MSM & HIV in the Anglophone Caribbean—A Situation Review
Although only 4 of the 12 Anglophone Caribbean countries publicly collect HIV prevalence data among men who have sex with men (MSM), in Jamaica, Guyana, and Trinidad and Tobago, researchers report an HIV prevalence of more than 20 percent among MSM. Moreover, a notable lack of human rights protection in the Anglophone Caribbean impedes efforts to improve the health of MSM. This technical brief provides basic information about HIV programming for MSM in the Anglophone Caribbean and reviews programming opportunities and resources for regional and local organizations involved.
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- Building Evidence
- Expanding Interventions
- Improving Rights
- Reinforcing Leadership
- Resources & References
Men who have sex with men (MSM)(1) in the Anglophone countries of the Caribbean(2) comprise a disproportionate share of the HIV epidemic (Baral et al. 2007; Cáceres et al. 2008). Although only 4 of the 12 Anglophone Caribbean countries publicly collect HIV prevalence data among MSM, in 3 of these 4 countries (Jamaica, Guyana, and Trinidad and Tobago) researchers report an HIV prevalence of more than 20 percent in this group (Joint U.N. Programme on HIV/AIDS [UNAIDS] 2008). This data clearly classifies MSM in the Anglophone Caribbean as a most-at-risk population (MARP) for HIV.
Guidance on good clinical and public health practice in HIV epidemics recommends channeling resources toward the prevention of infections and illness among MARPs by promoting health, reducing risk, and increasing access to—and utilization of—services. Despite the known extent of HIV among MSM in the Anglophone Caribbean, HIV interventions geared toward MSM remain severely underfunded. Foreign assistance and international donors—particularly the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)—provide some funding for programs for MARPs, but the programs that exist do not offer comprehensive services, only bits and pieces (e.g., providing condoms and information, education, and communication materials separately).
A notable lack of human rights protection in the Anglophone Caribbean also impedes efforts to improve the health of MSM (Waters forthcoming). This technical brief provides basic information about HIV programming for MSM in the Anglophone Caribbean, and reviews programming opportunities and resources for regional and local organizations involved in the response to HIV, including nongovernmental organizations, U.S. Government President's Emergency Plan for AIDS Relief (PEPFAR)-funded health program planners and implementers, U.S. Agency for International Development (USAID) Mission staff, and other stakeholders including governments and other international donors and agencies.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
According to 2008 U.N. General Assembly Special Session (UNGASS) Country Reports, three of the largest Anglophone Caribbean countries (Jamaica, Trinidad and Tobago, and Guyana) report an HIV prevalence of 20 percent or more among MSM; in other words, at least one in five MSM tested for HIV is found to be infected (UNAIDS 2008). This startlingly high percentage rivals the highest HIV prevalence found in any population around the world. Further calculations of odds ratios indicate that Caribbean MSM are between 6 and 30 times more likely to be infected with HIV than members of the general population (Baral et al. 2007; Waters 2010). The elevated HIV prevalence among MSM (above five percent) is especially striking when compared to the consistently low HIV prevalence (below one percent) among the general population in most of the region. This discrepancy suggests that HIV epidemics in the Anglophone Caribbean may be concentrated in specific subsets of the population (see Figures 1 and 2).
This hypothesis is reinforced by 25 years of epidemiologic surveys and rapid assessments documenting the multiple and interdependent sub-epidemics engendered by sex between men, sex work, and drug use. Several researchers propose that the epidemic in the Caribbean may be driven jointly by two practices: multiple concurrent sexual partnerships and sex with both men and women ("bisexual concurrency"). Other factors—such as the already high HIV prevalence among MSM, migration, poverty, gender identity, incarceration, and the hidden, "down low" interaction among MSM in the face of widespread discrimination—amplify the epidemic (Asociación para la Salud Integral y la Ciudadanía de América Latina y el Caribe 2005; Wagner and Camara 1997; Waters 2010). One HIV expert in the region has recently combined available evidence about male sexual behavior and MSM-related HIV prevalence to calculate that male-to-male sex may account for 89 percent of all annual HIV infections (6,750 of 7,500) among men in Trinidad and Tobago (Waters 2010). Averaged data from the Caribbean Epidemiology Centre (CAREC) and evidence from many Caribbean countries reinforce this conclusion, suggesting that unreported male-to-male sexual transmission may cause the majority of new HIV cases in the Caribbean at large (de Groulard et al. 2000; see Figure 3).
In all 12 Anglophone Caribbean countries, research points to the following consistent patterns:
- MSM are disproportionately infected with HIV; three major countries report an HIV prevalence of 20 percent or more among MSM.
- MSM may not self-identify, may identify as heterosexual or bisexual, and may have sex with both men and women. Lack of condom use and the high HIV prevalence among MSM probably exacerbate the role of bisexual concurrency as a driver of many HIV epidemics.
- MSM remain a high-risk population in the Caribbean due to discrimination on the basis of sexual orientation. Caribbean culture tends to reject homosexuality via extreme and frequently violent social disapproval. Local communities are generally homophobic, threatening MSM with social and economic marginalization, and sometimes with violence or even death. Numerous derogatory terms are used to describe MSM in the region and the lack of social anonymity, which is particularly pronounced in the smaller island states, drives MSM underground.
- Widespread discrimination against MSM is often exacerbated by institutionalized state policy and legislation that make sex between men illegal (Human Rights Watch 2004). MSM behavior is illegal in most of the Anglophone Caribbean. Some supportive social environments for MSM do exist on every island however, especially as facilitated by the internet, and gay social networks exist in the largest cities (e.g., Kingston, Georgetown, and Port of Spain/Chaguanas).
- The vulnerability of MSM to HIV is likely due not only to unprotected anal sex but also to other contextual health and rights issues such as poverty, youth, migration, sex work, drug use, gender identity, homelessness, incarceration, and the threat—or reality—of violence or marginalization.
- Most national health systems still have only weak quantified data for potential use in program design or funding allocations. Most countries have no certain calculation of the number of MSM who might be at risk for HIV infection or in need of HIV-related health services (see Box 1). A recent literature review of published and unpublished surveillance and research data on adult male-to-male sexual activity found that almost nothing had been published on MSM in the Anglophone Caribbean; what little that does exist focuses on male sexual identity rather than male sexual practice (Cáceres et al. 2006).
