Caribbean Crossroads

In June 2000, the heads of state and ministers of finance of the Caribbean nations summoned an urgent conference to assess the devastating effects of HIV/AIDS. The Caribbean Conference on HIV/AIDS, hosted by the government of Barbados on September 11-12 was an historic event. The conference recognized the central role of treatment and not just prevention in response to the epidemic. For the first time, the link was made between the actual economic impact of HIV/AIDS and what it would cost to control the epidemic.

From an epidemiological standpoint, the statistics are chilling. It is estimated that approximately 2 percent of the region's population--more than 500,000 people--are infected with HIV/AIDS. The rate of HIV/AIDS is sharply increasing, particularly among the most productive age groups. Already, it is the chief cause of death for men and women between the ages of 15 and 45. The Caribbean occupies the highest incidence of HIV/AIDS among women in Latin America and the Caribbean. By the year 2020, HIV/AIDS may account for 73.5 percent of deaths in this region.

Of the 12 countries with the highest HIV prevalence in the Americas, 9 are in the Caribbean. The island of Hispaniola, comprising Haiti and the Dominican Republic, accounts for 75 percent of the cases. Puerto Rico, included in the official statistics of the United States and ranking second within the U.S. infection rates, plays a special role in the transmission of the disease because it is a central transportation and commerce hub for the Caribbean.

The Epidemic under Our Noses

From culture to culture and island to island, HIV/AIDS is enveloped in a dark shroud of irrationality. Professionals working on the issue must wend their way through a labyrinth of stigma, taboo, denial, discrimination, and secrecy. HIV/AIDS is a condition related to sex, blood, death, disease, and forbidden or illegal behavior--men having sex with men, the sex trade (both male and female), drug abuse, and the sexual abuse of children. The fear associated with the disease thwarts efforts to address its causes and find solutions, starting at the level of private, isolated individuals and working all the way up to societal levels. Denial causes communities and nations to refuse to acknowledge the HIV threat. Nevertheless, the causes and consequences of the epidemic will inexorably require them to deal with many controversial issues: religion, human rights, cultural norms governing male and female sexuality, the social and economic status of women, sex workers, migration patterns, inequities in health care and education, and rising drug abuse.

The behavioral dynamics that fuel the epidemic in the Caribbean are linked to the sociocultural contexts of sex and sexuality:

• early initiation of sexual activity (60 percent by the age of 12 years in some countries), exacerbated by social and religious taboos that prevent teaching or discussing safe sex with young people;

• social norms that condone, or even encourage, multiple sexual partners in men of all ages;

• unprotected sexual intercourse due to cultural attitudes and the inaccessibility or unavailability of condoms;

• social and legal repression of same-sex partners, which drives homosexuals underground and results in bisexual relationships that increase the risk of HIV/AIDS transmission to women;

• continued denial by authorities of sexual activity in prisons, including the development of preventative programs;

• new sex trends in the region, often driven by poverty and inequity, such as sex tourism, sex work by school girls, housewives, and children;

• the emotional and socioeconomic dependence of women on men, hampering their ability to negotiate safe sex practices; and

• substance abuse, especially of drugs and alcohol, which impairs judgment and increases high-risk behavior.

Another dynamic surrounds national and institutional capabilities to cope with the epidemic:

• National elections result in a change of government every four to five years, creating discontinuous political commitment.

• Support for the National AIDS Programs in human resources and budget allocations has decreased even as the epidemic increases.

• National policies on testing and reporting of...