cases were identified in the XV Region and 110 in the I Region.
According to the information presented in Table 10, the HIV/AIDS incidence rates were
statistically higher among men compared to women in both regions every year between 2002 and
2012. In general, the higher rates are exhibited by males from the XV Region, except for the year
2005 when they exhibited an important reduction in their incidence rate of the disease that it
61
seems to be compensated with an increase in the rate registered among men from the I Region.
Additionally, it is possible to observe that the annual incidence rates for males and females of the
XV Region have shown an increase in the last 4 years, while the rates for men and women from
the I Region have shown a stabilization tendency over those years.
Table 10. HIV/AIDS Incidence in the XV Region and the I Region by Sex, 2002 - 2012
XV Region
Year
Males
N
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Rate
I Region
Females
N
Males
Rate
47.23
8.28
8
(34.45 – 63.19)
(3.58 – 16.32)
27.28
10.36
26
10
(17.82 – 39.97)
(4.97 – 19.05)
32
33.75
11
11.28
(23.09 – 47.64)
(5.63 – 20.18)
17
18.03
11
11.39
(10.5 – 28.86)
(5.69 – 20.38)
35
37.47
12
12.46
(26.1 – 52.1)
(6.44 – 21.77)
30
32.39
9
9.34
(21.85 – 46.23)
(4.27 – 17.72)
49
53.48
19
19.85
(39.57 – 70.69)
(11.95 – 31.0)
42
46.30
17
17.81
(33.37 – 62.58)
(10.38 – 28.52)
38
42.31
11
11.56
(29.94 – 58.07)
(5.77 – 20.69)
44
49.67
12
12.69
(36.09 – 66.67)
(6.55 – 22.16)
53
60.67
24
25.52
(45.45 – 79.35)
(16.35 – 37.97)
*Incidence rate per 100,000 population
45
p
value
N
0,000
28
0,000
23
0,000
27
0,000
44
0,000
35
0,000
13
0,000
48
0,000
36
0,000
37
0,000
47
0,000
40
Rate
20.94
(13.91 – 30.26)
16.75
(10.62 – 25.13)
19.16
(12.63 – 27.88)
31.14
(22.63 – 41.81)
23.61
(16.44 – 32.83)
8.55
(4.55 – 14.62)
30.81
(22.72 – 40.85)
22.56
(15.8 – 31.23)
22.65
(15.95 – 31.22)
28.13
(20.67 – 37.4)
23.38
(16.71 – 31.84)
Females
N
6
2
2
9
16
7
11
14
11
17
15
Rate
5.13
(1.88 - 11.16)
1.56
(0.0 - 5.64)
1.52
(0.0 – 5.5)
6.69
(3.06 – 12.7)
11.61
(6.63 – 18.85)
4.96
(1.99 – 10.22)
7.61
(3.8 – 13.62)
9.47
(5.18 – 15.89)
7.28
(3.63 – 13.02)
11.00
(6.41 – 17.61)
9.50
(5.32 – 15.67)
When the rates registered in the north among men and women were compared with the
incidence rates for males and females at the country level, the analysis showed that for both
sexes, the northern regions present higher HIV/AIDS incidence rates across the entire period
62
p
value
0,000
0,000
0,000
0,000
0,000
0,235
0,000
0,000
0,000
0,000
0,000
2002-2010. Males in the XV Region exhibited statistically significant higher rates every year,
except in 2005. On the other hand, the comparison between males from the I Region and the
country level showed more variable results, with some years in which the northern regions
showed meaningfully higher rates (2005, 2006 and 2008) and other years in which the
differences were not statistically significant (see Table 11).
Women presented a similar pattern in the sense that females from the XV Region present
HIV/AIDS rates that are significantly and consistently higher compared to the rates described for
women at the national level. In contrast, females from the I Region exhibit more variability; in
some years they showed significantly higher rates than the ones observed at the country level and
in other years (most of them) they present non-meaningful differences (see Table 12).
Table 11. HIV/AIDS Incidence among Males in the XV Region, the I Region and at the Country Level,
2002 - 2012
XV Region, Males
Country, Males
N
Rate*
N
Rate*
p
value
2002
45
47.23
1179
15.13
2003
26
27.28
1238
2004
32
33.75
2005
17
2006
I Region, Males
Country, Males
N
Rate*
N
Rate*
p
value
0,000
28
20.94
1179
15.13
0,088
15.71
0,005
23
16.75
1238
15.71
0,761
1164
14.61
0,000
27
19.16
1164
14.61
0,162
18.03
1107
13.74
0,266
44
31.14
1107
13.74
0,000
35
37.47
920
11.31
0,000
35
23.61
920
11.31
0,000
2007
30
32.39
1047
12.74
0,000
13
8.55
1047
12.74
0,150
2008
49
53.48
1279
15.41
0,000
48
30.81
1279
15.41
0,000
2009
42
46.30
1794
21.41
0,000
36
22.56
1794
21.41
0,756
2010
38
42.31
1442
17.04
0,000
37
22.65
1442
17.04
0,086
Year
* Incidence rate per 100,000 population
63
Table 12. HIV/AIDS Incidence among Females in the XV Region, the I Region and at the Country Level,
2002 - 2012
Year
XV Region,
Females
Country,
Females
N
Rate*
N
Rate*
2002
8
8.28
229
2.88
2003
10
10.36
240
2004
11
11.28
2005
11
2006
I Region,
Females
p value
Country,
Females
p value
N
Rate*
N
Rate*
0,002
6
5.13
229
2.88
0,157
2.99
0,000
2
1.56
240
2.99
0,353
233
2.87
0,000
2
1.52
233
2.87
0,365
11.39
253
3.08
0,000
9
6.69
253
3.08
0,019
12
12.46
263
3.17
0,000
16
11.61
263
3.17
0,000
2007
9
9.34
267
3.19
0,001
7
4.96
267
3.19
0,244
2008
19
19.85
295
3.48
0,000
11
7.61
295
3.48
0,009
2009
17
17.81
329
3.85
0,000
14
9.47
329
3.85
0,001
2010
11
11.56
292
3.38
0,000
11
7.28
292
3.38
0,011
* Incidence rate per 100,000 population
The sex risk ratio analysis also exemplifies the predominance of the disease among
males. It was performed by comparing the 2006-2010 cumulative incidence rates registered for
men and women from the XV Region, the I Region and at the country level. According to the
risk ratio estimations, in Chile as a whole, men are at 13.78 times higher risk of getting infected
with HIV than women. In contrast, in the XV Region males are at only 2.98 times higher risk
compared to females, which is not related with lower risk among man, but with a significantly
higher risk for women in this area compared to the rest of the country. A similar situation was
observed for the I Region (see Table 13).
64
Table 13. Relative Risk of HIV/AIDS by Sex in the XV Region, the I Region and at the Country Level, 2006 - 2010
HIV/AIDS Males
2006-2010 Cumulative Incidence*
HIV/AIDS Females
2006-2010 Cumulative Incidence*
Risk Ratio
Males versus Females
p value
XV Region
I Region
Country
211.72
(N = 194)
71.04
(N = 68)
2.98
( 2.29 - 3.87)
108.48
(N = 169)
40.83
(N = 59)
2.66
(1.99 - 3.53)
78.12
( 6,482)
5.67
(N = 480)
13.78
(12.84- 14.79)
0,000
0,000
0,000
The next analysis examined if the risk of HIV/AIDS was higher in males in the north
compared to Chile overall. It was observed that males in the XV and I regions are at 2.7 and 1.95
higher risk for incident HIV/AIDS than an average Chilean man. This differences were
statistically significant (see Table 14).
Table 14. Relative Risk of HIV/AIDS in Males from the XV Region and the I Region compared to Males
at the Country Level, 2006 – 2010
HIV/AIDS Cumulative
XV Region, Males
Incidence 2006-2010 *
211.72
XV Region, Males
211.72
I Region, Males
108.48
Country, Males
78.12
* Cumulative incidence rate per 100,000 population
I Region, Males
108.48
1.95 (1.59 - 2.40)
p < 0,001
-
Country, Males
78.12
2.7 (2.36 - 3.11)
p < 0,001
2.71 (2.36 - 3.10)
p < 0,001
-
Finally, with respect to women, between 2006 and 2010 the risk of being infected with
HIV for females in the XV and I regions was 12.53 and 7.20 times higher, respectively,
compared to an average Chilean woman (see Table 15).
65
Table 15. Relative Risk of HIV/AIDS in Females from the XV Region and the I Region compared to
Females at the Country Level, 2006 - 2010
HIV/AIDS Cumulative
XV Region, Females
Incidence 2006-2010 *
71.04
XV Region, Females
71.04
I Region, Females
40.83
Country, Females
5.67
* Cumulative incidence rate per 100,000 population.
