HIV and AIDS in the Caribbean

In 2008 an estimated 20,000 people in the Caribbean became infected with HIV, and around 12,000 died of AIDS. After sub-Saharan Africa, the Caribbean has a higher HIV prevalence than any other area of the world, with 1.0% of the adult population infected.¹

An overview of AIDS in the Caribbean

Due largely to their close geographic locations, the Caribbean is usually grouped with Latin America in discussions about HIV and AIDS, but the epidemics in these regions are very different. Even within the Caribbean, each country faces a unique situation. The diversity of the region – which is apparent in terms of politics, languages spoken, geographic location and wealth – is reflected in the significantly different ways that countries are affected.
At one extreme, the Bahamas has the highest HIV prevalence in the entire western hemisphere (3%); at the other, Cuba has one of the lowest (0.1%). Trinidad and Tobago (1.5%) and Jamaica (1.6%) are heavily affected, while Puerto Rico is the only Caribbean country apart from Cuba where it is thought that less than 1% of the population is living with HIV.² Other factors, such as AIDS mortality rates and transmission patterns, also vary across countries and areas. See our Caribbean statistics page for more data.
Before Haiti's devastating earthquake in January 2010, an estimated 2.2 percent of the population were living with HIV. Haiti's AIDS epidemic is one of the most severe in the Caribbean. Before the earthquake an estimated 126,800 people under the age of 49 were living with the virus, which included 6,800 children; and an estimated 19,000 people were receiving antiretroviral drugs (ARVs). Since the earthquake, thousands of people will still be in need of ARVs, and the priority for AIDS organisations is to get the medication to those in need. It is also critical that HIV prevention, treatment, care and support services are resumed.³

“Haiti's AIDS epidemic is one of the most severe in the Caribbean”

Prior to Haiti's earthquake there were signs of decreasing HIV infection levels, which were partly attributed to an increase in condom use and changes in sexual behaviour. Similarly, in the Dominican Republic prevalence fell from 1% in 2002 to 0.8% in 2007. However, HIV surveillance in the Caribbean is generally considered inadequate, so these reported trends are only vague indicators. Both HIV prevalence and AIDS cases are thought to be widely underestimated in the region.⁴
Reflecting global patterns, heterosexual sex is now the main route of transmission throughout the region, and it has been established that women and young people are particularly vulnerable.⁵ Little is known about the role that sex between men plays in the region’s epidemics – it has been estimated that men who have sex with men account for 12% of infections, but it is thought that the actual proportion is higher than this, since the rampant homophobia that exists throughout the region has led to denial and under-reporting.⁶
Despite differences between countries, 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.⁷ Additionally, poor availability of HIV and AIDS data makes it difficult to gain a clear picture of each country’s situation.

Responding to the crisis

AIDS activists in Haiti

Since countries in the Caribbean face common problems, and resources are limited, the need for a coordinated response to HIV and AIDS has long been recognised. The Pan Caribbean Partnership Against HIV/AIDS (PANCAP) was established in 2001, with the aim of preventing the spread of HIV and alleviating the suffering it causes across the Caribbean. PANCAP has brought together governments, non-governmental organisations, private sector groups, faith-based organisations and donor agencies to co-ordinate both prevention and treatment efforts.⁸ It has also helped to establish a Caribbean Regional Strategic Framework for HIV/AIDS, under which PANCAP members have made significant progress in drawing attention to the crisis and establishing dialogue between separate groups. In 2004 PANCAP was named a ‘best practice’ response by the Joint United Nations Programme on HIV and AIDS (UNAIDS).⁹
Some strong responses have been formed on a local level, too: most nations have developed National AIDS Commissions, strategic plans, legislation and HIV-related programmes and services.^{10 11}
However, since most countries in the region are limited by poor public infrastructure and fragile economies, acting out these responses has been difficult. Political leadership has also been varied. Many Caribbean islands are heavily dependent on tourism, and in some areas officials are reluctant to draw attention to the problem of AIDS for fear that this might discourage visitors.¹² This is exactly what happened to Haiti in the early 1980s, when it was established that a number of early cases of HIV in the United States had occurred among Haitian immigrants. Since AIDS had only recently emerged, people were quick to associate this new problem with Haiti:

“It was a disaster, the tourism industry died. Nobody wanted to come here. Even the Haitians in the United States were afraid to come” Jean Pape, founder of GHESKIO AIDS clinic in Haiti¹³

As well as concerns about tourists, fears about local opinions may also be obstructing political action. Many politicians have been vocal about the impact of the problem and the need to take action, but HIV and AIDS are heavily stigmatised in all Caribbean countries and this is limiting public demand for political initiatives.¹⁴ Traditional, religious and cultural norms prevent people from talking openly about HIV and AIDS in most countries, and create a situation where misinformation and prejudice thrive. It is hard for officials to properly address the issue in this climate, and politicians are sometimes reluctant to publicise the true nature of their AIDS epidemics. This may be influencing the lack of HIV surveillance and monitoring in the area.

HIV Prevention in the Caribbean

Numerous different approaches have been taken to preventing HIV in the Caribbean. Some programmes have achieved significant success, but the barriers of poverty and insufficient resources continue to limit HIV prevention throughout the region.¹⁵
It is difficult to give an overall assessment of how successful HIV prevention has been in the Caribbean, but the examples below give an indication of the achievements that have been made in certain areas.

Voluntary counselling and testing

In general, experts recommend that testing for HIV should occur with the consent of individuals involved, and should be complemented by counselling. Most countries in the Caribbean have opened voluntary counselling and testing (VCT) centres, and international agencies such as USAID and the Global Fund to Fight AIDS, Tuberculosis and Malaria have provided grants to expand such services in a number of countries.¹⁶
In the past, Cuba adopted the controversial approach of adopting mandatory testing among certain groups, such as pregnant women, hospital patients and inmates of prisons. If found HIV positive, individuals were taken to sanatoriums, where they were provided with care and support while their sexual partners were traced. The rules have relaxed in recent years: it is no longer compulsory for HIV positive people to stay at sanatoriums following an eight week probationary period, and testing is now generally voluntary, with the exceptions of blood donors and prisoners.¹⁷
Although Cuba’s approach has been questionable in terms of human rights, it has certainly worked – infection rates have remained exceptionally low. Additionally, reports suggest that the sanatoriums are far from the restrictive institutions that people have sometimes portrayed them to be. Even now that it is not compulsory, many HIV positive people choose to remain at the sanatoriums due to the quality of care and support that they receive.¹⁸

Providing condoms and information

Before the earthquake in Haiti, the Foundation for Reproductive Health and Family Education (FOSREF, a non-profit organisation established in 1989) provided basic training on reproductive health, including HIV and AIDS, to 500 teachers, 6,500 young workers, and 30,000 young volunteers who disseminate information to their peers. As a result, a large number of people were using condoms, and there was evidence of sexual behaviour change and reductions in HIV prevalence where the programme had been carried out. In 2006, FOSREF was awarded a United Nations Population Award for its work.¹⁹

On the other side of the Hispaniola Island, HIV prevalence has receded in the Dominican Republic. This decline is largely attributed to effective prevention campaigns, which have encouraged people to use condoms and reduce their number of sexual partners.²⁰ In the capital city of Santo Domingo, sustained efforts to promote consistent condom use and safer sexual behaviour among sex workers and their clients have been linked to decreasing HIV prevalence among pregnant women.²¹
There are still, however, major gaps in the Dominican Republic’s prevention programmes. In the bateyes - shanty towns, which are disproportionately affected by HIV – prevention tools such as condoms and information are not generally available. Researchers argue that the Dominican government’s response to HIV/AIDS has been weak and that investment in HIV/AIDS programmes is falling short.²²
Condom use is still stigmatised in many parts of the Caribbean. Many people are often too embarrassed to buy condoms from shops, and even to use them with their partners:

“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. Kitts²³

Preventing mother-to-child-transmission

Most countries in the Caribbean have taken steps to prevent mother-to-child-transmission of HIV. Cuba’s mother-to-child-transmission programme is one of the most effective in the world; all pregnant women are tested for HIV, and those that test positive are provided with antiretroviral drugs to reduce the risk of transmission. This scheme has helped to keep the total number of HIV-positive babies below 100.²⁴
In Barbados and the Bahamas, a combination of increased voluntary counselling and testing services and improved access to antiretroviral drugs has helped to significantly reduce the rate of mother-to-child-transmission.²⁵
AVERT is currently calling for improvements in PMTCT services worldwide through our Stop AIDS in Children campaign.

Media campaigns

In 2005, television and radio broadcasters in the Caribbean united to form the Broadcast Media Partnership on HIV/AIDS. This was followed by the announcement in August 2006 that a group of international donors - the Henry J. Kaiser Family Foundation, the Ford Foundation and the Elton John AIDS Foundation – would provide US$1 million to initiate the project. Participating broadcasters have promised that 12 minutes of airtime every day will be dedicated HIV/AIDS related programming, and that this coverage will include news, documentaries, dramas and other formats.

"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)²⁶

Some programmes have already been aired, and a website has been established. It is expected that the partnership will become fully operational during 2007.²⁷

HIV/AIDS education in schools

In 2002, ministers from several Caribbean countries convened in Havana, Cuba, to agree upon a commitment to HIV/AIDS education:

"We, the Ministers of Education of the Caribbean… recognize that education is integral to the fight against AIDS, and that the disease will not be overcome without the full involvement of the education sector." Havana Commitment of Caribbean Ministers of Education, November 2002²⁸

But while political commitment is seemingly in place, poverty and a lack of resources have generally hindered progress. Many children have no access to school education, particularly in rural areas, which are often acutely affected by HIV.²⁹ Cuba is the only Caribbean country that has made sex education mandatory at all levels of teaching, from preschool to university.³⁰

HIV prevention among risk groups in the Caribbean

“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”

Gareth Williams, JFLAG

There is a general lack of HIV prevention campaigns targeting sex workers and men who have sex with men in the Caribbean – two key risk groups in the region. These are hidden populations, which are highly stigmatised and not generally recognised as part of mainstream society.
HIV prevalence amongst men who have sex with men (MSM) varies between Caribbean countries. In Cuba MSM account for 80% of all reported HIV cases. Dominica (70%), Trinidad and Tobago (20%) and the Dominican Republic (11%) report a high percentage of infection among this group.³¹ Homophobia and cultural taboos about sex between men are major barriers to reaching this group with prevention campaigns. A good example is Jamaica, where groups attempting to provide HIV-related services to men who have sex with men have faced harassment from both the public and the police. In November 2005, Steve Harvey, head of Jamaica AIDS Support - a group that works with gay and bisexual people affected by HIV – was kidnapped and killed when it was discovered that he was homosexual.³²

“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)³³

This problem is not helped by Jamaica’s legal system, which bans sex between men. Such laws exist in most countries in the region. UNAIDS reports that, of the Caribbean countries that submitted data for its 2006 global report, over three-quarters had laws that may hinder the provision of prevention and treatment services to vulnerable and high-risk populations. This includes banning sex between men and not providing condoms to certain groups, such as prisoners.³⁴
Prevention is also lacking among commercial sex workers. The Caribbean is a popular destination for sex tourists, and several countries, such as the Dominican Republic, Jamaica and Trinidad and Tobago, have reported that sex tourism is linked to rising infection rates in certain areas.³⁵ Commercial sex work involving local clients also plays a significant role in some areas.³⁶
Injecting drug use, although a prominent factor in the spread of HIV worldwide, plays a minimal role in the epidemics of most countries in the Caribbean. The exceptions are Bermuda and Puerto Rico. In Puerto Rico, experts argue that there is an urgent need for more needle exchanges and methadone treatment clinics, which have proved efficient in lowering transmission rates among injecting drug users in other countries around the world.³⁷

Stigma and discrimination in the Caribbean

HIV-related stigma and discrimination are extremely common in the Caribbean. In some cases, prejudice towards people living with HIV is linked with homophobia; sex between men carries a high risk of HIV transmission and, as elsewhere, people in the Caribbean often associate HIV with homosexuality, despite the fact that the majority of infections occur through heterosexual sex.