Box 1. Quantifying HIV among MSM: Numerous Complexities
Understanding the specifics of the local epidemic is fundamental to designing appropriate, effective interventions to reduce HIV transmission. While research has begun to clarify the magnitude and implications of HIV among MSM in the Caribbean, the many gaps in knowledge make it difficult to know how best to reach specific populations, especially in the smaller islands. Continuing social stigma against MSM, and the diversity of sexual practices within the MSM community, make it difficult to estimate the size of the population. Poor reporting at the national and clinical levels impedes understanding of infection modes among MSM who are living with HIV, and social factors, such as class divisions and varying levels of openness about sexual orientation, further increase the difficulty of developing a detailed understanding of HIV among MSM in the Eastern Caribbean (Maiorana et al. 2010).
Access to HIV Prevention, Treatment, and Care and Support
Sustained reductions in HIV transmission and improvements in HIV treatment outcomes require:
- A spectrum of combined HIV prevention, treatment, and care interventions at individual, network, and structural levels, at multiple access points, by multiple providers, designed to be accessible and effective for their social contexts
- Community-centered programming, whereby trusted individuals from the targeted sexual and social networks engage peers in regular, sustained education and support
- Sufficient scale to reach the entire community or network with sustained health awareness and health care access (Coates, Richter, and Cáceres 2008).
These three aspects of health programming are not yet in place for Caribbean MSM. In the 2008 UNGASS Country Progress Reports, Anglophone Caribbean countries reported that only 50 percent of MSM indicated that they know how to protect themselves against HIV, although these data may be an over-calculation due to selection bias, respondent bias, and interviewer bias. A 2009 review of GFATM grants to the Government of Jamaica, the Organization of Eastern Caribbean States, and the Caribbean Regional Network of People Living with HIV/AIDS suggested that only a minimal portion of HIV funding reaches organizations serving MSM (International HIV/AIDS Alliance 2009). In addition, in its 2009 application to GFATM, the Pan Caribbean Partnership Against HIV and AIDS (PANCAP) noted:
Despite the success of a number of peer-based outreach programs for MSM and for female sex workers in the Caribbean, effective strategies to address key vulnerable populations and to change their behaviors to lower the risk of HIV transmission have not been widely disseminated in the region. In part that is because different countries have very distinct levels of prejudice and tolerance…In some places, very little has been possible.
A 2009 multicountry study on access to health care, conducted in Jamaica, Trinidad and Tobago, Belize, Antigua and Barbuda, and Saint Kitts and Nevis by the Caribbean Vulnerable Communities Coalition (CVC) Healthcare Working Group, explained that gay, bisexual, and other MSM face a variety of obstacles to accessing health care: social discrimination, judgmental or moralistic attitudes, overtly hostile health care providers, concerns about privacy and confidentiality, shame, a lack of health care services specific to their needs, and the inability to pay for alternate private sector health care (Baral et al. 2008). According to the CVC, these assorted barriers to screening and treatment for HIV and sexually transmitted infections (STIs) have major consequences for the health outcomes of MSM and their partners.
PEPFAR, through USAID, in partnership with the Caribbean HIV&AIDS Alliance (CHAA), is seeking to address HIV risk among vulnerable groups, including MSM. USAID is working on the roll-out and expansion of its Eastern Caribbean Community Action Project (EC CAP) II which focuses on MSM, sex workers, and people living with HIV. This project, which is now in the second phase of implementation, uses a comprehensive prevention approach to address the numerous complex and intertwined causes of the increased vulnerability of MSM. This includes addressing stigma and discrimination as a barrier to accessing health care and social services, while building the capacity of government and non-government providers to improve services for this vulnerable and key population.
EC CAP's behavior change approach is built on training peer outreach workers to take a holistic approach and support their clients along the behavior change continuum. Improving self-efficacy amongst MSM is a core objective of CHAA's peer-based behavior change program. The relationship between self-esteem and improved risk perception is fundamental to sustaining enhanced self-efficacy and long-term adoption of safer sex practices. CHAA works on a number of levels to support MSM who have problems with self-identity and low self-esteem, which are common in the smaller islands of the Organization of Eastern Caribbean States, where free expression of sexual orientation is not normally tolerated. CHAA's community workers offer MSM continuous follow-up, make referrals to supportive organizations, help with the formation of MSM support groups, and provide a safe space for MSM to meet.
Human Rights Environments
The success of HIV programming depends on people's freedom to seek services and support without encountering discrimination, blackmail, violence, and criminalization. HIV programs routinely report that supporting human rights is a necessary precondition for helping people access services and negotiate health care. Several studies have documented the link between human rights environments and HIV prevalence for MSM (Baral et al. 2008; Cáceres et al. 2009).
Unfortunately, according to 2008 data for regions around the world, the Caribbean comes in second globally in terms of legal and policy environments that pose barriers to HIV programming (Gruskin and Ferguson 2008). All Anglophone Caribbean governments criminalize sex between men, with the exception of the Bahamas, where these sodomy laws were repealed in 1991 and replaced with sanctions against sex acts committed in public places. Most Caribbean legal systems, as characterized in a recent UNAIDS-sponsored report, are "repressive" to homosexuality (Cáceres et al. 2009). Governmental attempts to legislate sexual behavior, sexuality, gender identity, and gender expression are usually ineffective, and are often counterproductive to their professed aims, actually contributing to people's vulnerability to HIV (Gruskin and Ferguson 2009).
A multicountry CAREC study in nine Caribbean countries documented the extreme stigmatization, discrimination, and physical violence faced by MSM a decade ago (de Groulard et al. 2000). More recent reports from CVC have contributed the following particulars:
- In Jamaica, gay men and lesbians report verbal abuse from work colleagues; vicious beatings by police, relatives, and community members; and homelessness after being driven from their communities by angry neighbors (White and Carr 2005). Hate murder is common, especially in Jamaica, but elsewhere as well (Human Rights Watch 2004).
- Also in Jamaica, men and women with same-sex partners report that homophobia and HIV-related stigma discourage them from seeking testing, treatment, and care services, and make individuals who are living with HIV less likely to reveal their seropositive status to their sexual partners (White and Carr 2005).
- In Trinidad and Tobago, business owners are reluctant to carry condoms for fear of being identified and prosecuted as prostitution establishments (Trinidadian and Tobagonian business owners 2008).
- In Belize, observational data collected by a research team from the U.S. Centers for Disease Control and Prevention revealed strong hatred for MSM, whose sexual practices are viewed as unnatural acts that are crimes against religious beliefs. MSM commonly experience threats of violence and verbal harassment while walking the streets of Belize City (Martin 2005).
