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HIV & AIDS in the Caribbean

THE CARIBBEAN - 2012 Statistics<br/>Number of people living with HIV: 250,000 | Adult HIV prevalence: 1.0%

In 2011, an estimated 13,000 people in the Caribbean became infected with  HIV, and around 10,000 died of  AIDS. 1 These figures show a 42 percent decline in new infections since 2001, and 48 percent decline in deaths, since 2005. 2 3 After sub-Saharan Africa, the Caribbean has a higher HIV prevalence than any other region in the world, with 1 percent of the adult population infected. 4

HIV prevalence remains above 1.5 percent in The Bahamas, Jamaica, Haiti and Trinidad & Tobago. 5 The region as a whole has been able to achieve 67 percent access to antiretroviral drugs (ARVs) in the general population, and 79 percent access for pregnant women to prevent mother-to-child transmission (MTCT) of HIV. 6 This rivals the achievements made in some high-income countries.

Reflecting global patterns, heterosexual sex is the main route of HIV transmission throughout the region and largely associated with commercial paid sex. 7 Women are particularly vulnerable to HIV infection; more than half of people living with HIV are women. Sex between men is a transmission route that is increasingly reported in the Caribbean. 8

The spread of HIV in the Caribbean has taken place against a common background of poverty, gender inequalities and a high degree of HIV-related stigma. Migration between islands and countries is common, contributing to the spread of HIV and blurring the boundaries between different national epidemics. 9

See our Caribbean statistics page for more data.

HIV transmission in the Caribbean

Unprotected heterosexual sex

The main route of HIV transmission is through unprotected heterosexual sex. Commercial paid sex accounts for a large proportion of the HIV infections via this transmission route. It is thought that the popularity of the region for sex tourists is the main reason for this. Some national AIDS programmes work hard to reduce the risk of transmission among sex workers by providing them with free condoms, HIV testing and counselling. Cuba, Haiti and Jamaica all reach 75-100 percent of their sex workers with HIV prevention programmes. 10

HIV prevalence amongst sex workers varies across the region, from 1 percent in Cuba, up to 17 percent in Guyana. 11 In 2011, Jamaica promoted its ‘Paradise for Real’ - Ministry of Tourism campaign which targeted condom use amongst tourists in order to reduce HIV transmission from or to its sex worker population. 12

Countries with limited HIV prevention programmes for sex workers tend to report higher HIV prevalence among this group, indicating the impact that targeted HIV prevention can have on reducing HIV transmission. The most striking example is Guyana, where prevention programmes reach only 21 percent of sex workers and HIV prevalence in this population is very high at 17 percent. 13

Sex between men

To lessen HIV transmission within this population, prevention programmes targeting MSM are becoming more widespread and effective. Four Caribbean countries achieved 75-100 percent access to HIV prevention programmes for MSM in 2011; The Bahamas, Cuba, Jamaica, and Saint Vincent & the Grenadines. 14

However, the law, homophobia and cultural taboos about men who have sex with men (MSM) remain major barriers to reaching this group with prevention campaigns. Most legal systems in the region ban sex between men. Higher HIV prevalence among MSM has been found in Caribbean countries that criminalise same-sex practices, than in those which do not. 15 For example Jamaica has the highest HIV prevalence amongst MSM in the region and also the highest punishment for same-sex relations, with up to 10 years imprisonment. 16 On the other hand, Cuba legalised same-sex relations in 1979, and the HIV prevalence among MSM there is much lower at 7 percent. 17 18

“Gays and lesbians in Jamaica exist with the possibility that you might be chased, you might be run down, you might be killed because of your sexual orientation, and when a day ends when that does not happen, we give thanks.” Gareth Williams, the Jamaica Forum for Lesbians, All-Sexuals and Gays (JFLAG)” 19

  • In Jamaica, 38 percent of MSM are HIV-positive
  • In Guyana, 19.4 percent of MSM are HIV-positive
  • In Haiti, 18.2 percent of MSM are HIV-positive 20 21

Research shows that voluntary medical male circumcision (VMMC) reduces the risk of becoming infected with HIV. However, to be effective, a circumcised man must also use preventative measures and practice safe sexual behaviour. 22

Drug use

Injecting drug use (IDU) plays a minimal role in the epidemics of most Caribbean countries. The overall numbers of people who inject drugs in this region and the prevalence of HIV among them are unknown, as few countries collect data on this group. 23 Up to seven countries have reported that injecting drug use populations exist, however, efforts to prevent HIV transmission among this group are almost non-existent. Only Puerto Rico, which has reported an HIV prevalence of 12.9 percent among IDUs, provides needle exchange services (NSP) and opioid substitution therapy (OST). 24

