Guyana Journal | HIV-AIDS in Caribbean

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Cultural Issues for HIV/AIDS Clients from the Caribbean
Myths and Realities
By Patrick C. Coggins
Guyana Journal, May 2007

The Purpose

The purpose of this study was to explore the extent to which HIV/AIDS has become an epidemic in the Caribbean region of the world. Additionally, the study was intended to identify indicators, causal factors, and cross cultural issues that have an impact on the spread of HIV/AIDS among the populations of the Caribbean.

The goal of this paper will be to address the cultural issues including the perception, prevention and treatment approaches that work effectively with Haitian and Caribbean HIV/AIDS clients. Particular focus will be on strategies that result in culturally competent assessment and interventions with clients.

The outcomes/objectives will be: 1) to understand the myths versus realities involved in HIV/AIDS prevention and treatment, 2) focus on the infection rate, 3) the socioeconomic and cultural parameters of treatment and prevention of HIV/AIDS among Haitian and Caribbean populations, 4) focus on six strategies that practitioners could use in prevention and treatment, and the examination of the practical assessment questions that will enable providers to be more culturally competent in their intervention and treatment of HIV/AIDS in the Haitian and Caribbean populations.

Table I. Percentage of Adults infected with the HIV virus or are living with AIDS

Research Questions

The research questions were two-fold, namely, 1) to ascertain whether the spread of HIV/AIDS in the Caribbean countries has reached epidemic levels, 2) to determine the basic routes of infection of the HIV virus, and 3) to ascertain whether there are known strategies that are in place to prevent the spread of the HIV/AIDS epidemic in the Caribbean.

Table II. CAREC Member Countries and Reported cases of AIDS (Camara et al, 2003)

Introduction

The Caribbean is heavily affected by HIV/AIDS. It is the leading cause of death among 15 to 44 year olds and has a prevalence of 2.11% among adults. Outside of Sub-Saharan Africa, the Caribbean is the second hardest hit region in the world with a UN estimated 360,000 to 500,000 people in the region living with the HIV/AIDS virus. The leading countries with HIV/AIDS are Haiti, Bahamas, Guyana, Belize, and the Dominican Republic; but Jamaica, Suriname, and Trinidad and Tobago have the lowest HIV/AIDS rates. The United Nations AIDS Program classifies Latin America and the Caribbean as the second leading region for HIV/AIDS infections, second only to the Sub-Saharan region of Africa.

The data in Table I show the HIV/AIDS prevalence in selected countries in the Caribbean including those countries with increasing high infection rates such as Dominican Republic, Haiti, Bahamas, Barbados, Belize, Guyana, Suriname, Jamaica, and Trinidad and Tobago.

In Haiti, the relationship between pregnancy and HIV/AIDS accounts for 12% of pregnant women in urban areas and 5% in rural areas. It is the most affected country with heterosexual activity being continuously fueled by extreme poverty. In the Dominican Republic 2%, or 130,000, of the pregnant women are living with HIV/AIDS; 8% of pregnant women are HIV positive. The Bahamas has a 3.6% prevalence rate. In 2003, 21.5% of female patients in Guyana that sought treatment for STD’s also had HIV.

CAREC member countries include Anguilla, Antigua & Barbuda, Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Jamaica, Montserrat, St. Kitts & Nevis, St. Lucia, St. Vincent, Suriname, Trinidad & Tobago, Turks & Caicos. Haiti and Dominican Republic account for 85% of total number of cases of HIV/AIDS in the Caribbean. Cuba has the lowest rate of infection rate in HIV.
Most of the data on HIV/AIDS in the Caribbean is based in reporting of AIDS cases in the region, which, though underreported, illustrate an inexorable trend upwards over the past decade, with considerable acceleration in the mid-late 1990’s. Between 1988 and 1998, the number of new AIDS cases in CAREC member countries increased by a factor of five per cent per country.

Historic Indicators for HIV/AIDS in the Caribbean
Heterosexual Transmission

Heterosexual transmission accounts for the majority of HIV infections and AIDS cases in the Caribbean with 64% of the occurrences. Both Haiti and the Dominican Republic report a 1:1 ratio. Dominica reports 3.6:1, Barbados 3.3:1, Antigua 2.8:1, and Trinidad 2.4:1. The highest rates of AIDS infection are among women who have little or no power to negotiate safer sex. As a result, 25 to 30% of the children born to HIV infected mothers will be infected with the virus. The major route of transmission in the Caribbean is heterosexual followed by male to male infection. However, the reporting of cases is severely limited due to strong stigma and potential discrimination. It is important to note that homosexuality is illegal in most countries. Twenty percent (20%) of new AIDS cases that are reported are due to heterosexual contact with women and men. Twenty-two percent (22%) of AIDS cases are reported as “unknown”, and 50% are due to sex with men (UN AIDS Report, 2005).

Social and Economic Factors

The social and economic impact that HIV/AIDS has had in the Caribbean has caused countries to expend 6% of the region’s GDP. Currently at 40 million dollars, it will grow to 80 million by the year 2020. Stigma, discrimination, illness, shame, and moral dilemma all play a part in dealing with the HIV epidemic. A significant issue is poverty with 222 million people living in abject poverty and destitution; for example, 96 million, or 42.9%, are poor, 40.1 million, or 18.1% are extremely poor, 136 million, or 61%, are living in extreme poverty; and only 33% of those living in poverty use contraceptives.

In 2005, 30,000 people in the Caribbean were newly infected with HIV/AIDS. In the Bahamas, Haiti, and Trinidad & Tobago, more than 3% of the population are living with HIV. Each year in Haiti, 24,000 people die from AIDS, and 200,000 children are orphaned by AIDS in the Caribbean. The largest range of people affected in the Caribbean has been 15-44 year olds. In 2005, there were 1 in 3 people living with HIV/AIDS in the Caribbean, including Latin America.

Infection Rate by Country

It is known that about 3% of the population living in the Caribbean have tested positively for HIV/AIDS. The Caribbean countries with the fastest rate of infection are the Bahamas, Barbados, Haiti, Trinidad & Tobago, Belize, Guyana, and the Dominican Republic. (CDC, Report, 2005) As will be discussed later, the mode of transmission and the increasing number of those infected are impacted by the commercial sex trade, heterosexual contact, and homosexual relations. Surprisingly, the infection rate caused by the intravenous drug use lags behind the other developed nations such as the United States. (Caricom Report, 2003)

Transmission Modes

In order to understand the magnitude of the HIV/AIDS epidemic in the Caribbean, it is essential that one focuses on the differences in modes of transmission between those infected in the Caribbean and those with the United States of America.