Caribbean hostility toward MSM—and its consequences for the success of health programming—are summarized in the recent PANCAP regional Round 9 funding proposal to GFATM:
Sexuality and repression are recurrent themes in Caribbean culture. Practices exist that are taboo and thus hidden, none more so than men having sex with men. Traditional small town and island societies, highly religious and prone to gossip, tend to strongly stigmatize those openly involved in male-to-male sex and sex work. As a result, men hide these activities, often migrating temporarily or permanently to gain anonymity. Discrimination can be extreme: violence is all too frequent in some places. Many who need testing and treatment services avoid them, since confidentiality is poorly guaranteed. Legal and regulatory systems reflect these barriers, as do the attitudes of some health service providers (as when AIDS patients are refused entry to public hospitals). Information on vulnerable populations is difficult to obtain due to their fears about lack of confidentiality. (PANCAP 2009).
In a recent study, Assessing the Feasibility and Acceptability of Implementing the Mpowerment Project, an Evidence-Based HIV Prevention Intervention for Gay Men, in Barbados (Maiorana et al. 2010), undertaken by the International HIV/AIDS Alliance/CHAA and the University of California, San Francisco, with funding from PEPFAR through USAID, the following key issues emerged:
- Among MSM interviewed, knowledge of HIV was relatively high, but many MSM engage in HIV risk behaviors as a result of low self-esteem and lack of condom negotiation skills. In addition, poor health-seeking behaviors, stigma and discrimination, and mistrust of the health system increase their vulnerability to HIV.
- Nongovernmental organizations, including United Gays and Lesbians Against AIDS Barbados and CHAA, conduct prevention activities such as condom distribution, promotion of testing, and educational sessions. HIV prevention mainly has targeted visible MSM populations.
Stigma and Discrimination
- MSM who are open about their sexuality frequently face discrimination, verbal harassment, and heckling on the street. Some persons reported that Christian faith-based organizations and the Rastafarian movement may fuel stigma by considering homosexuality an evil and unnatural abomination.
- Currently, AIDS is still widely associated with being gay. The double stigma attached to being gay and HIV-positive may negatively affect men's willingness to disclose their sexual preference and HIV status. MSM may not seek HIV testing or HIV care for fear of stigma or being treated differently when accessing services.
- Sodomy laws, while not commonly enforced, still make anal sex a criminal offense and contribute to homophobia.
The regional nongovernmental organization CHAA, which works across the English-speaking Organization of Eastern Caribbean States, has collaborated with USAID for the past five years to address these issues. As a result, CHAA has built up a considerable body of knowledge on the perspective of the MSM community about the consequences of a poor legal environment for MSM. CHAA's successful peer outreach model has ensured that hundreds of men have a supportive peer they can talk to. Through its EC CAP II program, CHAA has provided technical support, guidance, and small grants to help establish MSM support groups across its operational countries. These groups have proven highly valuable to their members, and have given many of the vulnerable men who attend an opportunity to build their self-confidence, work on negotiation skills, and address problems with identity and low self-esteem thus helping to reduce critical barriers to the adoption of safer sex practices and sustained behavior change.
In Jamaica, PEPFAR through USAID also supports the Health Policy Project (HPP), which focuses on policy and advocacy to reduce HIV-related stigma and discrimination, and address gender-based violence and gender norms (including masculinity). To date HPP has directly supported the lesbian, gay, bisexual, and transgender (LGBT) communities in two ways: 1) providing opportunities for policy dialogue on issues of concern for the LGBT community and 2) supporting the election of LGBT representatives, including MSM, to the Jamaica Country Coordinating Mechanism for GFATM. HPP Jamaica has also indirectly worked on issues that affect MSM by addressing stigma and discrimination in the National Strategic Plan, and by supporting the participation of key LGBT advocates from Jamaica in the 2011 Caribbean HIV/AIDS Conference. In 2012, HPP Jamaica will continue to support networking, strategic planning, and advocacy by LGBT groups, and continue to ensure evidence used in the national policy dialogue includes research on MSM.
Considerations for Improved Programming
Building Evidence and Taking Action
Research and surveillance—biological, behavioral, and social—of the HIV epidemic in the Anglophone Caribbean continues to be severely deficient. Consequently, HIV programs do not have a clear picture of which men are at highest risk for HIV infection or why. Program reporting is also lacking; for example, in the 2008 UNGASS reporting of the 12 Anglophone Caribbean countries, only Guyana and the Bahamas reported on three or more of the five indicators for MSM.
This lack of data can be overcome. Surveillance methods and tools appropriate for use in Caribbean countries already exist (Gayet and Fernández-Cerdeño 2009; Heckathorn 1997; Liau, Millett, and Marks 2006; Magnani et al. 2005; Mansergh et al. 2006). The Caribbean has already undergone a massive scale-up of programs to encourage HIV testing for pregnant women (which may have skewed male-female prevalence rates because women—especially pregnant women—are much more likely to be tested than are men). In Trinidad and Tobago, a 10-year effort to promote HIV testing among pregnant women attending public antenatal facilities resulted in 95 percent coverage by 2005. These effective strategies could also be applied to programming for MSM, but most countries still cannot—or will not—report on efforts related to HIV interventions among MSM (Pan American Health Organization [PAHO] and the World Health Organization [WHO] 2006; UNAIDS 2008).
Several international organizations, however, are working to improve research and surveillance studies focused on MSM in the Anglophone Caribbean. USAID is currently funding a number of MSM-related studies through the C-Change Project in Jamaica, including a qualitative ethnographic study of perceptions of stigma among MSM. Another study looks at the level of stigma directed at MSM at health clinics and nongovernmental organizations that serve this group. Findings from these studies will be available in April 2012 and will be used to develop new behavior change communication materials for MSM in Jamaica. GFATM is committed to helping overcome challenges to collecting and communicating data about HIV programming by and for MSM, transgender people, and sex workers, and has articulated a Strategy on Sexual Orientation and Gender Identities to encourage government partners to allocate funding for HIV-related research and data collection. Under this strategy, GFATM recommends financing the coordination of data collection and monitoring and evaluation (M&E) activities across health systems, which could be accomplished by funding the personnel, equipment, and space to manage and improve reach, analysis, and use of data for decision making.
UNAIDS and PAHO support the advancement of research and surveillance in Caribbean countries in a more hands-on manner. They provide guidelines and e-training for international UNGASS reporting about HIV programming and for M&E regarding HIV prevention among MSM. These organizations also offer regional in-person trainings for country HIV program managers focused on regional M&E frameworks and global UNGASS reporting. USAID also ensures that rigorous baselines are established at the start of large-scale projects, not only to guide program implementation but to also to feed into the overall information and surveillance systems in the region. Data gathered through the CHAA/USAID project is fed through the National AIDS Programmes on a quarterly basis.