I Region, Females
40.83
1.74 (1.23 - 2.45)
p < 0,001
1
-
Country, Females
5.67
12.53 (10.28-15.26)
p < 0,000
7.20 (5.72-9.07)
p < 0,000
-
HIV/AIDS Incidence by age
Between 2002 and 2012, the mean age of individuals diagnosed with HIV/AIDS in the north of
Chile was 34.99 years (sd = 12.09 yrs). In the XV Region, males showed a mean age of 34.97
years (sd = 12.62 yrs) and women presented a mean age of 35,44 years (sd = 13.73 yrs). In the I
Region, males and females exhibited a mean age of 35.22 (sd = 11.10 yrs) and 34.28 years (sd =
11.20 yrs), respectively.
Figure 16 shows the age distribution of the 2002-2012 HIV/AIDS cases diagnosed in the
north by sex and region. In all groups, 50% of all cases were concentrated between the beginning
of the 20’s and the beginning of the 40’s. In fact, according to the information contained in Table
16, more than 80% of the cases registered over the period among males and females from the
north of Chile were concentrated in people aged from 20 to 50 years old.
66
Females, XV Region
age
0
20
40
60
80
Females, I Region
Males, XV Region
0
20
40
60
80
Males, I Region
Figure 16. Mean Age of Individuals Diagnosed with HIV/AIDS in the XV Region and the I Region, by
Sex. 2002 - 2012
Table 16. HIV/AIDS in the XV Region and the I Region by Sex and Age Category, 2002 - 2012
XV Region
2002-2012
Males
Age
I Region
2002-2012
Females
Males
Females
N
%
N
%
N
%
N
%
0-9
2
0.49
3
2.08
3
0.79
2
1.77
10-19
25
6.08
9
6.25
18
4.76
5
4.42
20-29
137
33.33
43
29.86
103
27.25
36
31.86
30-39
118
28.71
36
25.00
130
34.39
36
31.86
40-49
75
18.25
30
20.83
84
22.22
25
22.12
50-59
34
8.27
15
10.42
35
9.26
7
6.19
60-69
16
3.89
6
4.17
4
1.06
2
1.77
70+
4
0.97
2
1.39
1
0.26
0
0
Total
411
100
144
100
378
100
113
100
67
The mean age observed in men and women from both regions was analyzed by
comparing males and females from the same region and by conducting same-sex comparison
between regions. The results show that there were not statistically significant differences in age
between groups (see Table 17).
Table 17. HIV/AIDS Age Distribution among Males and Females from the XV Region and the I Region
compared to the HIV/AIDS Age Distribution observed in Males and Females at the Country Level, 2006 - 2010
HIV/AIDS Age
Distribution
XV Region,
Males
XV Region,
Females
I Region,
Males
-
p = 0,651
p = 0,768
-
XV Region, Females
p = 0,651
-
-
p = 0,467
I Region, Males
p = 0,768
-
-
p =0,859
-
p = 0,467
p =0,859
-
XV Region, Males
I Region, Females
I Region,
Females
Later, the age distribution of HIV/AIDS in the northern regions was compared with the
data registered at the country level. The analysis was conducted using the 2006-2010 cumulative
HIV/AIDS incidence rates registered for each age category in males and females. The results of
the analysis show that there is a consist pattern with highest HIV/AIDS incidence rates among
people aged 30-39. One exception was noted. Women from the XV Region exhibited the higher
rates in the 20-29 age cohort. Additionally, all the six groups registered the lower incidence rates
in the extreme age cohorts, among people aged 0-9 and older than 70 years old (see Figure 17).
68
Figure 17. HIV/AIDS by Sex and Age Category in the XV Region, the I Region and at the Country Level,
2006 - 2010
Finally, the risk of getting infected with HIV in the different age categories was
compared between each northern region and the data registered at the country level.
The
analysis was conducted contrasting the cumulative incidence rates for the period 2006-2010. The
results showed that people from the XV Region aged 10 to 19, 20 to 29, 30 to 39, 40-49 and 6069 have a significant higher risk for HIV than an average Chilean of the same age. In addition,
people between 20 and 29 years old in the I Region were at higher risk for HIV/AIDS than the
average person in Chile (see Table 18 and Table 19).
69
Table 18. HIV/AIDS Incidence in the XV Region and at the Country Level by Age Category, 2006 - 2010
XV Region
Country
Age
Risk Ratio
N
Rate*
N
Rate*
0–9
2
6.88
67
5.21
10 - 19
14
42.19
329
22.81
20 – 29
86
290.08
2548
193.16
0 – 39
69
278.12
2496
204.39
40 – 49
54
214.26
1617
133.82
50 – 59
22
108.58
621
71.66
60 – 69
13
91.33
217
39.08
70+
2
43.29
32
10.32
1.32 (0.32 - 5.39)
p = 0,666
1.85 (1.08 - 3.16)
p = 0,041
1.50 (1.21 - 1.86)
p = 0,004
1.36 (1.07 - 1.77)
p = 0,016
1.60 (1.22 - 2.09)
p = 0,001
1.51 (0.99 -2.31)
p= 0,063
2.34 (1.33 -4.08)
p = 0,008
4.19 (1.00 - 17.48)
p = 0,088
*Cumulative Incidence Rate per 100,000 population
Table 19. HIV/AIDS Incidence in the I Region and at the Country Level by Age Category, 2006 - 2010
I Region
Country
Age
Risk Ratio
N
Rate*
N
Rate*
0–9
2
3.98
67
5.21
10 – 19
14
26.47
329
22.81
20 – 29
62
124.19
2548
193.16
30 – 39
83
179.99
2496
204.39
40 – 49
46
101.84
1617
133.82
50 – 59
18
58.52
621
71.66
60 – 69
3
19.45
217
39.08
70+
0
0
32
10.32
*Cumulative Incidence Rate per 100,000 population
70
0.76 (0.19 - 3.12)
p=1
1.16 (0.68 - 1.98)
p = 0,557
0.64 (0.50 - 0.83)
p = 0,000
0.88 (0.71- 1.10)
p = 0,269
0.76 (0.56 - 1.02)
p = 0,075
0.82 (0.51 - 1.30)
p = 0,447
0.50 (0.16 – 1.60)
p = 0,297
-
HIV/AIDS Mode of Transmission
From the total of 1,046 cases registered in the XV and I regions of the country between 2002 and
2012, information was available from 971 individuals regarding the likely mechanism in which
the person was exposed to the virus. Overall, the mode of exposure to HIV was characterized as
10.13% through bisexual practices (N = 106), 52.68% through heterosexual practices (N=551),
and 32.65% through homosexual practices (N=317). Seven people reported blood transfusion
exposure to the virus, 8 people endovenous drug use and 9 of the newly diagnosed cases were
borne from HIV positive mothers. Therefore, in the north of Chile, like in the rest of the country,
the main mode of transmission to HIV is through sexual contact.
Now, regarding sexual contact, the analysis by region showed that there are statistically
significant differences in the sexual behavior of people who got infected with HIV in the XV
Region and the I Region between 2002 and 2012 (p < 0,001). This difference would be mainly
associated with the fact that heterosexual transmission is considerably more prevalent in the XV
Region compared to the I Region (see Table 20).
71
Table 20. Mode of Transmission of HIV in the XV Region and the I Region, 2002 - 2010
Mode of Exposure
N
XV Region
(N = 555)
%
I Region
(N =491)
N
%
Total
(N=1,046)
N
%
Bisexual
60
10.81
46
9.37
106
10.13
Heterosexual
320
57.66
231
47.05
551
52.68
Homosexual
154
27.75
163
33.20
317
30.31
Missing data*
21
3.78
51
10.38
72
6.88
Total
555
100
491
100
1046
93.12
*Missing data was not included in the analysis.
Overall, the analysis by sex showed that 40.3% of men (N =318) reported heterosexual
contact, while more than 50% of them declared having sex with other men (12.93% bisexual (N
= 102) and 39.67% homosexual (N = 313)). At the same time, 90.1% of the 257 females who
were diagnosed with HIV/AIDS between 2002 and 2012 in the north of the country reported
heterosexual contact (N = 233). Therefore, the difference observed between sexes in the north
regarding type of sexual exposure was statistically significant (p < 0,000).
Later, same sex comparisons showed that males from the XV Region present a
predominance of hetero and bisexual contact while homosexual contact is the most prevalent
exposure among the HIV positive males from the I Region. The difference between both groups
of males was statistically significant (p value < 0,000). On the other hand, as we could expect,
almost all women in the XV and I regions were exposed to the virus through heterosexual
contact (p value = 0.323).
72
Additionally, when data by sex registered in each northern region was compared to the
numbers described at the national level for the period 2006-2010, the analysis shows that among
men from both northern regions heterosexual contact is significantly more frequent compared to
the frequency observed for Chilean men in average (XV Region men versus Country men: p
value < 0,001; I Region men versus Country men: p value = 0,014) (see Table 21 and Table 22).
