The Caribbean has an adult HIV prevalence of 1.1%, with the highest prevalence of 3.2% found in the Bahamas. Although new HIV infections declined by 40% from 2005 and 2013, there were still an estimated 12,000 new HIV infections and a total of 250,000 people living with HIV in the region in 2013.1
Five countries account for 96% of all people living with HIV in the region: Cuba, the Dominican Republic, Haiti, Jamaica and Trinidad and Tobago. Access to antiretroviral treatment (ART) has improved significantly with coverage currently at 42% of people 15 years or older living with HIV in the Caribbean – an increase of 31% since 2011.2
Concomitantly, the number of AIDS-related deaths in the region fell by more than half (54%). AIDS-related deaths however remain highly concentrated; with 98% occurring in five countries—the Bahamas, the Dominican Republic, Haiti, Jamaica and Trinidad and Tobago. Haiti alone accounted for 59% of all AIDS-related deaths in the region during 2013.3
The Pan Caribbean Partnership against HIV and AIDS (PANCAP), is an umbrella organisation that functions and coordinates the regional response to bring together national HIV programmes with international and regional partners. PANCAP’s principal remit is to foster cooperation and facilitate access to regional public goods and services that support the region’s response to the epidemic, guided by the Caribbean Regional Strategic Framework.4
Key affected populations in the Caribbean
The HIV and AIDS epidemic is disproportionate in the Caribbean, with certain groups bearing a higher burden than others. The key populations at higher risk of HIV infection, like other regions; remain gay, transgender and other men who have sex with men (GTM), female and male sex workers and their clients, young people, and people living with HIV. For example, men who have sex with men in the Caribbean are well documented to be up to 20 times more likely to be living with HIV than people in the general population.5
The epidemic is exacerbated by a range of socio-cultural realities including high levels of stigma and discrimination, alongside gender inequities and gender-based violence, and on-going challenges associated with multiple concurrent partnerships and intergenerational sex.6 7
Additional factors that affect key populations are high cross boarder mobility and an inherent tension between the role of the church in setting social norms, and cultural attitudes and practice of sexual expression. High levels of poverty and unemployment and under-employment, especially among youth and women in some countries within the region, also impact their vulnerability to HIV. These factors contribute to the marginalisation of these populations, often driving them ‘underground’, making it harder for them to access HIV interventions and services.8
Men who have sex with men in the Caribbean
In the Caribbean, unlike other regions, men who have sex with men (MSM) and transgender people are categorised as one group, rather than splitting the data into two. This gives a distorted view as to the effects of the HIV epidemic on the two groups, when in fact they experience different barriers and challenges.
Gay, transgender and other men who have sex with men experience high levels of HIV prevalence across the Caribbean. Data modelling suggests that in the Caribbean, MSM are assessed as being between 6 and 30 times more likely to be infected with HIV than members of the general population.9 The elevated HIV prevalence among MSM is especially striking when compared to the consistently low HIV prevalence (below 1%) among the general population in most of the region.10
Data from Jamaica shows that more than 30% of gay, transgender and other men who have sex with men are HIV-positive.11 HIV prevalence is also high among gay men and other men who have sex with men in the Bahamas, Belize, Dominica, Guyana, Haiti and Saint Vincent and the Grenadines.12
MSM remain a high-risk population in the Caribbean due to discrimination on the basis of sexual orientation and homophobia. Caribbean culture is heteronormative and often rejects homosexuality – depicting violence and strong socio-cultural disapproval. MSM therefore may not self-identify, or may engage in heterosexual or bisexual relationships as a means of keeping their practices hidden, thereby reducing their risk of violence and discrimination.13
Factors influencing stigma and discrimination against MSM include:
- religiously and socially conservative views (for example, societal homophobia)
- strong influence of faith-based organisations
- limited social spaces for men who have sex with men
- sodomy (buggery) laws challenge the right to equality.14
For much of the region, sex between men is illegal. While seldom enforced, existing legislation has the impact of institutionalising discrimination against MSM.15
Sex workers in the Caribbean
Sex workers are an established key affected population for HIV, with a high burden documented in female, male, and transgender sex workers.16
Sex work remains highly stigmatised in the Caribbean and is regarded as illegal in all English speaking countries. However, sex work is not specifically referenced in any law and the exchange of sexual services is not a criminal offence in the legislation of any Caribbean country. There are however, a range of laws that vary by nation, criminalising activities associated with the exchange of sex for money. This includes for example vagrancy, lewdness or public indecency. This has been a key contributing factor to the HIV prevalence among sex workers which remains high in some parts of the Caribbean.17 For example, recent data indicates that HIV prevalence among female sex workers in Haiti is 8.4%.18
Within the region sex workers are diverse, and come from a range of socioeconomic, ethnic, and regional backgrounds. In some countries, particularly within the Eastern Caribbean, sex workers are often mobile or undocumented migrants and work in a variety of settings, including brothels, bars, or on the street.19
Sex workers experience a range of human rights violations and social injustices including the denial of access to healthcare, poor working conditions, violence, and harassment by law enforcement. Sex workers are also frequently marginalised by social and religious institutions and subject to discrimination. For these reasons, many persons who engage in sex work do so covertly. These factors are significant barriers to HIV prevention and successful service delivery for sex workers in the Caribbean.20
