HIV HETEROSEXUAL TRANSISSION IN THE ENGLISH
SPEAKING CARIBBEAN
Paper prepared for the MAP/UNAIDS Meeting
Rio De Janeiro, Brazil
November 3-5, 1997
Dr Bilali Camara, Head, SPSTD, CAREC
A. INTRODUCTION
The HIV epidemic started in the Caribbean in the 1970s. The first AIDS case was
reported from Jamaica in 1982. In 1983, eight AIDS cases were reported from Trinidad
and Tobago, all of which were gay or bisexual men. But, buy 1985 female and paediatric
AIDS cases represented 29% of the total cases reported to CAREC. This shift occurred
very quickly, clearly indicating that AIDS was becoming a general population issue and
no longer a disease solely of gay or bisexual men. Considering the cumulative AIDS
cases as well as the annual incidence, the predominant mode of transmission of HIV is
reported as sexual and specifically heterosexual in absolute number. In the Caribbean,
from its start to the present the AIDS epidemic evolved into different but interdependent
homo/bi and heterosexual sub-epidemics which are shaped by country-specific social,
cultural and economic determinants.
The two molecular epidemiology studies undertaking in the Caribbean (Trinidad and
Tobago and Jamaica) have shown that the subtype B of the HIV 1 is the most prevalent
subtype. This corresponds to the one generally isolated in the USA and Western Europe
and which seems more associated with other modes of transmission which is observed in
the Caribbean subregion.
This article presents a summary of status and trends of HIV/AIDS in a context of its
heterosexual transmission in 19 CAREC Member Countries (CMCs), 18 English-
speaking and Suriname, for which data are available:
Anguilla, Antigua and Barbuda, Bahamas, Barbados, Bermuda, Belize, BVI,
Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts &
Nevis, St Lucia, St Vincent and the Grenadines, Trinidad and Tobago, Turks and
Caicos and Suriname.
It is important to note that since 1993, Turks and Caicos has stopped reporting AIDS
cases to CAREC.
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With regard to reported AIDS cases among females in ethnic minority groups, the first
results of an HIV prevalence study conducted in the early years of the epidemic among
West Indians of African descent created much controversy in Trinidad and Tobago.
Because of the sensitivity to this subject in the Caribbean environment and the
discrimination, which could consequently come from this type of study, it was not
considered as a priority. The female Maroons and Amerindians in Suriname and Guyana
could be targeted in the future for specific studies. Such an activity must be undertaken
with care to avoid stereotyping and ensure that individual and community rights are fully
respected.
As of December 1995, a total 8,199 AIDS cumulative cases were reported to CAREC by
its 19 member countries. This represented 134 cases per 100,000 population. This high
rate puts the Caribbean in the position of the second most affected part of the world after
sub-Saharan Africa. At the end of 1996, 1,572 new AIDS cases were reported despite the
fact that Belize, Guyana, Suriname and Turks and Caicos had not reported their AIDS
cases that year. The cumulative AIDS cases is 9,771 or 158 cases per 100,000
population. Recognising that some of those countries which have not reported cases for
1996 are among the most affected, therefore to reflect a true picture of the situation this
analysis will focus on AIDS data from 1982 to 1995.
An increasing trend in absolute annual reported AIDS cases is observed with a doubling
period of four years. This doubling period varies from country to country (e.g. it is only
two years in Jamaica). The death rate among AIDS cases is very high (63%). The
majority of the cases belong to the age group 24-44 years with a male predominance.
Among the AIDS cases, the distribution of category of transmission is: heterosexual
transmission 60%, homosexual and bisexual 14%, perinatal 5%, intravenous drug use
2%, blood transfusion 0.5%, other 0.5% and unknown category of transmission 18%.
The sexual transmission of HIV remains the important one in the Caribbean (74%) and
the IDVU is concentrated in tow CMCs (Bermuda and very few in the Bahamas) but the
proportion of AIDS cases related to use of other substances such as crack-cocaine is not
documented.
In 1995, 50% of the CMCs had reported an incidence of more than 10 cases per 100,000
population. These CMCs are:
Antigua and Barbuda, Bahamas, Barbados, Bermuda, Grenada, Guyana, Jamaica,
St Lucia and Trinidad and Tobago.