Specifically, people who use crack cocaine have been identified as a group at risk of HIV infection across the Caribbean, due to the link between crack cocaine use and high-risk sex. Harm reduction services for people who use crack cocaine exist in a number of countries. 25

  • 5 percent of crack cocaine users in Jamaica are living with HIV
  • 7.5 percent of crack cocaine users in St. Lucia are living with HIV

Laws that make drug use an offence can hinder accurate reporting of people who use drugs, particularly those that inject, and makes it harder for prevention programmes to reach this at-risk group. 26 27

Stigma and discrimination in the Caribbean

Stigma surrounding HIV is considered extremely severe in the Caribbean. This is mainly because of a lack of education on the subject; people are often blamed for contracting HIV, there are many false beliefs about HIV transmission, and HIV is associated with homosexuality. 28 29

Only five of the Caribbean countries have legalised same sex relationships. 30 In the countries where it is illegal, the stigma surrounding homosexuality is heightened which makes it more difficult for them to access HIV services. Some progress is being made in overcoming stigma, particularly through the work of organisations such as:

  • PANCAP Stigma Unit: represents people living with HIV, and collects research about the best practices to fight stigma. 31
  • The Caribbean Broadcast Media Partnership ‘Live Up’ campaign: aims to remove the taboo attached to HIV by talking about it.
  • DfID will complete their HIV/AIDS work on tackling stigma, but will not fund any other aspect of HIV in the region. 32 This suggests it is realised stigma is an area of HIV work that needs focus in the Caribbean.
  • Non-governmental organisations that work with at-risk populations (MSM and sex workers).

“With HIV, because it’s seen as a gay thing, there’s a lot of shame. If someone finds out they are positive, they’re afraid that everyone will assume they are gay, so it’s best to keep it to yourself.” - HIV Positive man, Jamaica 33

HIV prevention in the Caribbean

Voluntary counselling and testing

HIV testing and counselling (HTC) in the Caribbean varies, but is generally quite low. In 2011, only 5 percent of the population was tested for HIV in The Bahamas and Haiti. 34 In small island countries it is important to encourage testing to prevent HIV spreading throughout the population, and between islands in the region. However, figures are higher in Jamaica, as 59 percent of people had an HIV test in 2011. 35

  • Cuba has the lowest, and Suriname has the highest number of HIV tests within at-risk groups
  • MSM HIV testing is as low as 23 percent in Cuba, and as high as 97 percent in Suriname
  • Sex worker HIV testing is as low as 31 percent in Cuba, and as high as 95 percent in Suriname 36

To encourage uptake of HIV testing, the CHAA Eastern Caribbean Community Action Project II is training peer educators how to provide counselling and rapid testing, to heighten access for marginalised communities. This will also relieve testing and counselling pressures on national health centres. The Project currently reaches seven Caribbean countries. 37

Recommended strategies for providing HTC in the Eastern Caribbean have been highlighted in this paper, written by MEASURE Evaluation and USAID.

Providing condoms and information

Condom use is still taboo amongst certain groups in the Caribbean. For example, some female youths have reported condoms as ‘embarrassing’ and 'tainted'. Condoms are also linked to homosexual relations, and so some straight men choose not to use condoms so as not to be associated with that connection. 38 However, condom use among men and women aged between 15-49 in the Caribbean has increased over the last few years.

  • In 2011, in 4 of the 7 reporting Caribbean countries, more than half of the general population reported condom use at last sex 39
  • In 2009, almost all reported less than 50 percent 40

HIV prevalence is much higher among communities living near the bateyes (sugar plantations), than among the population at large in countries such as the Dominican Republic. This is due to a lack of sex education, more apparent sex work, male migrants sharing sexual partners, and a lack of access to national HIV prevention efforts in these communities. 41

“Women wonder what a guy’s been up to if he wants to use one... if you want to use a condom people assume something must be wrong.” - Harry, St. Kitts 42

Preventing mother-to-child-transmission (PMTCT)

  • In 2011, 79 percent of HIV-positive pregnant women requiring treatment for PMTCT in the Caribbean received it 43
  • This is second only to high-income countries
  • Among low- and middle-income countries the figure is only 57 percent 44

