An overview of the global epidemic
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The Caribbean is the second-most affected area in the world after sub-Saharan Africa, with a regional prevalence of 2.3% or one in 43 adults living with the virus, largely concentrated in five countries with prevalence above 2% – the Bahamas, Belize, Guyana, Haiti and Trinidad and Tobago, though Jamaica has the largest number of people with AIDS after Haiti. UNAIDS estimates that 440,000 people were living with HIV/AIDS in the Caribbean at the end of 2004. An estimated 53,000 people were newly infected with HIV during 2004 and 36,000 deaths due to AIDS occurred during that year. 

Over the past decade, the ratio of men with HIV to women with HIV has narrowed considerably and now nearly as many women as men are infected – about 49% of the total.

By and large the epidemic in the Caribbean is concentrated among heterosexuals, with sex between men and women being the main route of transmission. There is also evidence of a high rate of HIV infection among injecting drug users in Puerto Rico, where 43% of all HIV cases were among injecting drug users.

Rates of seroprevalence among men who have sex with men in Jamaica rose from around 10% in 1985 to 15% in 1986, then doubled to 30% over the next decade, but there have been no sentinel surveys among gay men since 1996, and present prevalence among gay men in a country where homosexuality is violently stigmatised is unknown.

Among heterosexuals, a similar disparity is opening up between men and women in infection rates as in Africa. In the Dominican Republic, women under 24 were twice as likely to be infected as their male peers and in Jamaica teenage girls (10-19) are 2.5 times as likely to have HIV as boys. The heterosexual epidemic of the Caribbean has two major driving forces; the early initiation of sexual relationships and the high turnover of sexual partners, common among young people. As is the case in Africa, girls are placed at risk of infection because of the fact that there is much sexual mixing, with young girls frequently becoming the partners of older men.

Twelve countries in this region, including the Dominican Republic and Haiti, several Central American countries (such as Belize and Honduras), and Guyana and Suriname, have an estimated HIV prevalence of 1% or more among pregnant women.

The worst affected countries are

 

Haiti

Around 260,000 people or 5.6% of the adult population are estimated to be living with HIV. Haiti has by far the worst epidemic of all the countries in the Caribbean. By the end of 1999, it has been estimated that almost 75,000 children had become orphaned by the epidemic. However the most recent data suggest a decline in HIV prevalence, with rates among women attending antenatal clinics falling from 4.5% in 1996 to 2.8% in 2003/4. A decline in prevalence in young people appears to be driven by lower incidence, but reductions in prevalence appear to have occurred among all age groups, a fact not easily explained.

Dominican Republic

In this country, sharing the island of Hispaniola with Haiti, about 85,000 people are living with HIV/AIDS, or 1.7% of the adult population.

Sentinel surveillance data from 1991 to 2001 suggest that HIV prevalence among pregnant women has stabilised or perhaps begun to decline in the Dominican Republic (where estimated adult HIV prevalence was 2.5% in 2001). These findings appear to correlate with evidence of increased condom use among female sex workers and a reduction in the number of sexual partners among men.

Jamaica

Jamaica has about 21,000 people with HIV, or 1.2% of the adult population, with nearly half (10,000) being women. The island has a long-established epidemic which means that it has the highest number of AIDS cases in the region after Haiti, with about 900 cases reported annually since 1999, and around 640 AIDS-related deaths. The most recent round of surveillance suggests no slackening off in the epidemic, with rates of 8% in men and 5% in women attending STI clinics and prevalence among pregnant women consistently at about 1.4%. 

Guyana

This country is on the South American mainland but is generally counted as a Caribbean country because of its historical ties to the UK. It is the worst-affected country in South America, with 11,000 people affected or 2.5% of the population.

Recent statistics reveal that the country is faced with a generalized HIV/AIDS epidemic affecting both males and females, and also children as a result of the predominantly heterosexual transmission of the epidemic.

Guyana recorded a total of 3163 HIV cases from 1982 to 2002. AIDS is currently the leading cause of death among persons in the 25–44 year age group, and the second leading cause of death overall. A cumulative total of 2588 deaths has been officially recorded.

Other countries

Trinidad and Tobago is seeing a steadily rising epidemic, with around 2.5% of the population infected. Life expectancy on the two islands is projected to be nine years lower than it would have been without AIDS in 2010. In contrast The Bahamas and Barbados seem to have had some prevention success. In the Bahamas HIV prevalence among pregnant women fell from 4.8% in 1993 to 3% in 2002, and in Barbados from 0.7% in 1999 to 0.3% in 2003. New HIV cases fell in the Bahamas from 734 in 1994 to 396 in 1999 and have remained at that level.

Cuba is the exception among Caribbean nations, with 3,300 people infected or considerably under 0.1% of the adult population. This is partly due to Fidel Castro’s highly controversial policy of quarantining people with HIV in the 1980s – a policy now abandoned. However there has been a fivefold increase in new cases between 1995 and 2000, largely among men who have sex with men.