The data in Table III indicate that, for the Caribbean, the number one mode of transmission and infection for HIV/AIDS is through commercial sex. This factor is triggered by the influx of visitors from other countries to these Caribbean countries. The islands with tourism are the ones that do not want to talk about it very much. (Peggy McEnroy, UNAIDS Caribbean, 2005)) Sexuality and HIV/AIDS are not discussed so as not to hurt tourism. Poverty and economic disparity are forcing men and women into commercial sex work, often with tourists. Over 40 million children in Latin America and the Caribbean live on the streets. Over 90% of those children engage in sex for money and favors. It is important to note that 15-24 year olds are particularly vulnerable to HIV infection. (AMFAR Caribbean Initiatives, 2005) In Guyana, Honduras, Trinidad & Tobago, Haiti, and the Dominican Republic, over 40% female/male sex workers tested positive for the HIV virus. The number two mode of infection in the Caribbean is that of heterosexual sex. The third mode of infection is that homosexual sex. Whereas, in the United States, the number one infection mode is heterosexual sex, followed by intravenous drug use, and similar to the Caribbean, homosexual sex is the third leading cause of infection. Knowing these modes of infection should shed light on the enormous intervention strategies that have been implemented by the governments of the Caribbean nations. A common reason for the increase in infection rate is low condom use. An encouraging result in the Dominican Republic is that with the concerted education about the use of condoms, they saw a reduction in the number of people infected by HIV/AIDS.

The reality is that in order to reduce the infection rate, countries have to convince residents to not only increase their use of condoms, but also reduce the number of partners. (UN Report, 2005) An even more serious challenge for the governments of the Caribbean is making treatment available for HIV/AIDS persons to receive access to antiretroviral drugs. While these drugs are costly, there are some promising news that should be noted. Cuba, Bahamas, Barbados, and the Dominican Republic provide treatment to those in need of HIV/AIDS care. However, what is more typical in the various Caribbean countries is the fact that one-third or less of the population receive treatment for HIV/AIDS such as in Trinidad and Tobago. (AMFAR Global Initiatives, 2005)

Infection Among Pregnant Women

The general concern is that normal pregnancy is a very serious and high risk experience; yet, a major scare for pregnant women in the Caribbean is becoming HIV/AIDS positive during pregnancy. Becoming HIV positive endangers not only the life of the mother, but also the life of the innocent child. Table IV shows how serious this problem is becoming in several countries in the Caribbean.

The AMFAR Global Initiatives Study (2005) found some alarming results when examining the data for infection rates among pregnant women in the Caribbean. The study found that the rate of infection among pregnant women in Haiti increased from 9.4% per 1000 in 1999 to 15.7% per 1000 in 2004. There is also a concern that countries like Guyana, Bahamas and Belize have infection rates of 7.1%, 3.6% and 3.8% respectively.

Death and HIV/AIDS in the Caribbean

It is essential to examine deaths and the number of persons infected by HIV/AIDS. As the researchers of AMFAR said, the actual number of persons infected and the number of deaths per year might be even higher due to the difficulty in identifying, reporting, and recording the information.

The World Bank Organization Report (2006) said that, as a region of the Caribbean, there were 500,000 newly infected HIV persons in 2005. Over 600,000 have died of HIV/AIDS in the last 20 years. The data in Table V is startling, especially since in 10 countries over 1,319,900 persons are HIV infected and over 38,700 died in 2004 from HIV/AIDS. What is even more alarming is that, according the World Bank Organization, in 2005 over 90,000 people died in Latin America and Caribbean countries. This data suggests an ever increasing number of people infected and dying from HIV/AIDS with no end in sight. (World Bank Organization, 2006)

Factors Fueling the HIV/AIDS Epidemic in the Caribbean

According to the World Bank Organization (2006), there are five primary factors fueling the HIV/AIDS epidemic in the Caribbean and the world, namely: 1) Stigma and Discrimination, 2) Lack of implementation capacity, 3) Lack of international control of HIV/AIDS, 4) Social factors and political and, 5) Economic instability. It was also reported that Latin America and the Caribbean are considered to be the World’s second leading region for HIV/AIDS behind Sub-Saharan Africa, which is considered the number one leading region.

1. Stigma and Discrimination
People living with HIV/AIDS feel isolated and stigmatized,even when they go for treatment they sense a stigma. The commercial sex workers are stigmatized by the society and given the onset of HIV/AIDS, these workers are visible and blamed for the spread of HIV/AIDS infection. The end results for commercial sex workers and those infected by HIV/AIDS is to go underground to avoid
discrimination.

2. Lack of Implementation Capacity
This is a critical policy issue at the governmental level of each Caribbean country. On one hand, the costs of drugs and intervention programs and services have curtailed the prevention activities of countries. However, more troublesome is the lack of systematic policies and strategies that will result in, not only the control of the epidemic, but also the prevention of the spread of the HIV/AIDS epidemic. The World Bank Organization (2006) reported that the fundamental difficulty is the tendency of the governments in Latin America and the Caribbean to be in a state of denial and blindness to affirmative efforts to control the commercial sex trade. It is for fear that any public concerted effort will have a negative impact on the tourism trade. The economy and the well being of the people from many of the Caribbean countries depend on the dollars generated from the tourist trade.

3. Lack of International Control of HIV/AIDS
One strategy for controlling the spread of HIV/AIDS across national borders was to require testing or reject foreigners with HIV/AIDS. The countries requiring HIV/AIDS testing before entry is granted to the country include: Argentina, China, Columbia, Costa Rica, Cuba, Hungary, Iraq, Israel, Mongolia, Burma, Philippines, Russia, South Africa, South Korea, Syria, Thailand, and the United States. Countries that reject foreigners with HIV/AIDS include: Indonesia, Malaysia, Sri Lanka, and Thailand. This list of countries that reject people from entry with HIV/AIDS and those countries requiring testing for HIV/AIDS will rise as long as we have the startling and deadly epidemic of HIV/AIDS. (2005) Some comfort in the midst of this alarming international trend of testing or rejection of those with HIV/AIDS can be found in the United Nations entity World Health Organization which maintains that HIV screening as documented evidence for travel is necessary as a public health perspective. (UNESCO Report, 2005)

4. Social Factors
There are many social and cultural factors that play an important role in the spreading of the epidemic at a rapid rate among Caribbean nations. The first factor is the unequal relationships among men and women where some women are economically dependent on men for their subsistence. The second factor operates in that this vulnerable position of most women provides fewer chances to negotiate safe sex. But, the third and critical social factor is the cultural and behavioral factor that encourages early sexual acts for both sexes. (World Bank Organization, 2006)

5. Political and Economic Instability
This political and economic instability provides the greatest challenge for the populations and the various governments. These facts include migration and mobility of the population that moves to follow the jobs and available economic opportunities. Many of these opportunities have shifted to the urban centers which, for the most part, are overcrowded, fast-pace, expensive to live, and basically plagued with several social problems. Additionally, this mobility has been characterized as one of the reasons for the break up of many close-knit families. (UNESCO Report, 2005) Another challenging issue is the internal political strive and disruptions in the economic life of the people. Places like Cuba, Haiti, Jamaica, and other Caribbean countries with challenges of political and economic upheaval continue to create tensions that result in unstable political and economic climate that is fueled with high levels of unemployment. (CDC, HIV/AIDS, 2003)

6. Conspiracy Beliefs and African Americans
The Conspiracy beliefs are something shared by African Americans and Caribbean residents alike. Many feel that HIV/AIDS is a form of genocide against Blacks. Others feel that AIDS has a cure and it is being held back from the poor. (CDC, HIV/AIDS, 2003; Bogart and Thorburn, 2005) The table shows the conspiracy beliefs and African Americans.

