U.S. Virgin Islands and Caribbean HIV epidemic need more attention, researchers say
HIV infection rate is high among sex workers
The Caribbean receives scant attention from HIV researchers and public health officials, and this has resulted in an epidemic that is poorly understood, an investigator says.
"I sometimes feel the Caribbean is somewhat neglected as far as HIV research," says Hilary Surratt, PhD, scientist with the Center for Drug & Alcohol Studies of the University of Delaware in Coral Gables, FL.
This is especially true with the English-speaking Caribbean, which is very diverse culturally, Surratt says.
"Chiefly, the incidence of HIV/AIDS in the English-speaking Caribbean is very high, but there hasn't been a significant focus of research in the region," Surratt says.
Funding is the issue. HIV research funds are spent in areas where the HIV epidemic is greater in scope, she notes.
"That's understandable, but from a U.S. perspective, there should be greater focus in the area because that's our neighbor," Surratt says.
Surratt characterizes the Caribbean's HIV epidemic as primarily heterosexual in nature, although it's associated with non-injection substance use and men who have sex with men (MSM).
"Sometimes those [heterosexual transmission] features are not as exciting to people in terms of research dollars, and that's why there's not a history of research being done here," she says.
Surratt found in her own research that drug-using migrant sex workers are particularly vulnerable to HIV infection and transmission throughout the Caribbean.1
"The sex workers are servicing, to a great extent, tourists from the United States, Canada, and other parts of the world," Surratt says. "They work the cruise ship routes and bars, and that's their target much more heavily than the local population."
Lindsey Wolf, another investigator who has focused on the Caribbean, agrees that the region needs more research attention.
"A big challenge in the Caribbean is identifying all of those who actually need treatment, and that will involve HIV screening expansion," says Wolf, who is a medical student at the University of California in San Francisco, and who was working as a senior research analyst with the Cost Effectiveness of Preventing AIDS Complications Group at Massachusetts General Hospital in Boston, MA, when she conducted a study on HIV and the Caribbean.
The UNAIDS' 2007 AIDS Epidemic Update states that the primary mode of HIV transmission in the region is unprotected sex between sex workers and clients, the UNAIDS report says.2
HIV prevalence among female sex workers in Guyana is 31 percent; in Jamaica it's 9 percent, and in the Dominican Republic it's 3.5 percent.2
"Unsafe injecting drug use is responsible for a minority of HIV infections, and contributes significantly to the spread of HIV only in Bermuda and Puerto Rico," the report states.2
While men who have sex with men (MSM) transmission also is a significant factor, it is hidden because of stigma, the report adds.2
Stigma also plays a role in suppression of efforts to get sex workers and others to be tested for HIV, Surratt says.
"Honestly, the challenges are tremendous and not just with the sex workers," she says. "It goes back to a sense that this is a small, close-knit community, and HIV still carries a stigma in the community."
People are reluctant to be tested for HIV because they're afraid they'll be seen by someone they know, Surratt says.
"Going to the HIV clinic is something nobody wants to be involved with because within five minutes everybody on the island will know that so and so was going to this particular location," she explains. "There are tremendous barriers for people to talk about HIV, much less being tested for HIV."
Surratt did not provide HIV testing as part of her study, mostly for this reason.
Wolf saw the stigma first-hand when she worked on the English-speaking island of St. Lucia as a health educator for children at a boys' technical school.
"People who have an HIV diagnosis haven't told people about it, not even their families because they don't want the word to get out," Wolf says. "The number of identified HIV cases is very low compared with the World Health Organization's projection of how many people are infected in the region."
The stigma needs to be addressed, and health care professionals should come up with strategies for screening for HIV, Wolf says.
"Basically, everyone should be tested, and those who need treatment should get treatment," Wolf adds.
Universal testing might even be feasible since the island populations are small, she notes.
"We looked into what we could do to break down these barriers, to see what would make people more likely to be HIV tested," Surratt says. "People told us very often that if you want people to be HIV tested, make the location not identified with HIV testing."
For example, an HIV testing site should offer other health care screenings, such as blood pressure checks, and a variety of services.
"If we had a mobile unit with an array of services, that would be ideal," Surratt says. "But, honestly, the resources are not there to do something like that."
Even folding HIV testing into the existing medical clinics wouldn't be feasible because these established sites are resource-strapped, and the staff might worry about being associated with HIV testing, she adds.
Some of the other factors that increase risk of HIV transmission in the English-speaking Caribbean involve the tendency of island residents to have a young initiation of sexual intercourse and young women engaging in sexual activity with older men, Surratt says.
"There is really broad acceptance of alcohol consumption, which is endemic to many parts of the Caribbean," Surratt says. "There is a broad acceptance of men having many different female sexual partners, and many of these factors drive the heterosexual epidemic."
In Surratt's study, she found a strong relationship between the sex workers' use of illicit drugs and their engaging in riskier levels of HIV behaviors.1
"Among the non-substance-using sex workers, we found that protected sex was very common," Surratt adds. "So their HIV risk was significantly less if they were non-using women, but if they were drunk or high then they'd forget about using condoms or could be convinced not to use condoms."
References:
- Surratt H. Sex work in the Caribbean Basin: patterns of substance use and HIV risk among migrant sex workers in the US Virgin Islands. AIDS Care. 2007;19(10):1274-1282.
- UNAIDS/WHO. 2007 AIDS Epidemic Update. Dec. 2007: available online at www.unaids.org.
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