With respect to women, heterosexual contact was identified as the main type of exposure to the
virus with no meaningful differences between women from the XV Region and women at the
country level (p value = 0,419), or between females from the I Region and females at the country
level (p value = 0,316) (see Table 21 and Table 23).
Table 21. Mode of Transmission of HIV by Sex in the XV Region, the I Region and at the Country Level,
2006 – 2010
XV Region,
Males
N
%
I Region,
Males
N
%
Bisexual
27
16.98
17
12.69
709
Heterosexual
69
43.40
52
38.80
Homosexual
58
36.48
57
Other
5
3.1
159
100
Mode of
Exposure
Missing Data*
Country,
Males
N
%
XV Region,
Females
N
%
I Region,
Females
N
%
12.43
1
1.8
0
0
N.D*
-
1,653
28.98
51
91.07
40
86.96
1,224
93.7
42.54
3,178
55.72
0
0
0
0
ND*
-
8
5.97
164
2.9
4
7.14
6
13.04
83
6.3
134
100
5,704
100
56
100
46
100
1,307
100
N.D = No data available. The HIV/AIDS National Report does not include information about bisexual and
homosexual exposure for women.
* Missing data was not included in the analysis
73
Country,
Females
N
%
Table 22. Mode of Transmission of HIV among Males from the XV Region and the I Region compared to
Males at the Country Level, 2006 – 2010
XV Region, Males
I Region, Males
Bisexual
Heterosexual
Homosexual
Bisexual
p = 0,114
-
-
p = 0,928
Heterosexual
-
p < 0,001
-
Homosexual
-
-
p < 0,001
Country, Males
Bisexual
Heterosexual
Homosexual
p = 0,014
P = 0,002
Table 23. Mode of Transmission of HIV among Females from the XV Region and the I Region compared
to Females at the Country Level, 2006 – 2010
XV Region, Females
I Region, Females
Bisexual
Heterosexual
Homosexual
Bisexual
Heterosexual
Homosexual
Bisexual
-
-
-
-
-
-
Hetero-sexual
-
p = 0,419
-
-
p = 0,316
-
Homo-sexual
-
-
-
-
-
-
Country, Females
Finally, the different types of sexual exposure were examined in both regions by sex and
age category in order to evaluate the possibility that cases of HIV/AIDS might have a different
sexual exposure to the virus according to their age. The analysis was made using data on
incidence from 2006-2010. Regarding males, the data showed that in the XV and I regions the
type of sexual exposure to the virus varied significantly between the different age cohorts (Males
XV Region: p value < 0,001; Males I Region: p value < 0,001). Based on the rough numbers, the
observed differences among males from the XV Regions may be related with the fact that the
heterosexual exposure seems to be more concentrated between 20 and 49 years old, while
bisexual and homosexual exposure seem to be more frequent among younger people aged 20-39
74
years old. Whit respect to the males from the I Region, the differences would be mainly related
with a tendency of homosexual exposure to be predominant among “young adult” new cases
while the heterosexual exposure even though it is concentrated in same age cohorts than the
previous one, shows a broader distribution (see Table 24).
Table 24. Mode of Transmission of HIV among Males from the XV Region and the I Region by Age
Category, 2006 – 2010
XV Region, Males
Age
Bisexual
I Region, Males
Heterosexual
Homosexual
Bisexual
Heterosexual
Homosexual
N
%
N
%
N
%
N
%
N
%
N
%
0-10
0
0.00
0
0.00
0
0.00
0
0.00
0
0.00
0
0.00
10-19
2
6.06
0
0.00
5
6.58
1
4.55
3
4.48
6
8.82
20-29
16
48.48
17
21.52
32
42.11
3
13.64
14
20.90
23
33.82
30-39
4
12.12
22
27.85
25
32.89
9
40.91
27
40.30
22
32.35
40-49
7
21.21
22
27.85
10
13.16
7
31.82
14
20.90
11
16.18
50-59
2
6.06
12
15.19
0
0.00
2
9.09
8
11.94
6
8.82
60-69
2
6.06
4
5.06
4
5.26
0
0.00
1
1.49
0
0.00
+70
0
0.00
2
2.53
0
0.00
0
0.00
0
0.00
0
0.00
Total
33
100
79
100
76
100
22
100
67
100
68
100
In relation to women, coherently with the results described in previous sections, almost
all cases in both regions were classified as heterosexual exposure (see Table 25).
75
Table 25. Mode of Transmission of HIV among Females from the XV Region and the I Region by Age
Category, 2006 – 2010
XV Region, Females
Age
Bisexual
I Region, Females
Heterosexual
Homosexual
Bisexual
Heterosexual
Homosexual
N
%
N
%
N
%
N
%
N
%
N
%
0-10
0
0
0
0
0
0
0
0
0
0
1
50.00
10-19
0
0
4
6.35
1
50.00
0
0
4
7.27
0
0
20-29
1
100
19
30.16
1
50.00
2
100
16
29.09
0
0
30-39
0
0
17
26.98
0
0
0
0
22
40.00
0
0
40-49
0
0
13
20.63
0
0
0
0
10
18.18
1
50.00
50-59
0
0
7
11.11
0
0
0
0
2
3.64
0
0
60-69
0
0
3
4.76
0
0
0
0
1
1.82
0
0
+70
0
0
0
0.00
0
0
0
0
0
0.00
0
0
Total
1
100
63
100
2
100
2
100
55
100
2
100
It was not possible to compare the situation observed in the northern regions with the
total numbers registered at the country level since there is not publically available data at the
country level about the different modes of exposures to the virus by age.
HIV/AIDS by Disease Status
According to the HIV/AIDS surveillance database, out of the 1,046 new HIV/AIDS cases
diagnosed in the XV and I regions between 2002 and 2012, 618 cases were diagnosed in the HIV
stage of the disease and 428 in the AIDS phase. Regarding the HIV cases, 52.8% of them were
identified in the XV Region (N = 326) and 41.2% in the I Region (N = 292). On the other hand,
53.5% of the AIDS cases corresponded to the XV Region (N = 229) and 46.5% to the I Region
76
(N = 199). Overall, a non-statistically significant difference was found between regions with
regards to the total number of HIV and AIDS cases registered over the period (p = 0.810).
Table 26 presents the HIV and AIDS incidence rates registered between 2002 and 2012
in each region. According to the data, there is a predominance of HIV cases in both regions,
however, the difference between the number of HIV and AIDS cases is not constant across the
time interval. For example, in the XV Region, the number of HIV cases was statistically higher
than the number of AIDS cases in 2002, 2006, over the period 2008-2010, and in 2012. In
Region I, even though the HIV cases are also predominant, the number of HIV cases seems to be
closer to the number of AIDS cases. The difference between HIV and AIDS incidence resulted to
be statistically significant only in 2006 and 2011. Furthermore, in 2003 and 2012 it was possible
to observe the opposite situation: a higher number of cases diagnosed in the AIDS phase of the
disease.
77
Table 26. HIV Incidence versus AIDS Incidence in the XV Region and the I Region, 2002 - 2012
XV Region
Y
Year
N
HIV
Rate*
I Region
AIDS
N
Rate*
17.67
9.88
19
(12.2– 24.7)
(6.0 – 15.4)
9.90
8.86
19
17
2003
(6.0 – 15.5)
(6.2 – 14.2)
13.06
9.41
25
18
2004
(8.4 – 19.3)
(5.6 – 14.9)
7.86
6.81
15
13
2005
(4.4 – 12.9)
(3.6 – 11.6)
16.87
7.91
32
15
2006
(11.5 – 23.8)
(4.4 – 13.0)
11.67
9.02
22
17
2007
(7.3 – 17.7)
(5.2 – 14.4)
20.82
13.88
39
26
2008
(14.8 – 28.5)
(9.1 – 20.3)
17.73
13.97
33
26
2009
(12.2 – 25.0)
(9.1 – 20.5)
16.76
9.73
31
18
2010
(11.4 – 23.8)
(5.8 – 15.4)
15.28
15.28
28
28
2011
(10.2 – 22.1)
(10.2 – 22.1)
26.46
15.99
48
29
2012
(19.5 – 35.1)
(10.7 – 22.9)
* Incidence rate per 100,000 population
2002
34
p
value
HIV
N
0.013
22
1
10
0.999
18
1
32
0,012
41
0,999
14
0,012
31
0,013
29
0,013
28
1
42
0,116
25
Rate*
8.51
(5.3 – 12.8)
3.77
(1.8 – 6.9)
6.61
(3.9 – 10.4)
11.47
(7.8 – 16.2)
14.33
(10.3 – 19.4)
4.77
(2.6 – 8.0)
10.32
(7.0 – 14.6)
9.43
(6.3 – 13.5)
8.90
(5.9 – 12.9)
13.05
(9.4 – 17.6)
7.60
(4.9 – 11.2)
AIDS
N
12
15
14
21
10
6
28
21
20
22
30
p
value
Rate*
4.64
(2.4 – 8.1)
5.65
(3.2 – 9.3)
5.14
(2.8 – 8.6)
7.53
(4.7 – 11.5)
3.50
(1.7 – 6.4)
2.05
(0 – 4.4)
9.32
(6.2 – 13.5)
6.83
(4.2 – 10.4)
6.36
(3.9 – 9.8)
6.84
(4.3 – 10.3)
9.12
(6.1 – 13.0)
0,083
0,315
0,469
0,125
0,000
0,066
0,695
0,257
0,257
0,012
0,505
The annual incidence rates of HIV and the annual incidence rates of AIDS were
compared between regions. The analysis showed that, in general, the HIV rates tended to be
statistically higher in the XV Region compared to the I Region. In contrast, the annual AIDS
incidence rates show more variability; in some years both regions showed similar AIDS rates
while for other years the AIDS rates were significantly different between them. However, it is
important to highlight that every time that the AIDS rates resulted to be statistically different
between regions it was because the XV region showed a higher rate compared to the I Region
(see Table 27).