A review of the conspiracy beliefs Table VI raises concerns since about a) 58.8% of the respondents said a lot of the information on AIDS is being held back from the public, b) 53.4% feel that the AIDS cure is being withheld from the poor, c) nearly 43.6% feel that new AIDS drugs use people as guinea pigs for the government, d) only 48.2% feel that AIDS is a man-made virus including a CIA conspiracy and creation of AIDS, e) only 38.4% feel medicines to treat HIV are saving lives in the Black community. The most promising trend is the fact that 75.4% felt that medical and public health personnel are trying to stop the spread of HIV in the black communities. (Bogart and Thorburn, 2005)

The implications of this trend of data on conspiracy beliefs signify a need for researchers to study, not only the conspiracy beliefs, but also the cultural beliefs that play an important part in peoples’ perception and response to the government’s efforts in preventing and treating the epidemic of HIV/AIDS in the Caribbean and other regions of the world.

What are the Solutions

Based on the Global Community (CARICOM) Caribbean it is important to understand that any solution sets must consider the reality of the diversity that exists in the Caribbean. The diversity can be described by the Caribbean Community (CARICOM), which created Pan Caribbean AIDS Partnership (PANCAP) linked to the Caribbean Epidemiology Center (CAREC) as a region with 25 countries, four major languages, and over 50 different cultures and 60 sub-cultures. (CDC Report, 2004/2005) Furthermore, 12 of the 25 Caribbean countries’ population are experiencing high infection rates. With the primary modes of infection being commercial sex, heterosexual sex, both account for about 64% of AIDS cases, with 20% homosexual or men to men infections, 6% of infections mother to child transmission and the remaining 10% based on a variety of transmission modes, including intravenous drug use, transfusions, etc. (CDC, 2004/2005)

First Solution: Prevention with the Youth

The first solution is to focus on the youth. The research shows that if there is any hope in preventing HIV/AIDS, it is necessary to educate the young people at an early age. Since the risky age in the Caribbean is 15-24 years and 61% of the population in the Caribbean is 15-24 years, it is necessary to examine the reason why 50% of new HIV infections occur in the age range 15-24 years. (UNESCO Report on HIV/AIDS, 2005) One study of college students in the Dominican Republic asked several questions including: Have you heard about STD’s; HIV and AIDS? Have you heard about the modes of transmission? Have you heard about the causes of the diseases? The responses to the questions were very startling, namely: 70 percent of the college students at one university reported being sexually active with no protection. The college students reported low or little use of condoms to reduce HIV/STD’s infections, and most alarming, was the college students’ comfort and obliviousness to their risky sexual practices. A further look at the experiences of the college students was the realization and evidence that they never participated in systematic education or curricula programs for HIV/AIDS and STD’s prevention. (UNESCO Review of Higher Education Institutions’ Response to HIV/AIDS, 2005)

Second Solution: Increase Testing of High Risk Population
The second solution to control the HIV/AIDS epidemic in the Caribbean is to increase the testing of all people, especially those in commercial sex and women and children at risk. The table that follows shows that over 441 women and children, in 2003, are living with HIV/AIDS in the 8 of the 25 Caribbean countries reported in Table VII.

The above figures in Table VII are estimates and are made with a large degree of uncertainty. For example, HIV prevalence in Haiti is estimated as being between 120,000 and 600,000; the figure for Barbados lies in the range 700-9,200. (Sources: UNAIDS, 2005) The data in Table VII, column four show that the unofficial estimates are two times the HIV rate reported by the countries.

Table VII also shows that over 36,400 women and children died in 2003 from HIV/AIDS. There is evidence that new infection rates of women are surpassing or equaling that of men. (Incardi et. al. 2005) There is a need for not only alarm, but also concerted actions to identify women and children. For example, the widespread infections of women are well documented in Trinidad & Tobago, i.e., the HIV infections have been documented to be six times higher among 15-19 year old females than among males of that same age. For the Dominican Republic and Jamaica, women are two and one-half times more likely to be infected with HIV compared to their male counterparts. (MAP, 2003/2004) Central to the issue of the high infection rate among women is the well documented fact that one-third of the men 15-29 years of age reported multiple partners in previous years and no use of condoms to protect transmission. (Caribbean Technical Group, 2004) Therefore, a concerted program of education including reduction of multiple partners, abstinence, use of condoms, and testing will result in the slowing of the HIV epidemic levels among women and children.

A Model for Testing of HIV

The data that follow shows the percentage of women that have received an HIV test, excluding a blood donation by race/ethnicity in the Caribbean countries.

The reports from CARICOM (2005) and UNAIDS Reports (2005) indicate that less than 33% of the women and men in the Caribbean countries have been tested for HIV infection. The table shows that 66% of Black or African American women ages 15-44 in the U.S. have been tested for HIV infection. This rate of testing is compared to 56% for Hispanics, 53% for white, and 49% multiple race or other. This high rate of testing, especially among African American women, was due in part to the concerted impact of intensive education in the media, churches, health and community organizations, and individual awareness among women. Until the Caribbean tests more than one-third of its women, there can be no hope to slow down the spread of HIV/AIDS. (UNAIDS, 2005) Many of the Caribbean countries report two factors for the low rate of testing namely, a) the high cost for the infra structure, testing supplies and personnel and b) getting voluntary testing the high risk and general population.

Making Treatment Available

The challenge for the nations in the Caribbean is to increase its financial resources directed towards the prevention and treatment of HIV/AIDS infected residents. There is a wide range of access to treatment, for example, in 2004 only 33% in Trinidad & Tobago received the antiretroviral treatment. About 12% in Haiti despite its alarming infection rate among residents. Only of HIV/AIDS infected people or 12% in the Dominican Republic received treatment. In general, only 10-15% of HIV/AIDS infected individuals in the Caribbean receive the treatment needed to arrest the disease. (CDC, 2005) In order to ensure that HIV/AIDS cases slow down in the region, it will be necessary for the Caribbean countries to increase a) the availability of antiretroviral therapy and drugs, b) increase in HIV/AIDS reporting, c) provide better surveillance techniques that will ensure that testing is done for high risk and other populations, and d) address heterosexual behavior, which is still a major source of the increase in the HIV infection rates. This latter group can be targeted through concerted education and awareness promotional efforts in the media such as radio, television and newspapers.

Faith Initiatives

The prevention of HIV/AIDS will require every institution in the Caribbean nations to play an active role in the state programs and prevention efforts. Thus, each Caribbean nation will have to develop a strategy that focuses on the “faith entities,” including churches. The churches and religious groups’ opposition to the use of condoms have influenced the behavior of some residents. The faith groups’ emphasis on abstinence and sex as a moral issue provides a major obstacle for governmental and community initiatives. The main issues overlooked is with the infection rates increasing in every Caribbean country; faith groups must work with government efforts of continue to devote time and resources to tending to those sick with AIDS and of course conducting burial ceremonies each day and week.

Health/Literacy

In order to be successful in any prevention or treatment program in HIV/AIDS, it will require that a concerted program be developed to increase the health literacy of residents. The insights into what works, how the disease of AIDS progresses, and the symptoms and side effects from antiretroviral drugs must be taught in a language that is understandable by all of the residents, despite age, race, religion, and gender.

The Sex Workers’ Registration

The study by Callega et al (2002), the United Nations AIDS Report (2004) and CDC Report (2005) all point to the fact that a basic way of life for some residents of the Caribbean nations is their involvement in the sex trade. The HIV infection rate is rising among female sex workers even though women workers are required to register in most countries and get a health card. For male sex workers, no health card is given to them since many countries do not recognize male sex workers (Callega et. al., 2002). The end result is that most male sex workers are forced to work underground since the data in this study.