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Taking into account the cumulative AIDS Cases from 1982 to 1995, 37% of the CMCs
reported more than 100 AIDS cases per 100,00 population (Bahamas (821), Bermuda
(566), Turks and Caicos (340 from 1982 to 1993) Barbados (244), Trinidad and Tobago
(164), St Kitts and Nevis (126) and Dominica (103).
B. AIDS TRENDS AND STATUS AMONG WOMEN
The CAREC Member Countries are among the countries with a very high incidence of
female AIDS cases in the western hemisphere. The sex ratio in annual AIDS cases
reported to CAREC has dramatically fallen from 1982 to 1985 and for the decade 1985 to
1995 it evolved continuously between 4 and 2 males to 1 woman at the regional level.
This trend varies from country to country but everywhere an increasing trend is observed
in female AIDS cases. From 1985 to 1995, the absolute number of female cases has
increased 19 fold, standing at 540 in 1995 and folds. The evolving trend shows that from
19% of the annual AIDS cases in 1985 the female AIDS cases represented 33% of the
annual cases in 1995. Compared to the male group, the female AIDS cases are
predominant only in the age group 15 -19 years underlying the fact that young female and
girls/teenagers are more likely to be exposed to HIV infection in the Caribbean. The
majority of the female AIDS cases is in the age group 24 - 44. In 1994, AIDS was the
eighth leading cause of death among females in the Caribbean just after cancer of the
breast.
C. AIDS TRENDS AND STATUS AMONG CHILDREN
As a consequence of its heterosexual transmission, an increasing trend of AIDS cases is
observed among children living in the Caribbean. From 1985 to 1995, children under
fifteen represented 5% of the cumulative AIDS cases as well as of the annual incidence.
This persistent trend is a major public health concern not only because of its direct
negative impact on children’s health but also because of its indirect negative impact on
the achievements of the Mother and Child Health programmes in the region.
D. HIV TRENDS AMONG PREGNANT WOMEN
HIV Surveillance data collected among pregnant women from different CMCs have
shown variability in prevalence and trends.
Montserrat: a countrywide yearly cohort of pregnant women was screened on an
anonymous/ unlinked basis for HIV during 1994 - 1995 using the blood collected for
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routine syphilis screening. A total of 203 pregnant women were enrolled in the study and
2 were HIV positive. The prevalence rate was 0.99% (2/203). (Source: CAREC-1995).
St. Lucia: a countrywide 18-month cohort of pregnant women was screened on an
anonymous basis for HIV during 1994 - 1995 using the blood collected for routine
syphilis screening. A total of 849 pregnant women were enrolled in the study and 1 was
HIV positive. The prevalence rate was 0.12% (1/849). (Source: CAREC- 1995).
St. Vincent and the Grenadines: a countrywide two-yearly cohort of pregnant women
was screened on an anonymous basis for HIV during 1994 - 1995 using the blood
collected for routine syphilis screening. A total of 4613 pregnant women were enrolled
in the study and 23 were HIV positive. The prevalence rate was 0.50% (23/4613).
(Source CAREC-1995).
Cayman Islands: a countrywide routine testing of a yearly cohort of pregnant women on
a voluntary basis for HIV has shown prevalence rates of 0% in 1991 (0/540) and 1992
(0/590), 0.17% in 1993 (1/567), 0.16% in 1994 (1/620) and 0% in 1995 (0/628). (Source:
Ministry of Health - Dr Alla Kumar, MOH).
Trinidad & Tobago: 3 countrywide cross-sectional studies (anonymous and unlinked)
among pregnant women were conducted using the same methodology in 1990, 1991 -
1992 and 1995 - 1996 with the blood collected for routine screening for syphilis. Over the
period 1990 through 1996, HIV seroprevalence was found to increase from 0.3% to 0.6%
to 1.0% in the three studies, respectively. Age specific prevalence rates for women less
than 25 years increased from 0.95 to 1.5 percent between 1991 and 1995. (Source:
CAREC-1996).
Jamaica: 3 countrywide anonymous and unlinked surveys were conducted among
pregnant women and have shown increasing HIV trends respectively from 0.14% in 1989
to 0.44% in 1992 to 0.6% in 1994 - 1995. (Source: EPI-Unit-Jamaica).
Guyana: During a 1992 - 1993 survey among Antenatal Clinic attenders, 1 in every 10
blood samples, which went to the National Laboratory for VDRL testing, was selected
and tested in an anonymous and unlinked manner for HIV. A total of 411 samples were
selected and 15 tested HIV positive (3.65%). (Source: NAP-Guyana-1996).