“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, Jamaica³⁸

In other cases, HIV is stigmatised because of general cultural taboos about sex, and unfounded fears that infection can be passed on through everyday contact.

“Why are my friends treating me this way? What could I have done to stop my mother dying of AIDS? I miss her so much and now nobody will talk to me.” Schoolgirl from the Caribbean³⁹

The effects of this prejudice are numerous. For one thing, it causes a great deal of stress and suffering to people who are living with HIV and their families, who often face social isolation and harassment. In another sense, stigma stops people who are at risk of infection from accessing information on prevention and testing, and reduces people’s willingness to buy condoms or alter their sexual behaviour. It also prevents people from accessing counselling services, support groups and treatment.

“Why are my friends treating me this way? What could I have done to stop my mother dying of AIDS? I miss her so much and now nobody will talk to me.”

Schoolgirl from the Caribbean

“I don’t want them [my neighbours] to think I am one of those people.” HIV positive woman, Guyana⁴⁰

It is generally acknowledged that stigma and discrimination are helping to fuel the HIV epidemics of Caribbean countries. Some progress is being made in overcoming this problem, particularly through the work of organisations of people living with HIV and non-governmental organisations that work with vulnerable populations.⁴¹ Many HIV prevention campaigns include anti-stigma messages.
At the same time, there is still an urgent need for stronger and more co-ordinated efforts to fight this problem. Since HIV-related stigma is often linked with negative attitudes towards marginalised groups, there is a particular need for government officials to review legislation that may be fuelling discrimination against such groups, such as laws against sex between men.⁴²

AIDS treatment in the Caribbean

The provision of antiretroviral drugs (ARVs), which delay the progression from HIV to AIDS, has been a major challenge for countries in the Caribbean, primarily due to the high price of the treatment.
In 2002, important progress was made when PANCAP signed a deal with six pharmaceutical companies that reduced the price of ARVs for all Caribbean countries.⁴³ Significant gains have been made in many countries since this agreement was signed; an estimated 51% of people needing antiretroviral treatment in the region are receiving it.⁴⁴

An HIV positive woman appealing for help
to afford HIV treatment in Jamaica

Progress however, has been uneven. Cuba is the only country in the region with universal access to ARVs, an achievement made easier by a low national HIV prevalence. For years, however, Cubans had no access to the medication because of the U.S. embargo that prevents the government from trading with U.S. pharmaceutical companies and their foreign-based subsidiaries. To overcome this problem, Cuban scientists began to manufacture generic versions of ARVs in 2001.⁴⁵ Today, the supply of these generic drugs is plentiful enough to cover everyone who needs them. The Cuban government has also offered to provide other Caribbean countries with ARVs, and to send them doctors and nurses to help in their fight against AIDS.⁴⁶
ARVs were first made available on a small scale in Haiti in 1998, when the U.S. organisation Partners in Health helped to launched a community-based scheme that trained and employed local Haitians to administer ARVs and provide support to those taking them.⁴⁷ As the poorest country in the Western Hemisphere, Haiti’s government could not afford to distribute treatment without help, and so from 2002, the Global Fund to Fight HIV, Tuberculosis and Malaria, along with other international organisations, provided funding for the programme. While only 41% of those needing ARVs in Haiti were receiving them by the end of 2007, this was double the amount that had access in 2005, and four times the figure for 2004.^{48 49 50}
In the aftermath of Haiti's earthquake it emerged that stocks of HIV treatment and prevention supplies had been destroyed. In response, Michel Sidibé, Executive Director of UNAIDS stated:

"We are seeing real suffering. It is in moments like this where those most at risk are forgotten. We must ensure that the marginalized members of our communities have access to HIV prevention, treatment, care and support services" ⁵¹

Unfortunately in the Dominican Republic the commitment to treatment provision has generally been lacking. Critics argue that the government’s treatment programme has been slow and inefficient, particularly in poorer areas:

“People with AIDS in the bateyes are dying without any kind of help.” Sister Concepcion Rivera, nurse, Dominican Republic⁵²

The way forward

There is still a long way to go before HIV and AIDS are under control in the Caribbean. Gaps exist in testing, treatment and prevention programmes, and stigma and discrimination are having a devastating effect. National responses to the crisis are generally lacking, though often as a result of weak public infrastructures and human capacity, rather than a lack of political will.⁵³ Additionally, monitoring and reporting of the epidemic is consistently poor, which makes it difficult to gain an understanding of the crisis and consequently holds back HIV prevention campaigns.
Nonetheless, there is some cause for optimism. Through PANCAP, countries in the region have proved that they can work together to make important headway, in terms of both treatment and prevention, and it is likely that the full potential of this collaboration has yet to be realised.⁵⁴ There are several success stories in the region: take Cuba’s 100% treatment coverage, or the progress made in preventing mother-to-child-transmission in Barbados. On top of this, continued support from international agencies such as USAID and the Global Fund to Fight HIV, Tuberculosis and Malaria will make a big difference in coming years. The involvement of such groups has encouraged political leaders to speak out more about HIV and AIDS.
These successes should be celebrated, but it is important that the severity of the Caribbean’s epidemics is not overlooked. Both within the Caribbean and amongst the international community, a greater level of discussion and decision-making is needed to fight the spread of HIV in the region.