Recommendations

Finally, Latin America, the Caribbean, and their forward thinking governments must have set a number of major goals to be achieved by implementing the recommendations by 2015, namely:

1. Caribbean Nations can increase the quality and years of life for all residents by ensuring that money is spent on the treatment and prevention of HIV/AIDS for all age and gender groups.

2. Caribbean Nations must eliminate the health disparities that currently exist with respect to the number of individuals who are tested for HIV infection. Unless all sex workers, males, children, women, and youth are routinely tested, monitored, and held accountable for unprotected sex, the chance of reducing the HIV infection rates would disappear and the epidemic of HIV/AIDS will increase in its severity. A closely related issue is what to do about visitors who carry HIV or who are at risk of being infected with the virus. Thus, it is essential that there be careful study of those hemispheric countries that require testing before entry, for example, Argentina, Colombia, Costa Rica, Cuba, and the United States to mention a few countries. (2005)

3. The future of the health of each nation in the Caribbean will be determined to a large extent by how effectively each government works with communities and individuals to reduce and reverse the HIV/AIDS epidemic, by ensuring that those populations experiencing disproportionate burdens of the HIV/AIDS disease, disabled physically and mentally, and suffering, from the ever present threat of premature death. (Guiding principles for Improving Health, U.S. Government Office of Minority Health Report, 2005)

4. It is important the Nations implement a massive education and preventive effort that is directed to the youths in the Caribbean since at risk for infections by HIV are the 15-24 years old. Since 61% of the population in the Caribbean is between the ages of 15-24, the urgency of the prevention efforts is paramount. (UNESCO Report, 2005) What is even scarier in the UNESCO Report in 2005 is that 50% of the new HIV infections occur in the age range of 15-24 years old. The thought of caring for AIDS victims if they survive premature death is costly and frightening. Therefore, it is suggested that the Caribbean nations move from an ideology of denial, blindness, and silence to a progressive ideology of acceptance, openness, and public acknowledgment that HIV/AIDS is at epidemic levels in all the Caribbean nations.

Implications

The results of this study show that the Caribbean is the second largest region for HIV/AIDS infection in the world. Given the fact that 61% of the Caribbean population lives in poverty, the reality for economic survival leads men, women, and children to enter the sex trade for money to sustain their lives. Therefore, unless the Caribbean nations can improve the economic well being for the majority of the individuals who live in the Caribbean countries, then the HIV infection rates will continue to devastate the populations of the Caribbean region.

CARICOM must recognize that a major source of transmission of the HIV epidemic is the sex trade that is stimulated by the tourist trade that many of the Caribbean islands are heavily dependent on for the money that supports a substantial part of each nation’s economy. There are optional and appropriate preventive measures, namely:

1. Identify all sex workers, test them often, and provide condoms on demand with sanctions for having unprotected sex. Among all, maintain an efficient and current registry that can be accessed
electronically by law enforcement and health workers.

2. Require that all people before entering the country take an HIV test at a certified lab in their country. This requirement may slow down the tourist trade, but in the long run, there will be benefits to each coun try in slowing down the infection rate while making sure that every one remains free of HIV/AIDS infection.

3. The need for a long term strategy is crucial with the infrastructure strategy being a health management system to screen, identify, track, and treat HIV/AIDS positive people in a comprehensive surveillance system.

4. Given the prevalence of the sex trade and the heterosexual relations with multiple partners, it is necessary to link other sexually transmitted diseases (STD’s) and HIV/AIDS into one screening process in order to address both diseases simultaneously. This strategy will save money, time and effort while addressing all of the sexually transmitted diseases.

5. As each Caribbean nation allocates more money for health care costs for treatment, including antiretroviral drugs, counseling, intervention, and prevention, it is also necessary for Caribbean nations to embark on a systematic program that trains HIV/AIDS health workers in new testing, detection, treatment, and prevention approaches and models. This will require working closely with the UNAIDS programs and the Center for Disease Control of the United States.

6. Stigma and myths must be replaced with health promotion language that is culturally relevant that targets all age groups with three simple messages. First, get tested; second, do not engage in unprotected sex; and thirdly, if diagnosed with HIV/AIDS, get treatment, avoid infecting others, and follow-up on the treatment regime. It is essential that each citizen understands that each person who is not infected will ensure that the individual, family and the population as a whole avoids premature deaths and burials and high costs of treatment for a long time. The money spent on treatment can be spent on economic development, providing jobs and improving the quality of life for very citizen in each Caribbean nation.

7. The most important implication of this study is the potential persistence of the HIV/AIDS epidemic due to the fact that 50% of the new HIV infections occur among the 15-29 year olds. Since this HIV infection is occurring earlier, then the costs and efforts for preventing and especially treatment will involve caring for young members of the population for a number of years. An underlying reality is that government intervention with prevention education must target children between the ages of 10-14 years and continue intensively to age 29 years and beyond.

Summary
If we believe that “Prevention is better than the cure,” then, it should be clear that eradication of one of the deadliest and most costly diseases to treat, HIV/AIDS, will require concerted efforts on the part of everyone. It is also obvious that anyone who cares about the Caribbean Nations must help by providing money, resources, and medical research and support to sustain the Health Care Management System for testing, treating and preventing HIV/AIDS. The United Nations, CARICOM, the Center for Disease Control (CDC), other branches of the United States government and other nations in Europe and Asia must find no comfort in the thought that the Caribbean is the second epidemic region behind Sub-Saharan Africa with respect to HIV infection rates, the number of the population living with HIV/AIDS disease and the number of deaths from the epidemic of HIV/AIDS.

========================================================
So, let you and me live by this “Personal Responsibility Principle” (Coggins, 2002).

Personal Responsibility Principle
“The price of greatness is taking responsibility for what you say and do.” – Winston Churchill

I cannot be responsible for someone I cannot change and that is you. I must be responsible for myself and the things I say or do in conducting myself. Only you have the power to change the things you do and yourself. If you will accept personal responsibility for your own behavior, and I accept personal responsibility for my behavior then together we will influence others around us to accept the same responsibility
for the things they say or do and their behavior.
The message is clear. Each of us must take personal responsibility for how we protect
ourselves and others from the dreadful disease of HIV/AIDS which threatens to cripple
the entire population of the Caribbean countries

========================================================

References
Calleja, Jesus MGarcia, Neff Walker, Paloma Cuchi, Stefano Lazzari, Peter D. Ghys, Fernando Zacarias. “Status of the HIV/AIDS Epidemic and Methods to Monitor it in the Latin American and Caribbean Region,” AIDS, vol. 16, (Dec, 2002)

“Caribbean: HIV and AIDS Statistics and Features, in 2003 and 2005,” UNAIDS/WHOAIDS epidemic update: December 2005. Caribbean technical Expert Group, 2004.

Caribbean Task Force on HIV/AIDS. “The Caribbean Regional Strategic Plan of Action for HIV/AIDS” August 2000.

“Guiding Principle for Improving Health,” Office of Minority Health, (U.S. Govt., 2005)

“HIV/AIDS in Latin America and the Caribbean,” The World Bank. (2006).