Considerations for Improved Programming (cont.)
Expanding and Targeting HIV Interventions
Scaling up HIV interventions in specific locations and populations could significantly curtail concentrated HIV epidemics. Such interventions may not need to be expansive or expensive, but they do need to be well-targeted to people living with or at high risk for HIV.
The impact of HIV on MSM can be reduced by creating and implementing programs based on proven HIV interventions that have been appropriately targeted and brought to scale. This targeting and scale-up is the clear recommendation of PAHO/WHO and a number of other global health and HIV agencies (see Resources, Tab 7), but it has not yet been put into practice in any Caribbean country. The first priority for health programs should therefore be to implement and expand what is known to work. International best practice recommends that all proven HIV interventions be implemented simultaneously, at multiple levels, from multiple providers, and at sufficient scale (Coates, Richter, and Cáceres 2008; Merson et al. 2008b; Piot et al. 2008).
A range of interventions has been proven internationally to reduce the HIV incidence and prevalence among MSM. These interventions include providing access to and promoting condoms and water- or silicone-based lubricants; educating and supporting sexually active men in safer sexual and drug-use practices; and providing welcoming clinical and social services (see Table 1; The Global Forum on MSM & HIV 2010; Global HIV Prevention Working Group n.d.; Vermund, Allen, and Karim 2009; WHO 2009). The most successful programs also feature parallel support for addressing legal and institutional (such as prison) policies; poverty-related issues (such as housing and nutrition); and the dynamics of gender, gender identity, sexuality, drug use, and race or ethnicity, as well as self-stigma which is often seen in highly homophobic environments such as the Caribbean. Several countries and cities have already begun to scale up HIV interventions at municipal or national levels, and thus may serve as useful examples for Caribbean programs (AIDS Projects Management Group 2009; Castel et al. 2010; South Africa National AIDS Council 2010).
TABLE 1: COMPONENTS OF EFFECTIVE COMBINATION HIV INTERVENTIONS for MSM
Interventions for the health and rights of MSM should be implemented by both governmental health programs and community-based providers. Because the stigmatization of MSM within their communities often obstructs their access to HIV care, Caribbean health program planners and implementers should place special emphasis on investing in community-based HIV programs, following the principles and strategies provided in the International Association of AIDS Service Organizations (ICASO) recommendations for Community Systems Strengthening and in recommendations by researchers and community advocates (Carr 2006; ICASO 2009)(3). In addition, given the close connections between the small island nations of the Caribbean (i.e., migration between islands; economic, political, and institutional interactions; and cultural and religious similarities), regional intervention efforts would also be valuable (PANCAP 2009).
Specific populations and HIV epidemics are not evenly distributed across the Caribbean. In order to effectively target HIV interventions for MSM, program planners and implementers should consider that the pattern of HIV infections among MSM may mirror the distribution and migration patterns of the general population. Several hypotheses may help to target HIV interventions for MSM in the Caribbean, as follows:
- An estimated half of all HIV infections among MSM are concentrated in Jamaica, Trinidad and Tobago, and Guyana.
- A high number of MSM migrate among the Caribbean countries and between the Caribbean and the United States, Canada, and the United Kingdom.
- On islands with smaller populations (i.e., Saint Lucia, Saint Vincent and the Grenadines, Grenada, Dominica, Antigua and Barbuda, and Saint Kitts and Nevis), it would be possible to implement HIV programming for MSM at a scale that could reverse or end epidemics. These islands may have high percentages of MSM with HIV—for example, a study in Dominica found that 71 percent of all HIV cases were among MSM—but the total number of men to support may only be in the hundreds for each island. However, given the reality that most MSM and others within the LGBT community are hidden, hard to reach, and face the many challenges discussed previously, access to health education and treatment for STIs, including HIV, remains limited.
- The long-term sustainability of the Caribbean's HIV response may be affected by a variety of global changes that are taking place: new global health frameworks, attempts to create sustainable funding streams, and the development and implementation of new health technologies (e.g., fixed dose combinations for first-line and second-line antiretroviral therapy, point-of-care STI diagnostics and HIV monitoring tools, and HIV prevention technologies such as pre- and post-exposure prophylaxis). Health program planners and implementers in the Caribbean should take advantage of these changes in order to create sustainable, universal health and rights programming. Central to this would be the involvement of trained peer and lay health workers who can help MARPs access socially sensitive services.
In addition to the interventions in Table 1, community-level behavior change communication and outreach has worked at the individual level to help MSM increase their self-efficacy. Peer leadership and the "safe spaces" model, which allow MSM to come together to discuss their own needs and develop joint solutions to risky behaviors, have proven highly successful in a number of locations, including the United States (Kegeles, Hays, and Coates 2006).
Over the past five years, CHAA and USAID have recognized the value and outcomes of a comprehensive programming approach for MSM. USAID's approach addresses issues at multiple levels, from the individual to the structural. This approach encompasses improving individual behaviors, distributing essential commodities, building social capital, and ensuring linkages to appropriate health and social services.
Considerations for Improved Programming (cont.)
Improving Rights Environments
All of the independent Caribbean countries are signatories to basic international agreements that set global standards for human rights, including the 1966 International Covenant on Economic, Social, and Cultural Rights and International Covenant on Civil and Political Rights, the 2001 U.N. General Assembly Declaration of Commitment on HIV/AIDS, and the 2006 Political Declaration on HIV/AIDS. These agreements endorse basic human rights for all people—freedom of expression, freedom of association and assembly, freedom against unlawful violence, and equal access to justice—and call on their signatories to champion these rights wherever they are violated. As U.S. Secretary of State Hillary Clinton stated in a 2009 speech about proposed Ugandan anti-homosexuality legislation, "When injustice anywhere is ignored, justice everywhere is denied." Many Caribbean countries, however, still foster extensive legal and societal human rights violations.
Basic goals for human rights interventions should:
- Advance positive norms about gender, diversity, pluralism, and human rights
- Provide basic information about human rights and basic protection against violence, blackmail, arrest and incarceration, and social and economic marginalization
- Uphold standards of non-discrimination, safety, and confidentiality, and provide training, counseling, representation, support, and social mobilization and empowerment.