References

1. UNAIDS (2009), '2009 AIDS epidemic update'.
2. UNAIDS 2008 Report on the global AIDS epidemic
3. UNAIDS (2010, 29th January) 'Building Haiti's AIDS response better'
4. UNAIDS 2008 Report on the global AIDS epidemic
5. UNAIDS (2009), '2009 AIDS epidemic update'.
6. UNAIDS 2008 Report on the global AIDS epidemic
7. The World Bank (2005), HIV/AIDS in the Caribbean region: a multi-organization review
8. PANCAP, press release (April 20th 2006)
9. UNAIDS press release (December 12th 2004), ‘Pan Caribbean Partnership Against AIDS Selected As International Best Practice’
10. CARICOM/PANCAP (March 2002), ‘The Caribbean Regional Strategic Framework for HIV/AIDS 2002-2006’
11. UNAIDS (2004), UNAIDS at Country-level: Progress Report 2004’
12. Frasca T. (2005), ‘AIDS in Latin America’, Palgrave/Macmillan, p.144
13. Cohen, J. (2006), ‘Haiti: Making Headway Under Hellacious Circumstances’, Science Vol. 313 Issue 5786, 28th July 2006
14. Yorke L. (March 2002), ‘Losing Paradise?’, Focus, magazine of the Joint Center for Political and Economic Studies
15. Fraser H. (2004), ‘Health and Wealth in Paradise’, Perspectives in Health – The magazine of the Pan American Health Organisation, Volume 9, Number 2
16. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Scaling up the Regional Response to HIV/AIDS Through the Pan Caribbean Partnership Against HIV/AIDS, round 3, proposal summary
17. Fink S. (May 2003), ‘Cuba’s Energetic AIDS Doctor’, American Journal of Public Health, 93(5):712-716
18. Zipperer M. (July 2005), ‘HIV/AIDS Prevention and Control: the Cuban Response’, The Lancet Infectious Diseases, Volume 5, Issue 7
19. UNFPA press release (13th April 2006), Bangladeshi Doctor, Haitian Family Planning Provider, Win 2006 United Nations Population Award
20. UNAIDS/WHO 2004 Report on the Global AIDS Epidemic
21. UNAIDS/WHO 2006 Report on the Global AIDS Epidemic
22. Cohen, J. (2006), ‘Dominican Republic: A Sour Taste on the Sugar Plantations’, Science Vol. 313 Issue 5786, 28th July 2006
23. Cole S. (April 2006), 'Closet of the Caribbean', Positive Nation, Issue 121
24. UNAIDS 2008 Report on the global AIDS epidemic
25. UNAIDS 2008 Report on the global AIDS epidemic
26. Inter Press News Service (August 18th 2006), 'Caribbean: HIV/AIDS goes primetime'
27. Inter Press News Service (August 18th 2006), 'Caribbean: HIV/AIDS goes primetime'
28. UNESCO (2003), ‘Education & HIV/AIDS: Quarterly Report to United Nations HIV/AIDS Theme Groups in the Caribbean on UNESCO’s programme and activities in the Caribbean’
29. United Press International (18th May 2006), 'U.N. Opens Caribbean Education Forums'
30. U.S. Centers for Disease Control and Prevention, International News, (April 19th 2006), ‘Latin America: Let's (Not) Talk About Sex’
31. UNAIDS 2008 Report on the global AIDS epidemic
32. Inter Press Service News Agency (September 26th 2006), ‘Rights-Jamaica: Hauling HIV/AIDS out of the closet’
33. Inter Press Service News Agency (September 26th 2006), 'Rights-Jamaica: Hauling HIV/AIDS out of the closet'
34. UNAIDS/WHO 2006 Report on the Global AIDS Epidemic
35. Sullivan M.P. (January 2005), ‘AIDS in the Caribbean and Central America’, CRS report for Congress
36. Cohen, J. (2006), ‘Dominican Republic: The Sun. The Sand. The Sex’, Science Vol. 313 Issue 5786, 28th July 2006
37. Cohen, J. (2006), ‘Puerto Rico: Rich Port, Poor Port’, Science Vol. 313 Issue 5786, 28th July 2006
38. Cole S. (April 2006), 'Closet of the Caribbean', Positive Nation, Issue 121
39. Department for International Development [DIFID] webpage (2006), Case Studies, 'Tackling HIV and AIDS stigma and discrimination in the Caribbean'
40. Amnesty International (2006, May), 'I am not ashamed!': HIV/AIDS and human rights in the Dominican Republic and Guyana'
41. UNAIDS (December 2004), ‘A Study of the Pan Caribbean Partnership against HIV/AIDS (PANCAP) Common goals, shared responses’
42. The World Bank (2005), HIV/AIDS in the Caribbean region: a multi-organization review
43. UNAIDS (December 2004), ‘A Study of the Pan Caribbean Partnership against HIV/AIDS (PANCAP) Common goals, shared responses’
44. WHO/UNAIDS/UNICEF (2009) 'Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector'
45. Fawthrop T. (December 2003), 'Cuba: Is It a Model in HIV-AIDS Battle?', Panos London
46. BBC News (16th July 2004), 'Cuba to help Caribbean fight AIDS'
47. Partners in Health website, Haiti: Partner Overview (accessed 5/10/06)
48. WHO (2008), 'Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector'
49. World Health Organisation, 3 by 5 Progress Report December 2004
50. World Health Organisation (2006), "Progress on Global Access to HIV Antiretroviral Therapy"
51. UNAIDS (2010, 29th January) 'Building Haiti's AIDS response better'
52. Cohen, J. (2006), ‘Dominican Republic: The Sun. The Sand. The Sex’, Science Vol. 313 Issue 5786, 28th July 2006
53. Cohen, J. (2006), 'Dominican Republic: The Sun. The Sand. The Sex', Science Vol. 313 Issue 5786, 28th July 2006
54. The World Bank (2005), HIV/AIDS in the Caribbean region: a multi-organization review