Human Immunodeficiency Virus (HIV) Testing Requirements for Entry into Foreign Countries. Bureau of Consular Affairs, U.S. Department of State. (2005)

Laura M. Bogart and Sheryl Thorburn, “Are HIV/AIDS Conspiracy Beliefs a Barrier to HIV Prevention Among African Americans?” Journal of Acquired Immune Deficiency Syndrome, 38, no. 2 (2005).

“Living with HIV/AIDS,” CDC: National Center for HIV, STD, and TB Prevention, Divisions of HIV/AIDS Prevention. Department of Health and Human Services. (2006).

“Special Report: AIDS in the Caribbean and Latin America,” AMFAR AIDS Research: Global Initiatives. (2005).
“UNESCO Review of Higher Education Institutions’ Responses to HIV and AIDS,” IIEP: HIV/AIDS Impact on Education Clearinghouse. (2006).

U.S. Center for Disease Control and Prevention (CDC), HIV/AIDS among African Americans Fact Sheet (2003).

* Peggy McEnroy (UNAIDS Caribbean, 2005))
* MAP, 2003
* (Emerson, 2005)
* Kaiser National Survey Found (2001)
* Caricom Report, 2003

This paper was presented at the Annual Grantee meeting of the Federal Government’s Center for Substance Abuse Treatment Targeted Capacity Annual Expansion HIV and HIV Outreach held on June 19-21, 2006 at Omni Shoreham Hotel, Washington, D.C.

Patrick C. Coggins, Ph.D., J.D., LLD (Hon.) is Jessie Ball duPont Chair’ Professor of Social Justice & Founder/Director Multicultural Education Institute, Stetson University, DeLand, Florida 32723. (386) 822-7360. E-mail

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Cultural Issues for HIV/AIDS Clients from the Caribbean
Myths and Realities
By Patrick C. Coggins
Guyana Journal, May 2007

The Purpose

The purpose of this study was to explore the extent to which HIV/AIDS has become an epidemic in the Caribbean region of the world. Additionally, the study was intended to identify indicators, causal factors, and cross cultural issues that have an impact on the spread of HIV/AIDS among the populations of the Caribbean.

The goal of this paper will be to address the cultural issues including the perception, prevention and treatment approaches that work effectively with Haitian and Caribbean HIV/AIDS clients. Particular focus will be on strategies that result in culturally competent assessment and interventions with clients.

The outcomes/objectives will be: 1) to understand the myths versus realities involved in HIV/AIDS prevention and treatment, 2) focus on the infection rate, 3) the socioeconomic and cultural parameters of treatment and prevention of HIV/AIDS among Haitian and Caribbean populations, 4) focus on six strategies that practitioners could use in prevention and treatment, and the examination of the practical assessment questions that will enable providers to be more culturally competent in their intervention and treatment of HIV/AIDS in the Haitian and Caribbean populations.

Table I. Percentage of Adults infected with the HIV virus or are living with AIDS

Research Questions

The research questions were two-fold, namely, 1) to ascertain whether the spread of HIV/AIDS in the Caribbean countries has reached epidemic levels, 2) to determine the basic routes of infection of the HIV virus, and 3) to ascertain whether there are known strategies that are in place to prevent the spread of the HIV/AIDS epidemic in the Caribbean.

Table II. CAREC Member Countries and Reported cases of AIDS (Camara et al, 2003)

Introduction

The Caribbean is heavily affected by HIV/AIDS. It is the leading cause of death among 15 to 44 year olds and has a prevalence of 2.11% among adults. Outside of Sub-Saharan Africa, the Caribbean is the second hardest hit region in the world with a UN estimated 360,000 to 500,000 people in the region living with the HIV/AIDS virus. The leading countries with HIV/AIDS are Haiti, Bahamas, Guyana, Belize, and the Dominican Republic; but Jamaica, Suriname, and Trinidad and Tobago have the lowest HIV/AIDS rates. The United Nations AIDS Program classifies Latin America and the Caribbean as the second leading region for HIV/AIDS infections, second only to the Sub-Saharan region of Africa.

The data in Table I show the HIV/AIDS prevalence in selected countries in the Caribbean including those countries with increasing high infection rates such as Dominican Republic, Haiti, Bahamas, Barbados, Belize, Guyana, Suriname, Jamaica, and Trinidad and Tobago.

In Haiti, the relationship between pregnancy and HIV/AIDS accounts for 12% of pregnant women in urban areas and 5% in rural areas. It is the most affected country with heterosexual activity being continuously fueled by extreme poverty. In the Dominican Republic 2%, or 130,000, of the pregnant women are living with HIV/AIDS; 8% of pregnant women are HIV positive. The Bahamas has a 3.6% prevalence rate. In 2003, 21.5% of female patients in Guyana that sought treatment for STD’s also had HIV.

CAREC member countries include Anguilla, Antigua & Barbuda, Bahamas, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Jamaica, Montserrat, St. Kitts & Nevis, St. Lucia, St. Vincent, Suriname, Trinidad & Tobago, Turks & Caicos. Haiti and Dominican Republic account for 85% of total number of cases of HIV/AIDS in the Caribbean. Cuba has the lowest rate of infection rate in HIV.
Most of the data on HIV/AIDS in the Caribbean is based in reporting of AIDS cases in the region, which, though underreported, illustrate an inexorable trend upwards over the past decade, with considerable acceleration in the mid-late 1990’s. Between 1988 and 1998, the number of new AIDS cases in CAREC member countries increased by a factor of five per cent per country.

Historic Indicators for HIV/AIDS in the Caribbean
Heterosexual Transmission

Heterosexual transmission accounts for the majority of HIV infections and AIDS cases in the Caribbean with 64% of the occurrences. Both Haiti and the Dominican Republic report a 1:1 ratio. Dominica reports 3.6:1, Barbados 3.3:1, Antigua 2.8:1, and Trinidad 2.4:1. The highest rates of AIDS infection are among women who have little or no power to negotiate safer sex. As a result, 25 to 30% of the children born to HIV infected mothers will be infected with the virus. The major route of transmission in the Caribbean is heterosexual followed by male to male infection. However, the reporting of cases is severely limited due to strong stigma and potential discrimination. It is important to note that homosexuality is illegal in most countries. Twenty percent (20%) of new AIDS cases that are reported are due to heterosexual contact with women and men. Twenty-two percent (22%) of AIDS cases are reported as “unknown”, and 50% are due to sex with men (UN AIDS Report, 2005).

Social and Economic Factors

The social and economic impact that HIV/AIDS has had in the Caribbean has caused countries to expend 6% of the region’s GDP. Currently at 40 million dollars, it will grow to 80 million by the year 2020. Stigma, discrimination, illness, shame, and moral dilemma all play a part in dealing with the HIV epidemic. A significant issue is poverty with 222 million people living in abject poverty and destitution; for example, 96 million, or 42.9%, are poor, 40.1 million, or 18.1% are extremely poor, 136 million, or 61%, are living in extreme poverty; and only 33% of those living in poverty use contraceptives.

In 2005, 30,000 people in the Caribbean were newly infected with HIV/AIDS. In the Bahamas, Haiti, and Trinidad & Tobago, more than 3% of the population are living with HIV. Each year in Haiti, 24,000 people die from AIDS, and 200,000 children are orphaned by AIDS in the Caribbean. The largest range of people affected in the Caribbean has been 15-44 year olds. In 2005, there were 1 in 3 people living with HIV/AIDS in the Caribbean, including Latin America.