Healthcare systems in the Caribbean have been scaling up HIV testing for all pregnant women, and administering the combination therapy approach to treatment. Barbados' have succeeded at PMTCT, as there were no reports of mother-to-child transmission of HIV during pregnancy between 2007-2010. 45 However, there are reports of some HIV-positive mothers are still breastfeeding their babies despite being advised not to, due to fear of their family realising their HIV status. 46

Media campaigns

A poster on a bus in Cuba reads '8 out of 10 people living with HIV in Cuba are men'Caribbean Broadcast Media Partnership - In 2006, the Caribbean Broadcast Media Partnership on HIV/AIDS (CBMP) was born. The initiative focuses around sharing HIV information amongst participating broadcasters, and integrating HIV into programmes, news bulletins and entertainment. 47 It is hoped that openly discussing the epidemic on air will break down stigmatising attitudes and lead to a decline of stigma and discrimination in the region. The corresponding Live Up campaign aims to get young people talking about what they can do to curb the epidemic. 48

"This is the first time broadcasters have come together to combat a social problem. We have a unique opportunity to leverage the communication power of our media platforms to raise awareness, fight stigma and intolerance, and support people already living with [HIV].” - Allyson Leacock, general manager of the Caribbean Broadcasting Corporation (CBC) 49

Jamaica’s campaigns - Jamaica ran several media campaigns between 2010-2011, promoting faithfulness, condom use and gender specific behaviours in Jamaica. Amongst them were ‘Stick to ONE Partner’; ‘Pinch, Leave an Inch and Roll’; and ‘Real Man Nuh Ride Widout Condom’. 50 Their catchy titles, informal nature and target of one specific audience is evidence of the country’s drive to eliminate HIV transmission.

HIV/AIDS education in schools

HIV education is needed to inform young people about HIV transmission, HIV testing and the benefits of early diagnosis. Young people aged 15-24 were previously considered a vulnerable group to HIV in the Caribbean, but efforts to include sex education in school curriculums has changed this. There has been a 35 percent drop in HIV prevalence amongst young Caribbean people between 2001-2011. 51

Despite this, testing uptake is especially low among male, rural and younger youth. 52 This emphasises the value of youth groups and community organisations which are an alternative source of HIV information for non-school attendees.

The Pan Caribbean Partnership Against HIV/AIDS (PANCAP)

The Pan Caribbean Partnership Against HIV/AIDS (PANCAP) directly responds to the HIV crisis by co-ordinating prevention and treatment efforts between governments, non-governmental organisations, faith-based organisations and donor agencies within the Caribbean. 53

PANCAP works in collaboration with the Caribbean countries to procure funding from various organisations, including PEPFAR and DfID. 54 In 2002, the power of collective bargaining enabled PANCAP to negotiate for cheaper drugs from six major pharmaceuticals, making treatment cheaper and more accessible in the Caribbean ever since. 55

HIV treatment in the Caribbean

  • In 2011, 67 percent of people in need of antiretroviral treatment in the Caribbean received it 56
  • This is substantially higher than the global figure of 54 percent 57
  • Countries achieving universal access to treatment include Cuba (>95 percent), Dominican Republic (80 percent) and Guyana (82 percent) 58

This high access to treatment was achieved in line with the 2010 WHO updated guidelines of administering ARVs to persons with a CD4 count of 350 cells/mm3 or less, rather than the previous recommendation of 200 cells/mm3. 59 Despite this achievement, greater commitment is needed to ensuring treatment supplies remain consistent; 54 percent of Latin American and Caribbean countries reported at least one ‘stock-out’ of ARV medicine during 2011. 60

Countries with low ARV treatment access include The Bahamas, which provides treatment to only 40 percent of those in need. 61 The Commonwealth of The Bahamas believes the gap in treatment is a result of stigma, which restricts people from seeking treatment, and increased demand to the National HIV Centre pharmacy. 62

The way forward

Stigma and discrimination in the Caribbean negatively affects progress in curbing the spread of HIV. Continued homophobia prevents MSM being able to access HIV services. The blame that surrounds HIV deters people from getting tested or accessing treatment and care.

Prevention initiatives, such as the Caribbean Broadcast Media Partnership, must be expanded across more communities to keep HIV a talking point and not a hidden issue.

To truly understand how to respond to an epidemic, countries must understand the characteristics of their own situation. However the lack of data on certain high-risk groups indicates gaps in the HIV response of certain Caribbean countries. A combined HIV prevention approach is needed if recent gains are to be sustainable.

 

References

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