78
Table 27. HIV and AIDS Incidence in the XV Region versus HIV and AIDS Incidence in the I Region,
2002 – 2012
Year
XV Region,
HIV
I Region
HIV
N
Rate*
N
Rate*
2002
34
17.67
22
8.51
2003
19
9.90
10
2004
25
13.06
2005
15
2006
p value
XV Region,
AIDS
I Region,
AIDS
p value
N
Rate*
N
Rate*
0,006
19
9.88
12
4.64
0,036
3.77
0,011
17
8.86
15
5.65
0,201
18
6.61
0,024
18
9.41
14
5.14
0,085
7.86
32
11.47
0,226
13
6.81
21
7.53
0,777
32
16.87
41
14.33
0,478
15
7.91
10
3.50
0,040
2007
22
11.67
14
4.77
0,007
17
9.02
6
2.05
0,001
2008
39
20.82
31
10.32
0,003
26
13.88
28
9.32
0,524
2009
33
17.73
29
9.43
0,011
26
13.97
21
6.83
0,013
2010
31
16.76
28
8.90
0,013
18
9.73
20
6.36
0,187
2011
28
15.28
42
13.05
0,523
28
15.28
22
6.84
0,004
2012
48
26.46
25
7.60
0,000
29
15.99
30
9.12
0,029
* Incidence rate per 100,000 population
When the HIV and AIDS rates observed in the northern regions were compared with the
rates at the country level, as it could be expected based on the previous results, the XV and I
regions showed statistically higher HIV incidence rates compared with the data registered at the
country level over the entire period 2002-2010, with the exception of the years 2003 and 2007
when the HIV rates observed in the I Region did not differ significantly from the rate registered
at the national scale (see Table 28). On the other hand, regarding the AIDS rates, the XV Region
still shows considerable higher rates than the country numbers while the results for the I Region
did not differ with respect to the AIDS data described for the country (see Table 29).
79
Table 28. HIV Incidence in the XV Region and the I Region versus HIV Incidence at the Country Level,
2002 – 2010
Year
XV Region, HIV
Country, HIV
N
Rate*
N
Rate*
2002
34
17.67
884
3.33
2003
19
9.90
940
2004
25
13.06
2005
15
2006
p value
I Region, HIV
Country, HIV
p value
N
Rate*
N
Rate*
0,000
22
8.51
884
3.33
0,000
3.38
0,000
10
3.77
940
3.38
0,733
880
3.21
0,000
18
6.61
880
3.21
0,002
7.86
871
3.01
0,000
32
11.47
871
3.01
0,000
32
16.87
767
2.53
0,000
41
14.33
767
2.53
0,000
2007
22
11.67
713
3.85
0,000
14
4.77
713
3.85
0,426
2008
39
20.82
868
4.21
0,000
31
10.32
868
4.21
0,000
2009
33
17.73
1246
5.18
0,000
29
9.43
1246
5.18
0,001
31
16.76
1033
2010
*Incidence rate per 100,000 population
4.10
0,000
28
8.90
1033
4.10
0,000
Table 29. AIDS Incidence in the XV Region and the I Region versus AIDS Incidence at the Country Level,
2002 – 2010
XV Region, AIDS
Country, AIDS
Year
I Region, AIDS
Country, AIDS
N
Rate*
N
Rate*
p value
p value
N
Rate*
N
Rate*
2002
19
9.87
524
3.33
0,000
12
4.64
524
3.33
0,253
2003
17
8.86
538
3.38
0,000
15
5.65
538
3.38
0,048
2004
18
9.40
517
3.21
0,000
14
5.14
517
3.21
0,079
2005
13
6.81
489
3.01
0,003
21
7.52
489
3.01
0,001
2006
15
7.91
416
2.53
0,000
10
3.49
416
2.53
0,308
2007
17
9.02
601
3.85
0,000
6
2.05
601
3.85
0,118
2008
29
13.88
706
4.21
0,000
28
9.32
706
4.21
0,000
2009
26
13.97
877
5.18
0,000
21
6.83
877
5.18
0,209
2010
18
9.731992
701
4.10
0,000
20
6.36
701
4.10
0,051
* Incidence rate per 100,000 population
80
The analysis of the HIV/AIDS incidence by disease status and sex was conducted
considering the HIV and AIDS cases diagnosed for the first time during the period 2006-2010 in
the XV Region, the I Region, and at the national level. The results showed that men and women
from the two northern regions and men and women at the country level presented a higher
number of cases diagnosed in the HIV stage of the disease compared to the number of AIDS
cases. These differences were statistically significant in all groups with the exception of women
from the XV Region who showed a more even proportion of HIV and AIDS cases (see Table
30).
Table 30. HIV Incidence versus AIDS Incidence among Males and Females from the XV Region, the I
Region and at the Country Level, 2006 – 2010
XV Region,
Males
I Region,
Males
Country,
Males
XV Region,
Females
I Region,
Females
Country,
Females
N
Rate*
N
Rate*
N
Rate*
N
Rate*
N
Rate*
N
Rate*
HIV
119
129.9
98
63.1
3661
44.1
30
31.3
45
31.8
966
11.4
AIDS
75
81.9
71
45.7
2821
34.0
38
39.7
14
9.9
480
5.7
p value
0,002
0,038
0,000
0,332
0,000
0,000
* Cumulative incidence rate per 100,000 population
Among males, men in the XV Region showed higher cumulative incidence rates in both
stages of the disease, HIV and AIDS, than men in the I Region. Among females, women from
the XV Region showed higher incidence rates in both phases of the virus compared to women in
the I Region (see Figure 18).
81
Figure 18. HIV Incidence versus AIDS Incidence among Males and Females from the XV Region, the I
Region and at the Country Level, 2006 - 2010
In relation to the age distribution of the HIV and AIDS cases in the north of Chile, as it
could be expected based on the natural history of the virus, people diagnosed with HIV tended to
be younger than people diagnosed with AIDS. More specifically, cases diagnosed in the HIV
stage of the disease tended to be more concentrated in the 20-29 and 30-39 age cohorts, while the
AIDS cases tend to be more concentrated in the 30-39 age group and older ones.
However, there are also important differences between the situation observed at the
regional level in the north and at the country scale. For example, the analysis of the cumulative
incidence rates for the period 2006-2010 showed that, at the national level, the HIV and AIDS
rates in the 0-9 and 10-19 age cohorts are close to 0. After this point, the HIV incidence rates
exhibit a fast increase in a manner where the highest HIV rates in the entire age spectrum are
82
registered among people aged 20-29 years old, followed by the 30-39 age cohort. In contrast, the
AIDS rate increases more gradually, showing its peak in the 30-39 age group. Among people
older than 40 years old, the HIV and AIDS rates remain almost the same, with a small
predominance of the AIDS rates.
In the XV Region, even though it is also possible to observe the same predominance of
HIV cases among the 20-29 and 30-39 age cohort and the peak of the AIDS rates in the 30-39
age group, the predominance of HIV cases among people between 20 and 29 years old and the
majority of AIDS cases after the forties are markedly higher compared to the scenario observed
at the national level.
Finally, in the I Region, the situation is slightly different since the higher HIV incidence
rate is registered among people aged 30-39 and decreases rapidly after that point, while the AIDS
rates remain stabilized around 50 per 100,000 population across the 20-29, 30-39 and 40-49 age
cohorts (see Figure 19).