Infection Rate by Country

It is known that about 3% of the population living in the Caribbean have tested positively for HIV/AIDS. The Caribbean countries with the fastest rate of infection are the Bahamas, Barbados, Haiti, Trinidad & Tobago, Belize, Guyana, and the Dominican Republic. (CDC, Report, 2005) As will be discussed later, the mode of transmission and the increasing number of those infected are impacted by the commercial sex trade, heterosexual contact, and homosexual relations. Surprisingly, the infection rate caused by the intravenous drug use lags behind the other developed nations such as the United States. (Caricom Report, 2003)

Transmission Modes

In order to understand the magnitude of the HIV/AIDS epidemic in the Caribbean, it is essential that one focuses on the differences in modes of transmission between those infected in the Caribbean and those with the United States of America.

The data in Table III indicate that, for the Caribbean, the number one mode of transmission and infection for HIV/AIDS is through commercial sex. This factor is triggered by the influx of visitors from other countries to these Caribbean countries. The islands with tourism are the ones that do not want to talk about it very much. (Peggy McEnroy, UNAIDS Caribbean, 2005)) Sexuality and HIV/AIDS are not discussed so as not to hurt tourism. Poverty and economic disparity are forcing men and women into commercial sex work, often with tourists. Over 40 million children in Latin America and the Caribbean live on the streets. Over 90% of those children engage in sex for money and favors. It is important to note that 15-24 year olds are particularly vulnerable to HIV infection. (AMFAR Caribbean Initiatives, 2005) In Guyana, Honduras, Trinidad & Tobago, Haiti, and the Dominican Republic, over 40% female/male sex workers tested positive for the HIV virus. The number two mode of infection in the Caribbean is that of heterosexual sex. The third mode of infection is that homosexual sex. Whereas, in the United States, the number one infection mode is heterosexual sex, followed by intravenous drug use, and similar to the Caribbean, homosexual sex is the third leading cause of infection. Knowing these modes of infection should shed light on the enormous intervention strategies that have been implemented by the governments of the Caribbean nations. A common reason for the increase in infection rate is low condom use. An encouraging result in the Dominican Republic is that with the concerted education about the use of condoms, they saw a reduction in the number of people infected by HIV/AIDS.

The reality is that in order to reduce the infection rate, countries have to convince residents to not only increase their use of condoms, but also reduce the number of partners. (UN Report, 2005) An even more serious challenge for the governments of the Caribbean is making treatment available for HIV/AIDS persons to receive access to antiretroviral drugs. While these drugs are costly, there are some promising news that should be noted. Cuba, Bahamas, Barbados, and the Dominican Republic provide treatment to those in need of HIV/AIDS care. However, what is more typical in the various Caribbean countries is the fact that one-third or less of the population receive treatment for HIV/AIDS such as in Trinidad and Tobago. (AMFAR Global Initiatives, 2005)

Infection Among Pregnant Women

The general concern is that normal pregnancy is a very serious and high risk experience; yet, a major scare for pregnant women in the Caribbean is becoming HIV/AIDS positive during pregnancy. Becoming HIV positive endangers not only the life of the mother, but also the life of the innocent child. Table IV shows how serious this problem is becoming in several countries in the Caribbean.

The AMFAR Global Initiatives Study (2005) found some alarming results when examining the data for infection rates among pregnant women in the Caribbean. The study found that the rate of infection among pregnant women in Haiti increased from 9.4% per 1000 in 1999 to 15.7% per 1000 in 2004. There is also a concern that countries like Guyana, Bahamas and Belize have infection rates of 7.1%, 3.6% and 3.8% respectively.

Death and HIV/AIDS in the Caribbean

It is essential to examine deaths and the number of persons infected by HIV/AIDS. As the researchers of AMFAR said, the actual number of persons infected and the number of deaths per year might be even higher due to the difficulty in identifying, reporting, and recording the information.

The World Bank Organization Report (2006) said that, as a region of the Caribbean, there were 500,000 newly infected HIV persons in 2005. Over 600,000 have died of HIV/AIDS in the last 20 years. The data in Table V is startling, especially since in 10 countries over 1,319,900 persons are HIV infected and over 38,700 died in 2004 from HIV/AIDS. What is even more alarming is that, according the World Bank Organization, in 2005 over 90,000 people died in Latin America and Caribbean countries. This data suggests an ever increasing number of people infected and dying from HIV/AIDS with no end in sight. (World Bank Organization, 2006)

Factors Fueling the HIV/AIDS Epidemic in the Caribbean

According to the World Bank Organization (2006), there are five primary factors fueling the HIV/AIDS epidemic in the Caribbean and the world, namely: 1) Stigma and Discrimination, 2) Lack of implementation capacity, 3) Lack of international control of HIV/AIDS, 4) Social factors and political and, 5) Economic instability. It was also reported that Latin America and the Caribbean are considered to be the World’s second leading region for HIV/AIDS behind Sub-Saharan Africa, which is considered the number one leading region.

1. Stigma and Discrimination
People living with HIV/AIDS feel isolated and stigmatized,even when they go for treatment they sense a stigma. The commercial sex workers are stigmatized by the society and given the onset of HIV/AIDS, these workers are visible and blamed for the spread of HIV/AIDS infection. The end results for commercial sex workers and those infected by HIV/AIDS is to go underground to avoid
discrimination.

2. Lack of Implementation Capacity
This is a critical policy issue at the governmental level of each Caribbean country. On one hand, the costs of drugs and intervention programs and services have curtailed the prevention activities of countries. However, more troublesome is the lack of systematic policies and strategies that will result in, not only the control of the epidemic, but also the prevention of the spread of the HIV/AIDS epidemic. The World Bank Organization (2006) reported that the fundamental difficulty is the tendency of the governments in Latin America and the Caribbean to be in a state of denial and blindness to affirmative efforts to control the commercial sex trade. It is for fear that any public concerted effort will have a negative impact on the tourism trade. The economy and the well being of the people from many of the Caribbean countries depend on the dollars generated from the tourist trade.

3. Lack of International Control of HIV/AIDS
One strategy for controlling the spread of HIV/AIDS across national borders was to require testing or reject foreigners with HIV/AIDS. The countries requiring HIV/AIDS testing before entry is granted to the country include: Argentina, China, Columbia, Costa Rica, Cuba, Hungary, Iraq, Israel, Mongolia, Burma, Philippines, Russia, South Africa, South Korea, Syria, Thailand, and the United States. Countries that reject foreigners with HIV/AIDS include: Indonesia, Malaysia, Sri Lanka, and Thailand. This list of countries that reject people from entry with HIV/AIDS and those countries requiring testing for HIV/AIDS will rise as long as we have the startling and deadly epidemic of HIV/AIDS. (2005) Some comfort in the midst of this alarming international trend of testing or rejection of those with HIV/AIDS can be found in the United Nations entity World Health Organization which maintains that HIV screening as documented evidence for travel is necessary as a public health perspective. (UNESCO Report, 2005)