Beyond services and interventions undertaken by civil society organisations with external funding, there are no comprehensive health programmes targeting sex workers in the CARICOM region despite large and diverse sex worker communities. Traditional programming for sex workers is aimed almost exclusively at female sex workers. However, the sex worker community also includes men who sell sex to women, men who sell sex to men, and transgender sex workers.21
Young people in the Caribbean
Over 40% of the Caribbean population is under 24 years of age, reflecting the huge number of people in this key affected population.22
The 2013 WHO Global School-Based Student Health Survey (GSHS) found that 56% of girls and 79% of boys have sex before the age of 14, and on average 38% of adolescents 13 – 15 years of age did not use a condom at last sexual intercourse.23
Additionally, data and some anecdotal evidence has also shown that women and girls are particularly vulnerable with many countries reporting increasingly early sexual initiation, along with consistently high numbers of teenage pregnancies and deliveries. This often correlates with higher levels of HIV infection among young people, particularly young females.24
Further, in many Caribbean countries, multiple adolescent pregnancies occur among girls from the lower socioeconomic brackets, indicating a lack of access to sexual and reproductive health services. The vulnerability of young women is also captured in the HIV prevalence for this group. The number of young women living with HIV is 1.2 times higher than the number of young men living with HIV. In Haiti for example, HIV prevalence among young women aged 15-19 years is 0.5%, more than double the figure for young men of the same age. Additionally, women aged 20–24 are three times more likely to be HIV-positive than men of the same age.25
HIV testing and counselling (HTC) in the Caribbean
Increasing the uptake of HTC services remains a critical prevention intervention, and key to the goal of universal access to treatment and reducing the transmission of HIV. There is significant variation in estimates of HIV testing coverage across national reporting, and limited data on uptake of testing among key populations due to inadequately disaggregated data or inconsistencies in data collection.26
The main HIV testing strategy utilised in the Caribbean has been voluntary counselling and testing (VCT) through static healthcare facilities and requires people to initiate testing on their own. Additionally, countries typically use blood drawn samples, which usually require a two-week waiting period between testing and receipt of results. This mode of testing, in addition to not reaching the most vulnerable, means there is a high rate of failure to return for results.27
Some countries have been utilising rapid testing technologies, however this has not been brought to scale. Led by the Pan American Health Organisation (PAHO), Provider Initiated Testing and Counselling (PITC) has been promoted in the region, however this has not been fully rolled out. For the Eastern Caribbean area, peer based community testing has been particularly beneficial in supporting uptake of services among populations at higher risk of infection.
Structural barriers to HTC including age of consent rules, lack of confidentiality and disclosure issues also remain challenges for the region. Alternative approaches and strategies including point-of-care rapid testing and task shifting to non-clinical providers that actively “seek, test, and treat” are needed to augment the number of people tested. This will also enable the region to reach first time testers and persons with the greatest risk of exposure to HIV with quality testing services more effectively.28
HIV prevention in the Caribbean
The Caribbean has well-established prevention of mother-to-child transmission of HIV (PMTCT) programmes. The percentage of HIV-positive mothers on antiretroviral treatment increased from 72% in 2011 to more than 95% in 2013, with many more women and infants in the region now receiving the HIV-related services they need.29
This increase reflects the acceleration of investment and programmatic efforts in support of the elimination initiative to end vertical transmission and congenital syphilis in the region.30
The Bahamas has experienced outstanding success with its PMTCT programme. There were only two cases of mother-to-child transmission in 2013, and no cases among pregnant women who adhered to their PMTCT ART drugs. This achievement is attributed to high ART coverage during pregnancy (91%); the administration of intravenous antiretroviral drugs during pregnancy and labour at hospital; oral prophylaxis given to new-born babies for six weeks; infant testing within two months (96%); and frequent counselling about ART adherence and the risks of breastfeeding at all postnatal appointments.31
Antiretroviral treatment in the Caribbean
Increased access to antiretroviral treatment (ART) over the last few years has led to a 30% drop in AIDS-related deaths from the peak in 2005. For the Caribbean, treatment coverage in 2013 was estimated at 42%, with 221,710 people eligible for treatment receiving it, based on the 2013 WHO Treatment Guidelines of a CD4 count of 500 and below.32
Financing the response has also become increasingly challenging for many countries as donor funding has decreased or in some cases ended, and domestic spending on HIV has yet to reach the levels needed to sustain the national response. Improved coordination at the national and regional levels is needed to increase the proportion of people living with HIV retained in care and achieve viral suppression, in order to reduce new HIV infections and also improve their quality of life.33
Barriers to HIV prevention in the Caribbean
Despite its small population size, the Caribbean has the second highest HIV prevalence globally after sub-Saharan Africa.34 Particularly within the last decade, the region has recorded significant progress in reducing new infections and increasing access to services. However, significant gaps remain in the coverage and quality of HIV prevention, care, and support services and AIDS remains a main cause of mortality for the region.