Key components of human rights interventions relating to HIV among MSM are described in Table 2. With regard to MSM in the Caribbean, rights-based interventions should follow these guidelines:
- Address the negative effects of masculine gender identities and gender roles. Researchers note that men's engagement in multiple sexual relationships and unprotected sex is often driven by the desire to prove their manhood. On the other hand, homosexuality is antithetical to the Caribbean notion of masculinity, creating a culture in which MSM are inclined to self-camouflage, having sex with—and marrying—women while also having sex with men. The resulting multiple partnerships and clandestine sexual activity drive HIV epidemics, yet this bisexual concurrency is almost entirely hidden due to societal disapproval of homosexuality (Houston n.d.; Lee et al. 2006).
- Reduce and eliminate constraints on men's health and access to health care. The threat of social exclusion, violence, blackmail, or arrest leads many MSM to avoid health services or to deny their homosexual behavior when they do access health services. Consequently, MSM who may have been exposed to HIV are less likely to obtain testing, counseling, or ongoing treatment. Health care providers should strive to target prevention messages and interventions to counteract this tendency.
- Engage expert stakeholders in program design, implementation, and monitoring. Far too few Caribbean MSM are able to provide informed input into national HIV program design or implementation. National health programs therefore lack the information that MSM could offer regarding potential improvements to HIV interventions.
- Strengthen national health programming. Many national health programs are sympathetic to scientific developments and good public health practice, but may face serious setbacks when opportunistic politics, sensationalist media, or discriminatory attitudes obstruct basic human rights.
- Engage the faith community. Across the Caribbean, religion plays an important and central role in setting societal norms, informing policies, influencing education, reinforcing cultural norms and identity, and guiding social morals. In the Eastern Caribbean countries, up to 80 percent of the population identify themselves as belonging to a faith denomination—mainly, but not exclusively, Christianity. With such high levels of population involvement in organized religion, it is essential for the faith community to be engaged in the national and regional HIV response to ensure a comprehensive, cohesive approach. CHAA has carried out four feasibility studies focused on the readiness and willingness of the faith community to engage in HIV projects, and, during the present project cycle, plans to advance this work and provide grants to faith-based organizations in each program country to begin implementing work to support the needs of MARPs, including MSM.
- Strengthen grassroots advocacy. Supporting and encouraging grassroots engagement is essential to rights-based programming, and ensures that members of the target population play central leadership roles in advocacy. The grassroots component supports the bottom-up impulse for rights-based change. It is critical to build up social capital among MSM peers and give them an avenue to explore change through advocacy. CHAA is adapting and rolling out a U.S. Centers for Disease Control and Prevention-tested intervention managed by the University of California, San Francisco known as Mpowerment. The Mpowerment Project is a model HIV prevention program designed specifically to address the needs of young MSM through a series of targeted interventions premised on a behavior change approach. (See www.mpowerment.org for more information.)
TABLE 2: COMPONENTS OF RIGHTS-BASED INTERVENTIONS TO ADDRESS HIV AMONG MSM
Several regional human rights initiatives endorse the principles of human rights as foundations of HIV program effectiveness and are seeking to facilitate local action and resilience. Those initiatives are as follows:
- In April 2009, the Commonwealth Lawyers Association (CLA) called on the Secretary-General of the British Commonwealth to establish a diverse group of consultants about the potential for decriminalizing sexual orientation in Commonwealth countries.
- In June 2009, the Organization of American States (OAS) approved a resolution on human rights, sexual orientation, and gender identity in the Americas at its 39th General Assembly session. This non-binding OAS Resolution 2504 and a preceding Resolution 2435, adopted by all Caribbean countries, called on all nations to condemn acts of violence and other crimes based on sexual orientation and gender identity, to investigate and prosecute such crimes, and to protect human rights defenders.
- In 2009, a Caribbean Regional Task Force on HIV, Homophobia, Stigma and Discrimination, and Human Rights was formed, with key participating organizations including PANCAP, CLA, the U.N. Special Envoy on AIDS, UNAIDS, UNDP, and the U.N. Development Fund for Women.
- The Caribbean Broadcast Media Partnership has engaged its members in conversations about potential antidiscrimination campaigns, with a 2009 consultation suggesting a media campaign theme of "All of us are different, but all of us have rights" (to be adapted to local terms).
- In keeping with the World AIDS Day 2009 theme of "Universal Access & Human Rights," the CVC presented highlights of human rights work being conducted in Jamaica, the Dominican Republic, Belize, Suriname, Saint Lucia, and Curacao, and recommitted to focus on human rights as a significant feature of the majority of issues that confront MSM and other vulnerable populations in the Caribbean.
Considerations for Improved Programming (cont.)
Reinforcing Leadership from Governments
Caribbean heads of government bear the ultimate responsibility for scaling up action against HIV. Program directors should request that governments enlist maximum support from all sectors and ensure strong management within interventions. National governments can implement and expand national HIV programming under the existing Caribbean Regional Strategic Framework and through multicountry and regional coordinating mechanisms such as PANCAP (PANCAP 2002).
Program implementers should work with national governments and regional mechanisms such as PANCAP to support intensified leadership and action in the following ways:
- Consistently champion principles of human rights, specifically the rights and equality of all people regardless of sexual orientation or gender identity. Endorse evidence-based policies and programs that respond to the documented needs of MSM in the Caribbean.
- Advocate for effective, transparent, and accountable management of HIV-related programs and resources, with the involvement of the communities who are the intended beneficiaries.
- Support regional training, capacity building, and fundraising for HIV interventions targeted to MSM.
Reinforcing Leadership from Communities
MSM and their advocates have always been at the forefront of the global response against HIV. Throughout the Caribbean, community members are working with discretion and perseverance to develop and sustain HIV programming for MSM; even in the smallest Caribbean islands, these individuals provide counseling and health services, build peer support networks, and speak out in the media on behalf of the health and rights of MSM. MSM and their allies in the Caribbean are needed both as leaders and as technical experts for these community-level interventions (Merson et al. 2008a).
During the past two decades, no Caribbean country has been spared the sensationalist media and local politics that threaten effective HIV programming for marginalized populations. MSM and their allies have direct experience with these undermining forces; they also have an enduring stake in both sustaining and expanding local services for HIV and addressing human rights issues. HIV prevention cannot succeed in the Caribbean without an accurate, current understanding of the complex dynamics of HIV exposure in local contexts. Similarly, scale-up of HIV testing, treatment, and care cannot succeed without accurate understanding of how these services might be accessed by target populations. For these reasons, MSM need to be involved as experts in the design and implementation of HIV-related health and human rights policies, practices, and interventions.
Health program planners and implementers should support intensified community leadership and action by and for MSM and their allies, following the recommended strategies of Caribbean MSM themselves (Carr 2008; ICASO 2009):
- Support regional organization and training for HIV programs for MSM to increase the potential of—and networks available to—interventions.