4. Social Factors
There are many social and cultural factors that play an important role in the spreading of the epidemic at a rapid rate among Caribbean nations. The first factor is the unequal relationships among men and women where some women are economically dependent on men for their subsistence. The second factor operates in that this vulnerable position of most women provides fewer chances to negotiate safe sex. But, the third and critical social factor is the cultural and behavioral factor that encourages early sexual acts for both sexes. (World Bank Organization, 2006)

5. Political and Economic Instability
This political and economic instability provides the greatest challenge for the populations and the various governments. These facts include migration and mobility of the population that moves to follow the jobs and available economic opportunities. Many of these opportunities have shifted to the urban centers which, for the most part, are overcrowded, fast-pace, expensive to live, and basically plagued with several social problems. Additionally, this mobility has been characterized as one of the reasons for the break up of many close-knit families. (UNESCO Report, 2005) Another challenging issue is the internal political strive and disruptions in the economic life of the people. Places like Cuba, Haiti, Jamaica, and other Caribbean countries with challenges of political and economic upheaval continue to create tensions that result in unstable political and economic climate that is fueled with high levels of unemployment. (CDC, HIV/AIDS, 2003)

6. Conspiracy Beliefs and African Americans
The Conspiracy beliefs are something shared by African Americans and Caribbean residents alike. Many feel that HIV/AIDS is a form of genocide against Blacks. Others feel that AIDS has a cure and it is being held back from the poor. (CDC, HIV/AIDS, 2003; Bogart and Thorburn, 2005) The table shows the conspiracy beliefs and African Americans.

A review of the conspiracy beliefs Table VI raises concerns since about a) 58.8% of the respondents said a lot of the information on AIDS is being held back from the public, b) 53.4% feel that the AIDS cure is being withheld from the poor, c) nearly 43.6% feel that new AIDS drugs use people as guinea pigs for the government, d) only 48.2% feel that AIDS is a man-made virus including a CIA conspiracy and creation of AIDS, e) only 38.4% feel medicines to treat HIV are saving lives in the Black community. The most promising trend is the fact that 75.4% felt that medical and public health personnel are trying to stop the spread of HIV in the black communities. (Bogart and Thorburn, 2005)

The implications of this trend of data on conspiracy beliefs signify a need for researchers to study, not only the conspiracy beliefs, but also the cultural beliefs that play an important part in peoples’ perception and response to the government’s efforts in preventing and treating the epidemic of HIV/AIDS in the Caribbean and other regions of the world.

What are the Solutions

Based on the Global Community (CARICOM) Caribbean it is important to understand that any solution sets must consider the reality of the diversity that exists in the Caribbean. The diversity can be described by the Caribbean Community (CARICOM), which created Pan Caribbean AIDS Partnership (PANCAP) linked to the Caribbean Epidemiology Center (CAREC) as a region with 25 countries, four major languages, and over 50 different cultures and 60 sub-cultures. (CDC Report, 2004/2005) Furthermore, 12 of the 25 Caribbean countries’ population are experiencing high infection rates. With the primary modes of infection being commercial sex, heterosexual sex, both account for about 64% of AIDS cases, with 20% homosexual or men to men infections, 6% of infections mother to child transmission and the remaining 10% based on a variety of transmission modes, including intravenous drug use, transfusions, etc. (CDC, 2004/2005)

First Solution: Prevention with the Youth

The first solution is to focus on the youth. The research shows that if there is any hope in preventing HIV/AIDS, it is necessary to educate the young people at an early age. Since the risky age in the Caribbean is 15-24 years and 61% of the population in the Caribbean is 15-24 years, it is necessary to examine the reason why 50% of new HIV infections occur in the age range 15-24 years. (UNESCO Report on HIV/AIDS, 2005) One study of college students in the Dominican Republic asked several questions including: Have you heard about STD’s; HIV and AIDS? Have you heard about the modes of transmission? Have you heard about the causes of the diseases? The responses to the questions were very startling, namely: 70 percent of the college students at one university reported being sexually active with no protection. The college students reported low or little use of condoms to reduce HIV/STD’s infections, and most alarming, was the college students’ comfort and obliviousness to their risky sexual practices. A further look at the experiences of the college students was the realization and evidence that they never participated in systematic education or curricula programs for HIV/AIDS and STD’s prevention. (UNESCO Review of Higher Education Institutions’ Response to HIV/AIDS, 2005)

Second Solution: Increase Testing of High Risk Population
The second solution to control the HIV/AIDS epidemic in the Caribbean is to increase the testing of all people, especially those in commercial sex and women and children at risk. The table that follows shows that over 441 women and children, in 2003, are living with HIV/AIDS in the 8 of the 25 Caribbean countries reported in Table VII.

The above figures in Table VII are estimates and are made with a large degree of uncertainty. For example, HIV prevalence in Haiti is estimated as being between 120,000 and 600,000; the figure for Barbados lies in the range 700-9,200. (Sources: UNAIDS, 2005) The data in Table VII, column four show that the unofficial estimates are two times the HIV rate reported by the countries.

Table VII also shows that over 36,400 women and children died in 2003 from HIV/AIDS. There is evidence that new infection rates of women are surpassing or equaling that of men. (Incardi et. al. 2005) There is a need for not only alarm, but also concerted actions to identify women and children. For example, the widespread infections of women are well documented in Trinidad & Tobago, i.e., the HIV infections have been documented to be six times higher among 15-19 year old females than among males of that same age. For the Dominican Republic and Jamaica, women are two and one-half times more likely to be infected with HIV compared to their male counterparts. (MAP, 2003/2004) Central to the issue of the high infection rate among women is the well documented fact that one-third of the men 15-29 years of age reported multiple partners in previous years and no use of condoms to protect transmission. (Caribbean Technical Group, 2004) Therefore, a concerted program of education including reduction of multiple partners, abstinence, use of condoms, and testing will result in the slowing of the HIV epidemic levels among women and children.

A Model for Testing of HIV

The data that follow shows the percentage of women that have received an HIV test, excluding a blood donation by race/ethnicity in the Caribbean countries.

The reports from CARICOM (2005) and UNAIDS Reports (2005) indicate that less than 33% of the women and men in the Caribbean countries have been tested for HIV infection. The table shows that 66% of Black or African American women ages 15-44 in the U.S. have been tested for HIV infection. This rate of testing is compared to 56% for Hispanics, 53% for white, and 49% multiple race or other. This high rate of testing, especially among African American women, was due in part to the concerted impact of intensive education in the media, churches, health and community organizations, and individual awareness among women. Until the Caribbean tests more than one-third of its women, there can be no hope to slow down the spread of HIV/AIDS. (UNAIDS, 2005) Many of the Caribbean countries report two factors for the low rate of testing namely, a) the high cost for the infra structure, testing supplies and personnel and b) getting voluntary testing the high risk and general population.

Making Treatment Available

The challenge for the nations in the Caribbean is to increase its financial resources directed towards the prevention and treatment of HIV/AIDS infected residents. There is a wide range of access to treatment, for example, in 2004 only 33% in Trinidad & Tobago received the antiretroviral treatment. About 12% in Haiti despite its alarming infection rate among residents. Only of HIV/AIDS infected people or 12% in the Dominican Republic received treatment. In general, only 10-15% of HIV/AIDS infected individuals in the Caribbean receive the treatment needed to arrest the disease. (CDC, 2005) In order to ensure that HIV/AIDS cases slow down in the region, it will be necessary for the Caribbean countries to increase a) the availability of antiretroviral therapy and drugs, b) increase in HIV/AIDS reporting, c) provide better surveillance techniques that will ensure that testing is done for high risk and other populations, and d) address heterosexual behavior, which is still a major source of the increase in the HIV infection rates. This latter group can be targeted through concerted education and awareness promotional efforts in the media such as radio, television and newspapers.