83
Figure 19. HIV and AIDS Incidence Rates in the XV Region, the I Region an at the Country Level by Age
Category, 2006 – 2010
5.1.3 HIV/AIDS Mortality in the XV Region and the I Region
According to the data published by the Department of Statistics and Health Information of the
Ministry of Health of Chile, between the years 2000 and 2010, 260 people died from AIDS in the
north of Chile; 114 in the XV Region and 146 in the I Region. Table 32 presents the number of
deaths and the AIDS mortality rates by region for the period 2002-2010. The values reflect that,
in general, each region presented highly variable mortality rates over the interval under study.
Nevertheless, it is possible to recognize an increasing trend in AIDS mortality in both areas
84
between 2002 and 2006. After that point, the AIDS mortality rates in both regions decreased
slightly followed by another increase in the last years of the decade.
Additionally, there is noted variability in the AIDS mortality rates between the regions.
In some years, AIDS mortality is higher in Region XV, while in other years AIDS mortality is
higher in the I Region. Overall, the differences observed were not statistically significant (see
Table 31).
Table 31. AIDS Mortality Rates in the XV Region and the I Region, 2002 - 2012
XV Region
I Region
Year
p value
N
Rate*
N
2.60
10
(0 – 6.1)
6.76
13
12
2001
(3.6 – 11.5)
3.12
6
10
2002
(1.1 – 6.8)
3.65
7
15
2003
(1.5 – 7.5)
4.70
9
7
2004
(2.1 – 8.9)
7.34
14
19
2005
(4.0 – 12.3)
7.38
14
19
2006
(4.0 – 12.3)
4.77
9
12
2007
(2.2 – 9.1)
4.80
9
20
2008
(2.2 – 9.1)
10.21
19
9
2009
(6.1 – 15.9)
4.87
9
13
2010
(2.2 – 9.2)
* Mortality rate per 100,000 population
2000
5
85
Rate*
3.87
(1.8 – 7.1)
4.64 (2.4 –
8.1)
3.87
(1.8 – 7.1)
5.65
(3.2 – 9.3)
2.57
(1.0 – 5.3)
6.81
(4.1 – 10.6)
6.64
(4.0 – 10.4)
4.09
(2.1 – 7.1)
6.66
(4.1 – 10.3)
2.93
(1.3 – 5.6)
4.13
(2.2 – 7.1)
0,604
0,419
0,702
0,392
0,309
0,860
0,859
0,823
0,452
0,001
0,825
On the other hand, when the AIDS mortality rates registered in the XV Region and the I
Region were compared to the AIDS mortality rates registered at the country level, it was possible
to observe that the northern regions of the country exhibit higher AIDS mortality rates than those
observed for Chile in general. These differences were statistically significant in some points of
timeframe, particularly in 2005, 2006 and 2008 (see Table 32).
Table 32. AIDS Mortality Rates in the XV Region and the I Region compared to AIDS Mortality Rates at
the Country Level, 2002 - 2010
XV Region
Country
Year
N
Rate*
N
Rate*
2000
5
2.6
458
3.0
2001
13
6.7
552
2002
6
3.1
2003
7
2004
p value
I Region
Country
p value
N
Rate*
N
Rate*
1
10
4.1
458
3.0
0,363
3.5
0,031
12
4.8
552
3.5
0,407
440
2.8
0,663
10
3.9
440
2.8
0,359
3.6
423
2.7
0,366
15
5.7
423
2.7
0,014
9
4.7
399
2.5
0,060
7
2.6
399
2.5
1
2005
14
7.3
390
2.4
0,000
19
6.8
390
2.4
0,002
2006
14
7.4
422
2.6
0,001
19
6.6
422
2.6
0,005
2007
9
4.8
398
2.4
0,062
12
4.1
398
2.4
0,147
2008
9
4.8
392
2.3
0,046
20
6.7
392
2.3
0,000
2009
19
10.2
435
2.6
0,000
9
2.9
435
2.6
0,725
2010
9
4.9
435
2.5
0,056
13
4.1
435
2.5
0,110
* Mortality rate per 100,000 population
In relation to the analysis of the AIDS mortality rates by sex, as we could expect based on
the distribution of the disease between males and females, men exhibited the highest AIDS
mortality rates over the last decade in both regions (2000-2010). The differences observed
between men and women turn out to be statically significant for almost every year, with
86
exception of the year 2008 in the case of the XV Region, and the years 2000, 2004 and 2009 in
the case of the I Region (see Table 33).
Table 33. AIDS Mortality Rates by Sex in the XV Region and the I Region, 2000 - 2010
XV Region
I Region
Males
Females
Year
N
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Rate*
N
Rate*
5.25
0
0
(1.7 – 12.2)
13.64
13
0
0
(7.3 – 23.3)
6.30
6
0
0
(2.3 – 13.7)
7.34
7
0
0
(2.9 – 15.1)
8.44
1.0
8
1
(3.6 – 16.6)
(0 – 5.7)
13.79
1.0
13
1
(7.3 – 23.6)
(0 – 5.8)
11.77
3.12
11
3
(5.8 – 21.1)
(0 – 9.1)
8.64
1.04
8
1
(3.7 – 17.0)
(0 – 5.8)
7.64
2.09
7
2
(3.1 – 15.7)
(0 – 7.6)
15.43
5.24
14
5
(8.4 – 25.9)
(1.7 – 12.2)
8.91
1.05
8
1
(3.8 – 17.5)
(0 – 5.9)
* Mortality rate per 100,000 population
5
p
value
Males
Females
p value
N
0,030
8
0,000
12
0,015
9
0,007
14
0,019
6
0,000
16
0,032
16
0,019
10
0,102
17
0,037
7
0,018
11
Rate*
5.98
(2.6 – 11.8)
8.97
(4.6 – 15.7)
6.73
(3.1 – 12.8)
10.20
(5.6 – 17.1)
4.26
(1.6 – 9.3)
11.32
(6.5 – 18.4)
10.79
(6.2 – 17.5)
6.58
(3.1 – 12.1)
10.91
(6.4 – 17.5)
4.39
(1.8 – 9.0)
6.73
(3.4 – 12.1)
N
Rate*
2
1.71
(0 – 6.2)
0,117
0
0
0,001
1
1
1
3
3
2
3
2
2
0.8
(0 – 4.3)
0.8
(0 – 4.3)
0.8
(0 – 4.2)
2.23
(0 – 6.5)
2.18
(0 – 6.4)
1.42
(0 – 5.1)
2.08
(0 – 6.1)
1.35
(0 – 4.9)
1.32
(0 – 4.8)
0,024
0,001
0,126
0,005
0,005
0,040
0,002
0,182
0,023
When the AIDS mortality rates registered by sex were compared between the XV
Region, the I Region and at the country level, the data showed that males in the XV and I regions
present in general higher mortality rates than men at the national level. However, in terms of
mortality counts, the number of deaths registered in both northern regions was never higher than
87
17 (number of deaths registered among males from the XV Region in the year 2010) (see Table
34).
Table 34. AIDS Mortality Rates among Males in the XV Region and the I Region compared to AIDS
Mortality Rates among Males at the Country Level, 2002 - 2010
XV Region,
Males
I Region,
Males
XV Region
versus
I Region
(p value)
XV Region
versus
Country
(p value)
I Region
versus
Country
(p value)
N
Rate*
N
Rate*
N
Rate*
2002
5
5.2
8
6.3
380
4.9
0,818
0,870
0,566
2003
13
13.5
12
9.2
357
4.5
0,262
0,000
0,023
2004
6
6.3
9
6.7
356
4.5
0,986
0,396
0,287
2005
7
7.3
14
10.2
331
4.1
0,531
0,116
0,001
2006
8
8.4
6
4.3
357
4.4
0,155
0,057
0,844
2007
13
13.8
16
11.1
398
2.4
0,439
0,000
0,002
2008
11
11.8
16
10.8
328
4.0
0,690
0,000
0,000
2009
8
8.6
10
6.6
365
4.4
0,469
0,044
0,254
2010
7
7.6
17
10.9
370
4.4
0,518
0,125
0,000
Year
Country,
Males
* Mortality rate per 100,000 population
Among women, there a very few recorded AIDS deaths in the north in Chile. The crude
number of deaths per region never goes higher than 3 in the entire decade 2000 – 2010 (see
Table 35). The low number of deaths does not allow for reliable comparisons between regions or
between regions and the country overall.
88
Table 35. AIDS Mortality Rates among Females in the XV Region and the I Region compared to AIDS
Mortality Rates among Females at the Country Level, 2002 - 2010
XV Region.