- Support opportunities for MSM-led community groups to have input into HIV programs, specifically to monitor how programs address their communities' health and rights needs.
- Support the core costs of community organizations, including personnel costs, space, information and communications technology, and management capacity.
Regional Caribbean Resources and Contacts
Key Regional Organizations
Asociación para la Salud Integral y la Ciudadanía de América Latina y el Caribe (Association for Integral Health and Citizenship in Latin America and the Caribbean or ASICAL)
A regional network of organizations supporting HIV programs among MSM, with participating groups from Mexico, Guatemala, Dominican Republic, Colombia, Ecuador, Peru, Brazil, Argentina, and Chile.
Caribbean Coalition of Vulnerable Communities (CVC)
A regional network of community groups in more than eight Caribbean countries working with MSM, sex workers, drug users, prisoners, and youth.
Regional hub (Jamaica) contact: Ian McKnight
Regional hub (Dominican Republic) contact: John Waters
Caribbean Forum for the Liberation of Genders and Sexualities (CARIFLAGS)
A non-incorporated affiliative group focused on the health and rights issues of sexual and gender minorities, comprising more than 35 advocates, allies, and organizations in 16 Caribbean countries.
Contact: Mario Kleinmoedig, Curacao
Caribbean HIV&AIDS Alliance (CHAA):
A regional nongovernmental organization working with vulnerable and most at risk communities to mitigate the impact of HIV. Extensive experience in rolling out comprehensive prevention programs with MARPs focused on building social capital, behavior change communication, addressing the social and structural barriers to accessing health services, and challenging stigma and discrimination.
Caribbean Trans in Action (CTA)
A non-incorporated affiliative group of transgender activists in more than 12 Caribbean countries advocating for the human rights and health of transgender persons in the region.
Contact: Mia Quetzal, Belize
Congreso de Organizaciones Gay de Centroamérica (Congress of Gay Organizations of Central America or CONGA)
A Central American coalition of organizations in seven countries focused on fighting homophobia and promoting LGBT rights, with HIV prevention work currently underway in Honduras, Nicaragua, and Costa Rica.
Contact: Norman Guttierrez, CEPRESI
Pan Caribbean Partnership Against HIV/AIDS (PANCAP)
A Caribbean regional collaboration mechanism working to advance HIV responses under the CARICOM Caribbean Regional Strategic Framework.
Contact: Carl Browne, PANCAP Coordinating Unit Director
Regional HIV Contacts in Latin America and the Caribbean
Latin America: Cesar Antonio Nuñez, Regional Director
Latin America: Maria Tallarico, RST HIV Cluster Leader
Caribbean: Salim October, Caribbean Subregional Focal Point
Rafael Mazin, Regional Advisor on HIV/AIDS
Key UNAIDS and UNAIDS-sponsored Documents
Cáceres, C., K. Konda, and E. Segura (Cayetano Heredia University School of Public Health, Lima), and R. Lyerla (UNAIDS). 2008. Epidemiology of Male Same-Sex Behaviour and Associated Sexual Health Indicators in Low and Middle-income Countries: 2003-2007 Estimates.
Cáceres, C., M. Pecheny, T. Frasca, R. R. Rios, and F. Pocahy. 2009. Review of Legal Frameworks and the Situation of Human Rights Related to Sexual Diversity in Low and Middle Income Countries. (PDF, 516 KB)
PAHO. forthcoming. "Sexual Health Assessment and Intervention Algorithms for Men Who Have Sex with Men."
UNDP. 2008. A New Agenda for Mainstreaming HIV in Low-Prevalence Environments, Review and Summary of Main Papers and Presentation. Delhi: UNDP.
AIDS Projects Management Group. 2009. The Policy and Practice Landscape for HIV Prevention, Treatment, and Care Among Gay and Other Men Who Have Sex with Men—Some Lessons from the Response Among Injecting Drug Users.
Altman, D. 2005. Rights Matter: Structural Interventions and Vulnerable Communities. Health and Human Rights 8(2):203–213.
Asociación para la Salud Integral y la Ciudadanía de América Latina y el Caribe. 2005. Desafíos y Lecciones Aprendidas: Prevención de las ITS, el VIH y el SIDA Entre Hombres Gay y Otros Hombres que Tienen Sexo con Hombres en América Latina y el Caribe Latino.
Baral, S., F. Sifakis, F. Cleghorne, and C. Beyrer. 2007. Elevated Risk of HIV Infection Among Men Who have Sex with Men in Low- and Middle-Income Countries 2000-2006: A Systematic Review. PLoS Medicine 4(12).
Baral, S., G. Trapence, F. Motimedi, S. Lipinge, F. Dausab, and C. Beyrer. 2008. HIV Prevalence, Risks for HIV Infection, and Human Rights Among Men Who Have Sex with Men (MSM) in Malawi, Namibia, and Botswana. PLoS ONE 4(3):e4997.
Beyrer, C., S. Baral, F. Sifakis, A. Wirtz, B. Johns, and D. Walker. 2010. The Global HIV Epidemics Among Men Who Have Sex with Men (MSM): Epidemiology, Prevention, Access to Care, and Human Rights. Washington, DC: The World Bank.
Cáceres, C., K. Konda, M. Pecheny, A. Chatterjee, and R. Lyerla. 2006. Estimating the Number of Men Who Have Sex with Men in Low- and Middle-Income Countries. Sexually Transmitted Infections 82(suppl 3):iii3–9.
Cáceres, C., K. Konda, E. R. Segura, and R. Lyeria. 2008. Epidemiology of Male Same-Sex Behaviour and Associated Sexual Health Indicators in Low- and Middle-Income Countries: 2003-2007 Estimates. Sexually Transmitted Infections 84:i49–i56.
Cáceres, C., M. Pecheny, T. Frasca, R. R. Rios, and F. Pocahy. 2009. Review of Legal Frameworks and the Situation of Human Rights Related to Sexual Diversity in Low- and Middle-Income Countries. Sexually Transmitted Infections 84:i49–i56. (PDF, 546 KB)
Carr, R. 2006. "Value Added of Community Care for Marginalised Groups." Presentation given at the regional meeting Universal Access by 2010: Addressing the Gap, Castries, St. Lucia, June 25–27.
Carr, R. 2008. "Challenges in Developing Strong Global Fund Proposals Related to Sexual Minorities, and What to Do About These Barriers." Paper presented at the Global Fund Partnership Forum, Senegal, December 8–10.