Faith Initiatives

The prevention of HIV/AIDS will require every institution in the Caribbean nations to play an active role in the state programs and prevention efforts. Thus, each Caribbean nation will have to develop a strategy that focuses on the “faith entities,” including churches. The churches and religious groups’ opposition to the use of condoms have influenced the behavior of some residents. The faith groups’ emphasis on abstinence and sex as a moral issue provides a major obstacle for governmental and community initiatives. The main issues overlooked is with the infection rates increasing in every Caribbean country; faith groups must work with government efforts of continue to devote time and resources to tending to those sick with AIDS and of course conducting burial ceremonies each day and week.

Health/Literacy

In order to be successful in any prevention or treatment program in HIV/AIDS, it will require that a concerted program be developed to increase the health literacy of residents. The insights into what works, how the disease of AIDS progresses, and the symptoms and side effects from antiretroviral drugs must be taught in a language that is understandable by all of the residents, despite age, race, religion, and gender.

The Sex Workers’ Registration

The study by Callega et al (2002), the United Nations AIDS Report (2004) and CDC Report (2005) all point to the fact that a basic way of life for some residents of the Caribbean nations is their involvement in the sex trade. The HIV infection rate is rising among female sex workers even though women workers are required to register in most countries and get a health card. For male sex workers, no health card is given to them since many countries do not recognize male sex workers (Callega et. al., 2002). The end result is that most male sex workers are forced to work underground since the data in this study.

Recommendations

Finally, Latin America, the Caribbean, and their forward thinking governments must have set a number of major goals to be achieved by implementing the recommendations by 2015, namely:

1. Caribbean Nations can increase the quality and years of life for all residents by ensuring that money is spent on the treatment and prevention of HIV/AIDS for all age and gender groups.

2. Caribbean Nations must eliminate the health disparities that currently exist with respect to the number of individuals who are tested for HIV infection. Unless all sex workers, males, children, women, and youth are routinely tested, monitored, and held accountable for unprotected sex, the chance of reducing the HIV infection rates would disappear and the epidemic of HIV/AIDS will increase in its severity. A closely related issue is what to do about visitors who carry HIV or who are at risk of being infected with the virus. Thus, it is essential that there be careful study of those hemispheric countries that require testing before entry, for example, Argentina, Colombia, Costa Rica, Cuba, and the United States to mention a few countries. (2005)

3. The future of the health of each nation in the Caribbean will be determined to a large extent by how effectively each government works with communities and individuals to reduce and reverse the HIV/AIDS epidemic, by ensuring that those populations experiencing disproportionate burdens of the HIV/AIDS disease, disabled physically and mentally, and suffering, from the ever present threat of premature death. (Guiding principles for Improving Health, U.S. Government Office of Minority Health Report, 2005)

4. It is important the Nations implement a massive education and preventive effort that is directed to the youths in the Caribbean since at risk for infections by HIV are the 15-24 years old. Since 61% of the population in the Caribbean is between the ages of 15-24, the urgency of the prevention efforts is paramount. (UNESCO Report, 2005) What is even scarier in the UNESCO Report in 2005 is that 50% of the new HIV infections occur in the age range of 15-24 years old. The thought of caring for AIDS victims if they survive premature death is costly and frightening. Therefore, it is suggested that the Caribbean nations move from an ideology of denial, blindness, and silence to a progressive ideology of acceptance, openness, and public acknowledgment that HIV/AIDS is at epidemic levels in all the Caribbean nations.

Implications

The results of this study show that the Caribbean is the second largest region for HIV/AIDS infection in the world. Given the fact that 61% of the Caribbean population lives in poverty, the reality for economic survival leads men, women, and children to enter the sex trade for money to sustain their lives. Therefore, unless the Caribbean nations can improve the economic well being for the majority of the individuals who live in the Caribbean countries, then the HIV infection rates will continue to devastate the populations of the Caribbean region.

CARICOM must recognize that a major source of transmission of the HIV epidemic is the sex trade that is stimulated by the tourist trade that many of the Caribbean islands are heavily dependent on for the money that supports a substantial part of each nation’s economy. There are optional and appropriate preventive measures, namely:

1. Identify all sex workers, test them often, and provide condoms on demand with sanctions for having unprotected sex. Among all, maintain an efficient and current registry that can be accessed
electronically by law enforcement and health workers.

2. Require that all people before entering the country take an HIV test at a certified lab in their country. This requirement may slow down the tourist trade, but in the long run, there will be benefits to each coun try in slowing down the infection rate while making sure that every one remains free of HIV/AIDS infection.

3. The need for a long term strategy is crucial with the infrastructure strategy being a health management system to screen, identify, track, and treat HIV/AIDS positive people in a comprehensive surveillance system.

4. Given the prevalence of the sex trade and the heterosexual relations with multiple partners, it is necessary to link other sexually transmitted diseases (STD’s) and HIV/AIDS into one screening process in order to address both diseases simultaneously. This strategy will save money, time and effort while addressing all of the sexually transmitted diseases.

5. As each Caribbean nation allocates more money for health care costs for treatment, including antiretroviral drugs, counseling, intervention, and prevention, it is also necessary for Caribbean nations to embark on a systematic program that trains HIV/AIDS health workers in new testing, detection, treatment, and prevention approaches and models. This will require working closely with the UNAIDS programs and the Center for Disease Control of the United States.

6. Stigma and myths must be replaced with health promotion language that is culturally relevant that targets all age groups with three simple messages. First, get tested; second, do not engage in unprotected sex; and thirdly, if diagnosed with HIV/AIDS, get treatment, avoid infecting others, and follow-up on the treatment regime. It is essential that each citizen understands that each person who is not infected will ensure that the individual, family and the population as a whole avoids premature deaths and burials and high costs of treatment for a long time. The money spent on treatment can be spent on economic development, providing jobs and improving the quality of life for very citizen in each Caribbean nation.

7. The most important implication of this study is the potential persistence of the HIV/AIDS epidemic due to the fact that 50% of the new HIV infections occur among the 15-29 year olds. Since this HIV infection is occurring earlier, then the costs and efforts for preventing and especially treatment will involve caring for young members of the population for a number of years. An underlying reality is that government intervention with prevention education must target children between the ages of 10-14 years and continue intensively to age 29 years and beyond.

Summary
If we believe that “Prevention is better than the cure,” then, it should be clear that eradication of one of the deadliest and most costly diseases to treat, HIV/AIDS, will require concerted efforts on the part of everyone. It is also obvious that anyone who cares about the Caribbean Nations must help by providing money, resources, and medical research and support to sustain the Health Care Management System for testing, treating and preventing HIV/AIDS. The United Nations, CARICOM, the Center for Disease Control (CDC), other branches of the United States government and other nations in Europe and Asia must find no comfort in the thought that the Caribbean is the second epidemic region behind Sub-Saharan Africa with respect to HIV infection rates, the number of the population living with HIV/AIDS disease and the number of deaths from the epidemic of HIV/AIDS.