Bahamas: Since 1993, countrywide HIV screening for pregnant women has been done
on a routine and voluntary basis and results on the yearly cohort are analysed and
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published. In 1993 the seroprevalence was 4.8% (187/3899) it went to 4.2% (135/3209)
in 1994 and to 3.6% (127/3505) in 1995. (Source: MOHE-Bahamas-1996).
Barbados: Since 1991, a voluntary non-anonymous and linked HIV screening for
pregnant women has been carried out on a routine basis. The level of participation of
pregnant women in this surveillance activity varies very much from ANC to ANC. This
is a limiting factor for any interpretation of the observed results. The seroprevalence
went from 2% in 1991 to 1.2% in 1992 to 0.8% in 1993 to 0.9% in 1994 to 1.8% in 1995
and 1.0% in 1996. (Source: MOH-Barbados-1996).
E. HIV TRENDS AMONG FEMALE COMMERCIAL SEX WORKERS
(CSWs)
Due to the illegal nature of prostitution in the Caribbean, it is difficult to estimate the
extent of commercial sex work and this should be taken into consideration when
interpreting results coming out of studies on this subject. In some CMCs prevalence
studies were conducted among CSWs, and their results follow:
Trinidad & Tobago: a study of female prostitutes in Port of Spain, Trinidad was
initiated in June 1988. 226 prostitutes were enrolled in the study and of these 13% were
HIV positive. Street prostitutes were more likely to be HIV positive than those who
operated from brothels. (Source: MRC-POS-1996).
Jamaica: HIV prevalence among female Commercial Sex Workers in the capital city
(Kingston), has remained at the same level, 12% in 1989 and 11% in 1994 - 1995. In St
James, screening of female Commercial Sex Workers (31% of whom are cocaine addicts)
showed a prevalence of 22% in 1994 - 1995. (Source: EPI-UNIT-MOH, Jamaica-1995).
Guyana: a seroprevalence study conducted by Bunya, Sharma et al in 1989 among
CSWs has shown a rate of 43.14% (22/51). In 1993, Carter, K et al conducted a study in
this group and found a seroprevalence of 25% (27/108). (Source NAP-Guyana-1996).
F. FEMALE COCAINE ADDICTS
Bahamas: During 1990 - 1991 the National AIDS Programme in Bahamas conducted an
HIV prevalence study among this group and the rate was 44.4. Source: MOH-Bahamas
Nassau-1996).
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G. CONCLUSION
Heterosexual transmission of HIV is a major public health issue. In this region more and
more women are being infected, resulting in an increase in perinatal transmission and
paediatric AIDS cases. It is important to address issues contributing to the increasing
trends of both HIV and AIDS among women. Many underlying factors which put
women at risk contribute to the increasing trends of HIV infection among women. The
sexual behaviour and practices coupled with gender differences and the existing social
and cultural norms are the major factors impacting on women's health in general and on
the HIV transmission in this group.
In general, the prevailing pattern in the Caribbean is one of:
Early introduction/initiation of sexual activity (By 18 years the vast majority of
Caribbean youth have had their first sexual encounter).
Cultural acceptance of sexual experimentation for boys and young men -casual sex,
serial monogamy - is an accepted part of the cycle that moves from unstable
relationships towards stable ones.
Multiple concurrent partnerships which are socially acceptable for males (Machismo).
A perception of sex as natural and necessary for maintaining good health. Repression
of sexual urges is believed to result in poor mental and physical health.
Sex being independent of stable relationships, marriage and love.
Unprotected first sexual intercourse and intercourse with a “steady” partner
Low approval rate of condom use among males and females coupled with the
“churches” opposition to condom use.
A very strong discrepancy between cultural and moral taboos and actual practices.
Poor partner communication on sexual needs and concerns, emotional and socio-
economic dependence and male dominance during the sexual act.
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Repression of same sex preference contributing to widespread bisexual practices
which are not acknowledged by the females partners.
Anecdotal evidence of new sex patterns across the region - patterns that appear to be
the consequence of prevailing socio-economic realities. For example sex tourism and
occasional commercial sex work observed among housewives and school girls.
Less evidence of sustained mutual fidelity, partner reduction, abstinence and
alternatives to penetrative sex in the heterosexual communities.
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