Castel, A., R. Samala, A. Griffin, T. West-Ojo, A. Greenberg, N. Rocha, and S. Hader. 2010. "Monitoring the Impact of Expanded HIV Testing in the District of Columbia Using Population-Based HIV/AIDS Surveillance Data." Abstract 34. Presented at the 17th Conference on Retroviruses and Opportunistic Infections, San Francisco, CA, February 16-19.
Coates, T. J., L. Richter, and C. Cáceres. 2008. Behavioural Strategies to Reduce HIV Transmission: How to Make Them Work Better. Lancet 372(9639):669–684.
Colvin, M., M. Gorgens-Albino, and S. Kasedde. 2009. Analysis of HIV Prevention Response and Modes of HIV Transmission: The UNAIDS-GAMET Supported Synthesis Process. Geneva: Joint U.N. Programme on HIV/AIDS.
CVC Healthcare Working Group. forthcoming. Access to Healthcare for Vulnerable Groups. CVC Healthcare Working Group.
Day, M. (Caribbean Harm Reduction Coalition). Personal correspondence. May 2010.
Denison, J. A., K. R. O'Reilly, G. P. Schmid, C. E. Kennedy, and M. D. Sweat. 2008. HIV Voluntary Counseling and Testing and Behavioral Risk Reduction in Developing Countries: A Meta-Analysis, 1990-2005. AIDS and Behavior 12(3):363–373.
Diouf, D., A. Moreau, C. Castle, G. Engelberg, and P. Tapsoba. 2004. "Working with the Media to Reduce Stigma and Discrimination Towards MSM in Senegal." Abstract WePeC6153. Presented at the XV International AIDS Conference, Bangkok, July 11–16.
Ehrhardt, A. A., S. Sawires, T. McGovern, D. Peacock, and M. Weston. 2009. Gender, Empowerment, and Health: What Is It? How Does It Work? Journal of Acquired Immune Deficiency Syndrome 51(Suppl. 3):S96–S105.
Gayet, C., and A. Fernández-Cerdeño. 2009. "Time Location Sampling and Respondent Driven Sampling: Techniques Implementation for Monitoring Concentrated HIV/AIDS Epidemic in Mexico." Paper presented at the IUSSP International Population Conference, September 27-October 2.
de Groulard, M., G. Sealy, B. Brathwaite, P. A. Russell-Brown, H. Wagner, C. O'Neil, C. Allen, and J. Emmanuel. 2000. "Homosexual Aspects of the HIV/AIDS Epidemic in the Caribbean: A Public Health Challenge for Prevention and Control." International Conference on AIDS Abstract 13:ThOrD732.1
Gruskin, S., and L. Ferguson. 2008. "Ensuring an Effective HIV Response for Vulnerable Populations: Assessing National Legal and Policy Environments." Paper presented at the XVII International AIDS Conference, Mexico City, Mexico, August 3–8.
Gruskin, S., and L. Ferguson. 2009. Government Regulation of Sex and Sexuality: In Their Own Words. Reproductive Health Matters 17(34):108–118.
Gupta, G. R., J. O. Parkhurst, J. A. Ogden, P. Aggleton, and A. Mahal. 2008. Structural Approaches to HIV Prevention. Lancet 372(9640):764–775.
Healthy People 2020. 2001. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. Washington, DC: U.S. Department of Health and Human Services.
Heckathorn, D. 1997. Respondent-Driven Sampling: A New Approach to the Study of Hidden Populations. Social Problems 44(2).
Herbst, J. H., R. T. Sherba, N. Crepaz, J. B. Deluca, L. Zohrabyan, R. D. Stall, and C. M. Lyles. 2005. A Meta-Analytic Review of HIV Behavioral Interventions for Reducing Sexual Risk Behavior of Men Who Have Sex with Men. Journal of Acquired Immune Deficiency Syndrome 39(2):228–241.
Holtgrave, D., and J. McGuire. 2007. Impact of Counseling in Voluntary Counseling and Testing Programs for Persons at Risk for or Living with HIV Infection. Clinical Infectious Diseases 45(s4):S240–S243.
International Association of AIDS Service Organizations (ICASO). 2009. Opportunities for Including Community Systems Strengthening (CSS) in Proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria. (PDF, 141 KB)
International HIV/AIDS Alliance. 2009. Report on Access to Global Fund Resources by HIV/AIDS Key Populations in Latin America and the Caribbean. United Kingdom: International HIV/AIDS Alliance.
Jamaica's Forum for Lesbians, All-Sexuals and Gays. Personal correspondence. May 2010.
Johnson, W. D., D. R. Holtgrave, W. M. McClellan, W. D. Flanders, A. N. Hill, and M. Goodman. 2005. HIV Intervention Research for Men Who Have Sex with Men: A Seven-Year Update. AIDS Education and Prevention 17(6):568–589.
Kegeles, S. M., R. B. Hays, and T. M. Coates. 2006. The Mpowerment Project: A Community-Level HIV Prevention Intervention for Young Gay Men. American Journal of Public Health 86(8):1129-1136.
Kippax, S. 2008. Understanding and Integrating the Structural and Biomedical Determinants of HIV Infection: A Way Forward for Prevention. Current Opinion in HIV and AIDS 3(4):489–494.
Koblin, B., M. Chesney, and T. Coates. 2004. Effects of a Behavioural Intervention to Reduce Acquisition of HIV Infection Among Men Who Have Sex with Men: The EXPLORE Randomised Controlled Study. Lancet 364(9428):41–50.
Lee, D., C. Fairley, R. Cummings, M. Bush, T. Read, and M. Chen. 2010. MSM Prefer Rapid Testing for Syphilis and May Test More Frequently Using It. Sexually Transmitted Diseases 2010;37(9):557–558.
Lee, R. K., C. Poon-King, G. Legall, C. Trotman, S. Samiel, and C. O'Neil. 2006. "Risk Behaviours for HIV Among Men Who Have Sex with Men in Trinidad & Tobago." Abstract CDD0366. Presented at the XVI International AIDS Conference, Toronto, Canada, August 13–18.
Liau, A., G. Millett, and G. Marks. 2006. Meta-Analytic Examination of Online Sex-Seeking and Sexual Risk Behavior Among Men Who Have Sex with Men. Sexually Transmitted Diseases 33(9):576–584.
Magnani, R., K. Sabin, T. Saidel, and D. Heckathorn. 2005. Review of Sampling Hard-to-Reach and Hidden Populations for HIV Surveillance. AIDS 19(Suppl 2):S67–S72.