Females
I Region,
Females
XV Region
versus
I Region
(p value)
XV Region
versus
Country
(p value)
I Region
versus
Country
(p value)
N
Rate*
N
Rate*
N
Rate*
2002
0
0
2
1.7
65
0.8
0,1989
0,374
0,293
2003
0
0
0
0
70
0.8
1
0,359
0,291
2004
0
0
1
0.8
64
0.8
0,389
0,381
0,974
2005
0
0
1
08
51
0.6
0,397
0,439
0,859
2006
1
1.0
1
0,8
65
0.8
0,798
0,788
0,939
2007
1
1.0
3
2.2
59
0.7
0,526
0,699
0,050
2008
3
3.1
3
2.2
43
0.5
0,612
0,001
0,011
2009
1
1.0
2
1.4
66
0.8
0,834
0,761
0,428
2010
2
2.1
3
2.1
60
0.8
0,949
0,103
0,064
Year
Country,
Females
* Mortality rate per 100,000 population
Additionally, the risk for dying from AIDS was compared between males and females
from the XV Region, the I Region and at the national level by analyzing the cumulative mortality
rate registered in each sex group between 2006 and 2010. According to the data, males are at a
significant higher risk of dying from AIDS compared to women in both northern regions and in
Chile in general (see Table 36).
Table 36. Relative Risk of HIV/AIDS by Sex in the XV Region, the I Region and at the Country Level,
2006 - 2010
AIDS Mortality Rate 2006-2010,
Males
AIDS Mortality Rate 2006-2010,
Females
Risk Ratio
Males versus Females
p value
XV Region
I Region
Country
51.29
(N = 47)
8.36
(N = 8)
1.75
(1.57 - 1.95)
41.72
(N = 65)
8.3
(N = 12)
1.63
(1.48 - 1.79)
21.91
( 1,818)
3.46
(N = 293)
1.74
(1.74-1.77)
0,000
0,000
0,000
* Mortality rate per 100,000 population
89
On the other hand, when AIDS mortality in males was compared across the three groups
(XV Region, I Region, and Country), males in the XV and I regions seemed to be at a similar
risk for dying from HIV. Also, men in both northern regions were at higher risk for AIDS
mortality than an average Chilean man. Specifically, men in the XV and I regions are at 2.34 and
1.9 times higher risk than an average Chilean man for dying from AIDS, respectively (see Table
37). Again, because of the low number of observations among women in the northern regions, no
relative risk analysis was performed among females.
Table 37. Relative risk for AIDS- related death among Males from the XV Region and the I Region
compared to Males at the Country Level.
AIDS Mortality Rate
XV Region, Males
2006-2010 *
51.29
Males, XV Region
1
51.29
Males, I Region
41.72
Males Country
21.91
* Mortality rate per 100,000 population
I Region, Males
41.72
1.22 (0.84 – 1.79)
p = 0,283
1
-
90
Country, Males
21.91
2.34 (1.75 – 3.13)
p = 0,000
1.90 (1.48 – 2.43)
p = 0,000
1
5.2
ASSOCIATION BETWEEN THE HIV/AIDS EPIDEMIC AND DIFFERENT
DEMOGRAPHIC AND SOCIOECONOMIC FACTORS AT THE REGIONAL LEVEL
The 2006-2010 cumulative incidence rates of HIV, AIDS and HIV/AIDS were correlated with
the following socioeconomic factors: birth rate, general mortality rate, age structure of the
population, percentage of immigrants, poverty rate, unemployment rate, average income per
capita, contribution of the region to the national GDP, income inequality (Gini coefficient),
gender inequality, smoking, alcohol consumption, prostitution, drug trafficking, condom use and
prevalence of misconceptions about HIV/AIDS and its means of transmission. The values
observed in each region for the different variables under analysis are presented in the document
“Appendix B”.
The results of the analysis showed that when the HIV and AIDS cases were considered
together, the HIV/AIDS rates presented a significant positive correlation with the percentage of
immigrants, prostitution, and drug trafficking (at minor and major scale), as well as a significant
negative association with the variable “always using condom over the last 12 months” (See Table
38). When the analysis considered only the HIV cases, which in theory corresponded to those
people more recently infected with the virus, the same variables showed a statistically significant
correlation. In addition, birth rate, the average income per capita, and the percentage of youth
who reported using condom during their last sexual intercourse also showed a significant
positive association with the disease. Poverty rate and alcoholism among men showed a
significant negative correlation with the HIV rates at the regional level (see Table 38).
91
When the analysis only considered the AIDS cases registered between 2006 and 2010,
the same situation described for the analysis of the AIDS cases together with the HIV cases was
observed, with the percentage of immigrants, prostitution problems, drug trafficking (at minor
and major scale) and always using condom or not over the last 12 months showing a positive
significant correlation with the AIDS rates at the regional level (see Table 38).
Table 38. Results of the Correlation Analysis between HIV/AIDS Incidence and several Demographic and
Socioeconomic Factors at the Regional Level
Birth Rate (2009)
General Mortality Rate (2009)
% population <15 yrs (2009)
% population >64 yrs (2009)
% immigrants (2010)
% poverty (2009)
% unemployment (2009)
Average income per capita (2009)
% of the national GDP (2010)
Income inequality (2006)
Gender inequality (2006)
Smoking (2009)
Alcoholism among men (2006)
Alcoholism among women (2006)
Prostitution (2006)
HIV Rates*
2006-2010
rs = 0.609
p = 0,016
rs = -0.429
p = 0,110
rs = 0.228
p = 0,415
rs = -0.282
p = 0,308
rs = 0.724
p = 0,002
rs = -0.513
p = 0,050
rs = -0.261
p = 0,348
rs = 0.479
p = 0,071
rs = 0.093
p = 0,742
rs = - 0.134
p = 0,633
rs = 0.406
p = 0,133
rs = 0.268
p = 0,334
rs = -0.485
p = 0.067
rs = -0.107
p = 0,703
rs = 0.732
p = 0,002
92
AIDS Rates*
2006-2010
rs = 0.278
p = 0,316
rs = -0.136
p = 0,629
rs = 0.000
p = 1,000
rs = 0.136
p = 0,629
rs = 0.538
p = 0,039
rs = - 0.299
p = 0,279
rs = 0.000
p = 1,000
rs = 0.243
p = 0,383
rs = 0.345
p = 0,208
rs = 0.032
p = 0,909
rs = 0.369
p = 0,177
rs = -0.036
p = 0,899
rs = -0.018
p = 0,950
rs = 0.134
p = 0,633
rs = 0.691
p = 0,004
HIV/AIDS Rates*
2006-2010
rs = 0.382
p = 0,160
rs = -0.231
p = 0,408
rs = 0.047
p = 0.869
rs = 0.000
p =1
rs = 0.541
p = 0,037
rs = -0,329
p = 0,231
rs = -0.360
p = 0,899
rs = 0,254
p = 0,362
rs = 0.379
p = 0,164
rs = 0.360
p = 0.899
rs = 0.403
p = 0,137
rs = 0.036
p = 0,899
rs = -0.104
p = 0,713
rs = 0.115
p = 0,684
rs = 0.730
p = 0,002
Table 38 continued
Drug Micro-traffic (2010)
rs = 0.568
p = 0,027
rs = 0.668
p = 0,007
rs = 0.671
p = 0,006
Drug Traffic (2010)
rs = 0.521
p = 0,046
rs = 0.539
p = 0,038
rs = 0.543
p = 0,037
rs = -0.574
p = 0,025
rs = -0.614
p = 0,015
rs = -0.674
p = 0,006
rs = 0.521
p = 0,046
rs = 0.357
p = 0,191
rs = 0.375
p = 0,168
rs = -0.431
p = 0,109
rs = -0.095
p = 0.737
rs = -0.239
p = -0,390
% of people who always use of
condom over the last 12 months
(2006)
% of youth who reported using
condom during their last sexual
intercourse (2009)
Misconceptions about HIV/AIDS
(2009)
*Incidence rate per 100,000 population
93
6.0
DISCUSION
According to the data reported by the Ministry of Health, since the beginning of the epidemic in
the 1980’s, Chile has shown comparatively lower numbers of HIV/AIDS with respect to other
countries in the region. However, between 1996 and the year 2000 there were 5,203 new cases
diagnosed with HIV/AIDS in the country, and over the period 2006 – 2010, the number of new
HIV/AIDS cases increased up to 7,912. In this context, the main objective of this research was to
describe the epidemiological profile of the HIV/AIDS epidemic in the XV Region and I Region
of Chile, a geographic area that registered the largest increase in the number of HIV/AIDS cases
over the last 10 years and the higher incidence rates in the country at present.
In summary, the analysis showed that individuals from the XV Region and the I Region
were at significant higher risk for HIV/AIDS than an average Chilean person (relative risk of 2.9
and 1.6, respectively). On the other side, when the relative risk for HIV/AIDS was analyzed by
sex, data registered at the country level showed that men in Chile were at 13.78 times higher risk
of getting infected with HIV than women. In contrast, in the XV Region and the I Region males
were at only 2.98 and 2.66 times higher risk for the disease compared to females, respectively.