Within the Caribbean the HIV epidemic is intensified by a range of socio-cultural factors including high levels of stigma and discrimination and inherent tensions between the role of religious institutions in setting social norms and cultural attitudes particularly in relation to the practice of sexual expression. These feature alongside complex gender inequities and on-going challenges associated with gender-based violence. These factors are also compounded by economic realities linked to unemployment and under-employment, especially among youth and women, and high levels of poverty, which contribute to high risk behaviours such as multiple concurrent partnerships and transactional sex.35 36
Caribbean countries also continue to contend with financial and human rights barriers to eliminating new HIV infections, AIDS-related deaths and discrimination. Key issues such as stigma and discrimination, access to services and the absence of legal and social protection of sub-populations remain challenges.
Worryingly, support for HIV prevention programmes has decreased in some countries. For example, in Trinidad and Tobago, the number of HIV prevention activities reported has significantly decreased between 2004 and 2010. Although the National AIDS Coordinating Committee is trying to reach out to the most vulnerable, there is little political support and funding for these efforts. 37% of Trinidad and Tobago’s $11 million national budget went to prevention, but most of this (95%) supported prevention activities within the general population, and was not directed at key populations who are most affected by HIV.37 This is even more evident in the sub-region of the Eastern Caribbean, where withdrawal of donor funding puts at risk the capacity of individual countries to finance their national HIV responses.38 39
The future of HIV and AIDS in the Caribbean
One of the biggest challenges for the region will be increasing access to HIV testing and treatment. Countries have acknowledged the public health necessity and cost saving benefits of initiating treatment earlier, however most countries in the region do not seem positioned to achieve this.
Additionally, innovative strategies to reach and provide services to key populations, where the HIV epidemic is concentrated also need to be developed. Critically, Caribbean countries will need to revaluate their funding needs particularly based on HIV treatment requirements and the need for sustainable responses.
Key priority actions for the regional response include:
- expansion of effective and appropriate services for key populations and people living with HIV, to protect their health and reduce the risk of HIV transmission
- implementing effective responses to reduce stigma and discrimination in the health sector – including addressing sexuality and sexual diversity in service delivery
- increasing the number of people with HIV that know their status and decreasing late diagnosis
- increasing the number of people on ART – and achieving suppressed viral loads.40 41
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- 10. Avrett, S (2012) ‘Men Who Have Sex with Men and HIV in the Anglophone Caribbean: A Situation Review’. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One,Task Order 1
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- 16. Decker, M. R., et al (2014) ‘Human rights violations against sex workers: burden and effect on HIV’, The Lancet, Vol. 385, No. 9963, p186–199 Published online: July 21, 2014
- 17. Greenberg, J., (2012) ‘From Tolerance to Rights: HIV and Sex Work Programs in the Caribbean - Effective Models and Opportunities for Scale Up’
- 18. UNAIDS (2014) 'The Gap Report'
- 19. Kerrigan, D., et al (2014) ‘A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up’, The Lancet, Vol. 385, No. 9963, p 172–185. Published online: July 21, 2014
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- 21. UNAIDS (2010) ‘The Status of HIV in The Caribbean’
- 22. UNAIDS (2014) 'The Gap Report'
- 23. WHO Global School-based Student Health Survey (GSHS), cited in UNAIDS (2014) ‘The Gap Report’
- 24. UNAIDS (2014) 'The Gap Report'
- 25. UNAIDS (2014) 'The Gap Report'
- 26. UNAIDS (2014) 'The Gap Report'
- 27. Andrinopoulos, K., et al (2013) ‘Strategic HIV Testing and Counseling Models for the Eastern Caribbean’
- 28. Andrinopoulos, K., et al (2013) ‘Strategic HIV Testing and Counseling Models for the Eastern Caribbean’
- 29. UNAIDS (2014) 'The Gap Report'
- 30. UNAIDS (2014) 'The Gap Report'
- 31. The Bahamas Ministry of Health (2014) ‘The Commonwealth of The Bahamas Country Report 2014’
- 32. UNAIDS (2014) 'The Gap Report'
- 33. UNAIDS (2014) 'The Gap Report'
- 34. UNAIDS (2014) 'The Gap Report'
- 35. Allen, C, (2012) ‘Addressing the Links Between Gender-Based Violence and HIV in the Caribbean: Summary of Research and Recommended Actions’
- 36. Avrett, S (2012) ‘Men Who Have Sex with Men and HIV in the Anglophone Caribbean: A Situation Review’. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One,Task Order 1
- 37. AIDSTAR-One (2011) ‘PEPFAR Caribbean Regional HIV Prevention Summit On Most- At-Risk Populations And Other Vulnerable Populations. Nassau, Bahamas, March 15–17, 2011’
- 38. UNAIDS (2014) 'The Gap Report'
- 39. UNAIDS (2013) ‘Global Report 2013’, UNAIDS / JC2502/1/E- Revised and reissued, November 2013
- 40. UNAIDS (2014) 'The Gap Report'
- 41. UNAIDS (2013) ‘Global Report 2013’, UNAIDS / JC2502/1/E- Revised and reissued, November 2013