Maiorana, A., J. Myers, G. Rebchook, G. Bombereau-Mulot, R. Lall, N. Kassie. 2010. "Assessing the Feasibility and Acceptability of Implementing the Mpowerment Project, an Evidence-Based HIV Prevention Intervention for Gay Men, in Barbados." Abstract no. TUPE0684. Presented at the XVIII International AIDS Conference, Vienna, July 18–23, 2010.
Makadon, H. J., K. H. Mayer, J. Potter, and H. Goldhammer, eds. 2008. The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Philadelphia, PA: American College of Physicians.
Mansergh, G., S. Naorat, R. Jommaroeng, R. Jenkins, S. Jeeapant, K. Kanggarnrua, et al. 2006. Adaptation of Venue-Day-Time Sampling in Southeast Asia to Access Men Who Have Sex with Men for HIV Assessment in Bangkok. Field Methods 18:135–152.
Marks, G., N. Crepaz, J. W. Senterfitt, and R. S. Janssen. 2005. Meta-Analysis of High-Risk Sexual Behavior in Persons Aware and Unaware they are Infected with HIV in the United States: Implications for HIV Prevention Programs. Journal of Acquired Immune Deficiency Syndrome 39(4):446–453.
Martin, C. 2005. Multi Centric Study with Vulnerable Populations, Unpublished Final Report, Belize. Atlanta, GA: U.S. Centers for Disease Control and Prevention.
Merson, M., J. O'Malley, D. Serwadda, and C. Apisuk. 2008a. The History and Challenge of HIV Prevention. Lancet. 372 (9637): 475-488.
Merson, M., N. Padian, T. J. Coates, G. R. Gupta, S. M. Bertozzi, P. Piot, et al. 2008b. Combination HIV Prevention. Lancet 372(9652):1805–1806.
Moncada, J., J. Schachter, S. Liska, C. Shayevich, and J.D. Klausner. 2009. Evaluation of Self-Collected Glans and Rectal Swabs from Men Who Have Sex with Men for Detection of Chlamydia Trachomatis and Neisseria Gonorrhoeae by Use of Nucleic Acid Amplification Tests. Journal of Clinical Microbiology 47(6):1657–1662.
Niang, C., A. Moreau, K. Kostermans, H. Binswanger, C. Compaore, M. Diagne, et al. 2004. "Men Who Have Sex with Men in Burkina Faso, Senegal, and The Gambia: The Multi-Country HIV/AIDS Program Approach." Abstract WePeC6156. The XV International AIDS Conference, Bangkok, July 11–16.
Orozco, C. (UniBAM.) Personal correspondence. May 2010.
Pan American Health Organization (PAHO) and the World Health Organization (WHO). 2006. Assessment Report for the Evaluation of National Services for the Prevention of Mother to Child Transmission of HIV and Syphilis, 2000–2005. Washington, DC: PAHO and WHO.
PANCAP. 2009. Global Fund Round 9 Proposal.
Pao, D., D. Pillay, and M. Fisher. 2009. Potential Impact of Early Antiretroviral Therapy on Transmission. Current Opinon in HIV and AIDS 4(3):215–221.
Peacock, D., L. Stemple, S. Sawires, and T. J. Coates. 2009. Men, HIV/AIDS, and Human Rights. Journal of Acquired Immune Deficiency Syndrome 51(Suppl 3):S119–S125.
Piot, P., M. Bartos, H. Larson, D. Zewdie, and P. Mane. 2008. Coming to Terms with Complexity: A Call to Action for HIV Prevention. Lancet 372(9641):845–859.
Quinn, T. C., M. J. Wawer, N. Sewankambo, D. Serwadda, C. Li, F. Wabwire-Mangen, et al. 2000. Viral Load and Heterosexual Transmission of Human Immunodeficiency Virus Type 1. New England Journal of Medicine 342(13):921–929.
Silverman, B., and T. Gross. 1997. Use and Effectiveness of Condoms During Anal Intercourse: A Review. Sexually Transmitted Diseases 24(1):11–17.
Simpson, J., and I. McKnight. 2010. "Caribbean Trans in Action: Building a Caribbean Regional Transgender Movement." Paper presented at the XVIII International AIDS Conference, Vienna, Austria, July 18–23.
Trinidadian and Tobagonian business owners. Interviews. April 2008.
UNAIDS. 2003. "Sexual Behaviour Change and HIV/AIDS: Challenges and Experiences." Amsterdam: Share-Net, Netherlands Network on Sexual & Reproductive Health and AIDS.
UNDP-Guyana, SASOD, and GuyBow. Personal correspondence. May 2010.
University of Michigan Medical School. 2005. Caring for Lesbian, Gay, Bisexual, and Transgender Patients, A University of Michigan Resource Guide. Ann Arbor, MI: University of Michigan Medical School.
Vermund, S. H., K. L. Allen, and Q. A. Karim. 2009. HIV-Prevention Science at a Crossroads: Advances in Reducing Sexual Risk. Current Opinion in HIV and AIDS 4(4):266–273.
Vernazza, P., B. Hirschel, E. Bernasconi, and M. Flepp. 2008. HIV Transmission Under Highly Active Antiretroviral Therapy. Lancet 372(9652):1806–1807.
Vittinghoff, E., J. Douglas, F. Judson, D. McKirnan, K. MacQueen, and S. P. Buchbinder. 1999. Per-Contact Risk of Human Immunodeficiency Virus Transmission Between Male Sexual Partners. American Journal of Epidemiology 150(3):306–311.
Wagner, U., and B. Camara. 1997. "More Effective HIV Prevention Through Strengthening of Epidemiological Surveillance in the Caribbean." Paper presented at the Congress of the German Society for Tropical Medicine, Heidelberg, Germany, September 24–27.
Waters, J. forthcoming. MSM, Transgender Persons, and Sex Workers in the Caribbean: A Level Ground Look at Underground Behaviour and How It Affects Us All. Washington, DC: PAHO and WHO.
Waters, J. (Centro de Orientation Integral). Personal correspondence. March 2010.
Weller, S., and K. Davis. 2002. Condom Effectiveness in Reducing Heterosexual HIV Transmission. Cochrane Database System Review 1:CD003255.
White, R., and R. Carr. 2005. Homosexuality and HIV/AIDS Stigma in Jamaica. Culture, Health & Sexuality 7(4):1–13 and 347–359.
WHO. 2010. Mental Health Gap Action Programme (mhGAP). Geneva: WHO.
Wickramasuriya, T. 1994. Attitudes of Medical Students at Cave Hill Campus Towards AIDS. West Indian Medical Journal 43(Suppl. 1):22.