This situation was not related with a lower risk among men, but with a significantly higher risk
for women in this area of the country. In fact, women who live in the north were at 12.53 (XV
94
Region) and 7.20 (I Region) times higher risk for HIV/AIDS than an average Chilean female.
Coherently, heterosexual exposure to the virus in men was also significantly higher in the
northern regions, compared to the country in general, where the epidemic remains highly
concentrated among men who have sex with men. Additionally, young people aged 10-19 and
20-29 years were also at higher risk in the north than at the country level, particularly in the XV
Region.
Prior to the implementation of the national online platform for HIV/AIDS in 2006, the
XV Region and the I Region showed highly variable annual incidence rates of HIV/AIDS.
However, after 2007, when the new notification system in the national plan was already
operative in all regions, both northern regions started to show HIV/AIDS annual incidence rates
that followed a similar oscillation trend to the one observed at the country level. This finding is
consistent with the fact that in Chile, as a Unitarian state, most of the public policies are designed
and implemented in a highly centralized and standardized manner. Therefore, these regional
disparities observed in the HIV/AIDS rates across the country over the last years could not be
explained solely by differential improvements in the HIV/AIDS national policies, but that other
factors might be playing an important role at a more local scale.
Regarding the incidence of the disease by sex, the northern regions showed the same
pattern described for the country about an HIV/AIDS epidemic highly concentrated among men.
However, both men and women from the XV and I regions exhibited higher incidence rates than
an average Chilean. This last point is particularly interesting when the prevalence of the different
types of sexual exposure were analyzed for the period 2006-2010 since the higher rates for
95
females observed in the northern regions are concordant with the predominance of heterosexual
exposure to the virus among men from the XV Region and almost equal proportion of
heterosexual and homosexual exposure among males from the I Region. This situation is
completely different than the scenario registered at the country level where homosexual exposure
represented more than 50% of the total number of men diagnosed in the country over the period
while only 28.98% reported heterosexual exposure to the disease. The differences observed
between the northern regions and the country level to this respect were statistically meaningful.
In this context, the statement made by the Ministry of Health about HIV/AIDS being a
disease “highly concentrated among males who have sex with males” might be representative of
the specific situation observed in the capital of the country where the majority of cases is
registered, but it does not apply for the north of the country. Furthermore, this particular
characteristic of the epidemic in the north might be a key element to understand why the
incidence rates of the disease in the area are the highest ones registered in the country. For
example, in a region with less the 200,000 people like the XV Region, if the disease would be
concentrated among men who have sex with men, the incidence would likely have remained
concentrated in a relatively reduced circle of people. Contrarily, the fact that heterosexual
exposure is the main mode of transmission in this area generates new opportunities for the virus
to spread since a higher proportion of the population is at risk. The implications and possible
social factors associated with these findings are further explored later when the results from the
correlation analysis are discussed.
96
In relation to the age of people who was diagnosed with the virus in the north of Chile
between 2002 and 2012, the analysis showed that the mean age for men and women was 35 years
old and these findings did not differ significantly from the mean age registered for men and
women at the country level. However, there were statistically significant differences between the
XV and I regions and the country level when the incidence rates of the disease were compared
for each ten-years age category, showing that young people aged 20-29 years old were at higher
significant risk for HIV/AIDS in the north compared to an average Chilean person.
The analysis of the HIV/AIDS epidemic by age category also allows an indirect
evaluation of the health policies implemented by the government to prevent the vertical
transmission of the disease. The results showed that the number of children diagnosed with the
virus have remained low at the region and country level even when the general rates of the
disease have increased among women. Actually, over all the period 2002-2012, there were only
10 children between 0 and 9 years old diagnosed with disease in the north of Chile.
In this context, it seems that the different measures implemented by the government have
had positive results on keeping the number of children affected at a low level. Similarly, the
lower number deaths and AIDS mortality rates registered in both, men and women, at the
regional and country level may also be associated to the improvements in the national HIV
policies, this time related with law that guarantees access to treatment to every HIV positive
people in the country.
97
Nevertheless, the data show that there is still work to do regarding the primary
prevention of the disease, especially to increase the population coverage of HIV testing. For
example, when the proportion of cases diagnosed in the HIV stage of the disease was compared
with the number of cases diagnosed in the AIDS phase for every year between 2002 and 2010,
even though there was a significant predominance of HIV cases, the rough numbers showed that
there was an important fraction of people who were diagnosed with the disease when it was
already in its AIDS stage.
When the analysis about the proportion of HIV and AIDS cases was stratified by sex, the
situation registered in the XV Region was different than what was observed for the I Region and
for the country in general. In the I Region and at the country level, high proportions of both men
and women were diagnosed at the HIV stage over the period 2006-2010. In contrast, in the XV
Region, men were most frequently diagnosed at the HIV stage, while, on the other side, roughly
one-half of the women were diagnosed at the HIV stage, and one-half were diagnosed at the
AIDS stage. This observation indicates that far more women than men are being identified with
this disease at its later stages in this area of the country.
The fact that in the XV Region an important proportion of the female cases are identified
as AIDS cases could be related to the common perception that women are at a lower risk for
HIV, and therefore, they may be less likely to seek or get timely testing for HIV. It would be
interesting to further explore the marital/relationship status of women who are being diagnosed
with the virus as well as the HIV status of their partners in order to evaluate a possible
98
transmission of the virus from married/stable-couple men who are having sex with women
outside their “official” relationship to their “official” female partners.
Some preliminary evidence on the role of social and economic indicators in HIV/AIDS
was identified from the correlation analysis. This assessment found a consistent positive
association of the HIV/AIDS, and the HIV and AIDS rates by themselves, with key social
variables, including the percentage of immigrants in the region, the prevalence of prostitution,
and the level of drug trafficking at a minor and major scale. These social factors have been
linked previously in the HIV/AIDS literature with higher rates of the virus in the developing
world.
Furthermore, both the XV Region and the I Region have a higher proportion of
immigrants with respect to their total population compared to other regions of the country. These
regions also have higher rates of arrests for major and minor scale drug trafficking, and a higher
percentage of people reporting prostitution problems in their neighborhoods.
In relation to the higher prevalence of immigrants in the north, it should be noted that
these regions are the only areas of the country that are in direct contact with the rest of the
continent, without natural barriers like the Andean Mountains or the Pacific Ocean. This
geographic scenario also enables easy travel by road to reach Regions I and XV, rather than
travel by air or sea.
Therefore, the north of Chile is the most popular route selected by
immigrants to cross the border.
The last point is particularly important since most of Latin American immigrants who
come to Chile are people with low socioeconomic status in their home countries who emigrate to
99
pursue better work and economic opportunities, attracted by the exponential growth that Chilean
economy has experienced over the last 10 years. The expansion in the Chilean economy has
made the country a target for major drug trafficking too, mainly marihuana and cocaine, drugs
that in most of the cases enter to the country through the northern regions since the immigration
control in the borders is less rigorous than customs and immigration checkpoints at the airports.
Therefore, the fast economic growth of the country might be indirectly related with the
increase in the rates of the disease. In the correlation analysis, key economic variables including
average income per capita and poverty rate, both show a significant association with HIV rates in
the region. In general, as income per capita increases, the incidence of HIV increases, and as
poverty rates decline, the incidence of the disease tends to increase.
It is important to emphasize that this finding was limited to HIV incidence only. Neither
AIDS incidence, nor the combined HIV/AIDS incidence, was related to these economic
indicators. This may be suggestive of the theory that HIV rates are more responsive to change in
the economy than AIDs rates. In theory, HIV infection is closer in time to change in the
economy than AIDS incidence. Change in the economy is also correlated with change in social
indicators. More disposable income with an advancing economy, for example, may be associated
with secondary markets in prostitution and drugs.
Prostitution may be correlated in a more direct way with the increase observed in the
disease rates over the last decade, especially considering that heterosexual context is the
predominant exposure to the virus in the north of Chile. The fact that the main economic
100
activities in the north are related with mining, fishing and manufacture set the conditions for a
higher concentration of men compared to other regions as we can verified with the estimations
from the 2012 national census and thus, for a higher prevalence of sex trade.
Since the correlation analysis was performed using aggregate data at the regional level
and not individual data about the people who were actually diagnosed with HIV over the period
under consideration, it is not possible to establish any definitive conclusion, much less directly
relate some of the factors making categorizations like immigrants = sex workers, or immigrant =
drug dealer. While this analysis is intended to provide insights about possible structural factors
that might be interacting to increase the vulnerability to HIV/AIDS in the Chilean population,
these demographic, social and economic factors and their correlation with the HIV/AIDS should
be further analyzed in order to evaluate how they related with each other at the individual level
and the mechanism by which they might be affecting HIV/AIDS incidence rates.
101
7.0
CONCLUSIONS
The present research is intended to provide new information about the characteristics of the
HIV/AIDS epidemic in Chile and help to understand the social and economic factors that might
be playing a key role in the increased risk for HIV/AIDS observed in some areas of the country,
particularly in the XV Region and I Region.
Because of the centralized organization and administration of Chilean Government,
public policies face structural barriers that can limit their effectiveness. In this environment,
many policy efforts are focused on accomplishing a homogenous implementation of the
corresponding actions across the country. This situation, while positive in some contexts, may
have a negative context at the local level due to the diversity of the Chilean population. Standard
programs may not work as effectively for diverse populations compared to homogeneous
populations. In addition, the fact that more than 40% of the total population of the country lives
in the capital, Santiago, further contributes to the potential for structural barriers in national
policies.
In this sense, the HIV/AIDS national policies have not been the exception for this
tendency. On one side, it is possible to observe the significant impact of the national HIV/AIDS
102
protocol to the prevention of the vertical transmission of the disease as well as the effectiveness
of the regulations aimed to provide timely and accessible treatment to HIV positive people.
However, based on the significant increase in the HIV rates observed in the northern regions
compared to the rest of the country, it seems that HIV primary prevention campaigns may have
failed in these regions. Also, since HIV is a sexually transmitted disease, it has the potential of
infect a significant amount of people over a short period of time. Thereby, to observe lower rates
today is not a guarantee of having lower disease rates tomorrow, especially if the profile of the
epidemic is experiencing a “heterosexualization” by switching from being an infection highly
concentrated among men who have sex with men to a disease with higher probabilities of being
transmitted through heterosexual contact.
Considering this scenario, new education and prevention campaigns should be developed
in order to address the specific characteristics of a diverse population in the northern regions of
the country, with the groups at higher risk being defined according to local analyses of the
epidemic behavior.
103
APPENDIX A
HIV/AIDS SURVEILLANCE SYSTEM IN CHILE
The HIV/AIDS national surveillance protocol defines a procedure in which HIV testing is
performed on a voluntary basis. Now, prior to take the blood sample, the person must receive
counseling about the disease and sign an informed consent. During the counseling session about
safe sex, the person will be also asked about different sociodemographic aspects to be recorded
in the official form defined by the health authorities. This sociodemographic information,
together with the results of the test, are later included in the online surveillance database.
Table 39 describes in detail the type of information included in the HIV/AIDS database.
Table 39. Information registered in the HIV/AIDS Surveillance System of Chile
Variable
Operational Definition
Values
Reporting date
Date in which the data was uploaded to
the database.
Format dd/mm/yyyy
Region
Region of residence of the client
1;2;3;4;5;6;7;8;9;10;11;12;13;14;15
Sex
Biological sex of the client
Male; Female
Year of birth
Year of birth of the client based in
his/her ID information
Format yyyy
104
(Table 40 continued)
Age
Age in years of the person tested based
on his/her ID information
Open field
Education Level
Self-reported highest education level
achieved by the client
Primary school; Middle school; High
school, Undergraduate/Graduate;
Technical studies; Unknown; None
Occupation
Self-reported primary occupation of the
client
Open field
Nationality
Nationality of the client based on his/her
ID information
Codes according to international
standards
Self-reported ethnicity with respect to
the 9 officially recognized indigenous
groups in the country
If woman, self-reported pregnancy
status of the client at the moment of the
test
Aymara, Atacameño, Quechua,
Diaguita, Colla, Rapa Nui,
Mapuche, Kawashkar; Yagan; None
Sexual Behavior
Self-reported sexual behavior of the
client
Homosexual; Heterosexual;
Bisexual
Sexual Worker
Self-reported sexual worker condition
over the last year
Yes/No
Inmate
Legal status of the client based in
his/her situation at the moment of the
test
Yes/No
Blood Transfusion
Self-reported blood transfusion over the
last 6 months
Yes/No
Injection Drug User
Self-reported endovenous drug use. No
timeframe specified
Yes/No
Number of Sexual
Partners
Self-reported number of sexual partners
over the last year
Open field
Condom Use
Self-reported condom use over the last
year
Always; Sometimes; Never
Work exposition to
the virus
Self-reported occupational exposure to
the virus by the client. No timeframe
specified
Yes/No
HIV positive mother
Is the client an HIV positive mother’s
child?. Self-reported
Yes/No
Ethnicity
Pregnancy Status
Disease classification
Initial disease status
If test positive, classification of the
disease status based on the criteria
established by the CDC in 1993 for
adults and in 1994 for people aged <13
If test positive, disease status at the
moment of diagnosis based on the
criteria defined by the CDC in 1993 and
1994.
105
Yes/No
Adults: A1; A2; A3; B1; B2, B3, C1;
C2; C3
People aged <13: N1; N2; N3; A1;
A2; A3; B1; B2, B3, C1; C2; C3
HIV or AIDS
APPENDIX B
CORRELATION ANALYSIS DATASET
Table 41. Values registered at the regional level for the different variables considered in the correlation analysis
Region
XV
I
II
III
IV
V
RM
VI
VII
VIII
IX
XIV
X
XI
XII
HIV/
AIDS
138.8
73.6
55.6
41.6
38.8
51.2
56.2
30.8
27.8
32.3
27.0
43.0
47.7
21.4
26.7
HIV
AIDS
83.3
45.6
36.9
25.3
22.2
24.5
34.3
15.1
14.7
17.5
13.6
25.2
30.3
21.4
21.6
55.5
28.0
18.7
16.3
16.6
26.7
21.9
15.7
13.1
14.8
13.4
17.8
17.4
0
5.1
Birth
Rate
16.8
17.1
17.1
17.6
14.4
13.4
14.7
14.3
13.9
14.0
14.3
13.9
15.4
16.5
14.0
Mortality
Rate
5.5
3.9
5.0
4.9
5.1
6.7
5.3
5.6
6.0
5.9
6.1
6.4
5.9
4.4
6.1
% <15
% > 64
23.7
25.0
24.7
25.0
23.7
21.6
22.4
23.1
22.9
22.7
23.9
22.9
23.9
25.3
21.5
9.6
6.1
6.2
7.7
9.3
10.4
8.6
8.9
9.0
9.0
9.5
9.7
8.4
6.7
8.5
106
%
immigrants
6.10
6.60
3.70
0.90
0.69
1.24
3.35
0.53
0.44
0.49
0.90
0.90
0.77
1.61
1.55
%
poverty
12.8
15.8
8.0
17.5
16.6
15.1
11.5
12.8
20.7
21.0
27.1
20.4
14.2
15.1
9.1
income
per capita
201647
205420
229196
187141
175525
203680
341023
185510
171600
172958
149051
195073
157205
278626
323090
%GDP
0.6
3.4
11.3
2.4
3.2
8.1
47.9
4.5
3.4
7.9
2.2
1.2
2.5
0.5
0.9
Table 40 continued
Region
%
Unemployment
Gini
Coef.
XV
I
II
III
IV
V
RM
VI
VII
VIII
IX
XIV
X
XI
XII
9.27
6.13
5.80
9.45
7.99
12.01
10.09
7.48
9.16
12.59
13.15
11.29
10.53
6.92
8.26
0.52
0.43
0.45
0.46
0.49
0.48
0.56
0.47
0.50
0.51
0.52
0.51
0.49
0.44
0.50
Gender
Inquality
Index
0.858
0.810
0.812
0.799
0.786
0.805
0.809
0.831
0.802
0.804
0.796
0.796
0.803
0.802
0.811
%
Smoking
42.4
30.7
42.8
41.7
43.9
38.2
46.6
32.1
34.4
33.6
32.4
26.5
40.1
48.5
41.5
%
Alcoholism
Men
23.2
23.2
15.8
10.1
28.3
32.1
22.6
23.6
34.3
29.7
36.5
24.6
24.6
12.3
14.3
%
Alcoholism
Women
7.3
7.3
8.7
1.7
7.4
7.4
2.4
7.1
7.5
9.6
10.3
10.6
10.6
2.1
1.8
107
%
Prostitution
Micro
Trafficking
Macro
Trafficking
Condom
Use
HIV
Misconceptions
11.4
11.4
8.8
3.5
8.1
6.4
9.1
7.0
6.2
8.5
3.1
10.6
10.6
7.6
4.1
11.09
8.88
8.52
2.48
3.30
4.86
5.99
3.06
1.60
1.19
0.61
0.58
0.55
0.91
1.00
2.01
3.15
3.76
1.34
0.91
0.70
0.65
0.79
0.49
0.26
0.25
0.30
0.10
0.30
0.38
41.61
34.42
30.77
35.07
27.23
34.61
353.7
33.67
28.91
29.92
28.52
31.95
31.8
38.28
34.29
18.9
28.7
15.7
17.8
25.5
32.9
17.2
31.1
19.7
24.1
34.8
19.9
28.7
28.4
18.2
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