-20,000 new infections, approx. 250,000 PLHIV for 2010 alone
AMIDST reports of seeing a stabilizing or significant reduction in new infections in some 56 countries across the world at the end of 2010, the reality for the Caribbean is that HIV continues to spread unabated across the region, in spite of a reported decline in a few countries. For the year under review, there were 20,000 new infections, and of the approximate quarter-million people living with HIV in the Region, by the end of the reporting period, some 12,000 persons aged 15-44 had died of AIDS-related illnesses.
This startling revelation was made by UWI (University of the West Indies)’s Dr. J. Peter Figueroa, Professor of Public Health, Epidemiology and HIV/AIDS, as he delivered the feature lecture at the 56th Annual Council and Scientific Meeting held at the Princess Hotel here in Georgetown.
The lecture, titled ‘The Challenge of HIV Prevention in the Caribbean’, was the first of a series of presentations on the opening day of the conference, which ran from April 14-16, and was attended by a large gathering of high-profile CHRC (Caribbean Health Research Council) delegates drawn from around the Caribbean region.
Noting that HIV continues to spread in the Caribbean, despite the few countries now showing a decline, Dr. Figueroa, after critically and analytically examining the dynamics of the spread and impact of the disease in the Caribbean, said:
“We need to expand our programmes in HIV Prevention, using a combination of approaches which we need to monitor and evaluate. And we have to build our capacities in order to expand coverage and improve the quality of what we do. We must begin to come to grips with some of the structural changes that we need in our society, to reduce our social vulnerability and improve the lot of many of those who are marginalized.”
Of the more than quarter-million people living with HIV in the Caribbean, Dr. Figueroa, who is based at UWI’s Mona Campus, identified Haiti as having about 50% of this amount, with the Dominican Republic accounting for another 60,000, and Jamaica about another 32,000. Those three countries alone, he said, account for about 200,000 PLHIV, hence the need for much more work to be done.
But while each country will have their own national response for dealing with HIV, Dr. Figueroa said: “… truth is… if we were to control the epidemic in the Caribbean, it would have to be through the coverage quality and resources invested, combining different approaches.”
On that score, he cited a number of critical areas that need to be addressed as a precursor to confronting the challenges of HIV prevention. For instance, he is of the opinion that given the magnitude of the spread and impact of the epidemic in the Caribbean, germane to achieving any measurable success in confronting the challenges of HIV prevention would be to first consider what the main drivers of the epidemic are.
And one of the crucial approaches, he said, would be to look at where the bulk of the HIV infections is coming from; whether from this or that section of the population, as such knowledge would help determine the drivers of the epidemic at any given time, in our given context. 
“We need to understand our cultural context, and we have to monitor and evaluate what we do,” Dr. Figueroa said.
Among behaviours considered key drivers of the epidemic are:
* the high risk habits of some heterosexual men, especially unprotected sex
* having multiple sex partners and transactional sex;
* transactional sex whereby even persons who are not ‘sex workers’ give sex in exchange for favours or rewards
* Men having sex with men (MSM), engaging in unprotected anal intercourse with bi-sexuals (down low), acting as a breach to the general population
* Men having sex with men and not using condoms, or informing their partners of their status
* The reluctance of many persons, especially the most at risk persons (MARPS), to use condoms
* Others who, after having sex with a partner for a certain period of time, do not bother to use condoms anymore, even though they might not have taken the HIV test
* Early sexual activity among young people

Noting that young people should be considered a priority in the national response to HIV, Dr. Figueroa said that sexual activity among young men now begins around 16, while for girls it has dropped from ‘over 18’ to ‘under 17’ in the last 15 years.
“We are not going to get away from the reality of young people being sexually active,” he said, adding that “the current approach to the problem among adults appears to be to pretend that they [the young people] are not sexually active…”  He proposed the inclusion of sex education in schools and condom demonstrations as part of the response.
Considering the controversial sexual patterns within society, which ultimately put all sexually active persons at risk, Dr. Figueroa, contended that given the high rate of HIV sexual transmission, all Men who have Sex with Men, constitute a clear breach to the general population, especially since, very often, they do not disclose their status to their partners.
Commenting on the risk factors in relation to sex workers and other vulnerable or most at-risk persons (MARPS), Professor Figueroa also shared the findings of surveys done in named Caribbean countries, targeting sex workers in the streets, bars and night clubs.
“We took urine and blood samples and checked for HIV and other STI’s. The results revealed that 65% of sex workers on the streets had some sexually-transmitted infections, and about 16 percent of them were HIV-infected. For sex-workers in the bar, as many as 40% of them had a STI.”
Interestingly enough, 30% of the women who frequented clubs and claimed they didn’t have more than one sex partner had some sort of STI when tested. About 23% of the males had STIs.
And on HIV rates among MSM in Jamaica, for example, Professor Figueroa said:
“This is really a problem there, and the rates of HIV infection have continued to remain high.”
He, however, cautioned against excluding such persons from society, adding that it is a signal that could lead to them taking more risks. On this note, he alluded to MSM going underground because of Stigma and Discrimination, and eventually turning to female partners, making them vulnerable. But again, the reality is that many people living with HIV still do not know their status, hence the importance of getting tested.
He listed as being among methods of prevention: Condom use; Male Circumcision, Behavioural Change; Mother-to-Child Transmission; Voluntary Counselling and Testing; anti-retroviral Therapy (Treatment as Prevention); microbicide trials – only one of which has so far shown some promise; and Pre-Exposure Prophylaxis (Pre-P), now being tested.
Of the lot, he rated condom use as the most effective tool against HIV transmission, but added that even condoms must be used consistently [and correctly] if they are to continue to be effective.
“The efficiency of transmission prevention,” he said, “is going to depend on whether you use a condom.  Condoms are effective, but their use must be consistent.”
And, making the case for male circumcision, which has made a big impact on HIV prevention, Dr Figueroa proposed the promotion of infant male circumcision, saying that a man who is circumcised is at less risk of contracting HIV.
Testimony to the efficacy of this intervention, he said, is the some 28,000 new infections being averted in the Caribbean countries over a ten-year period.  Prevention-of Mother-to-Child Transmission has also recorded measured success, with some countries in the Caribbean seeing the rate of transmission come down to just about 5% at this time.
Said Dr. Figueroa, having explored the various options: “There’s no magic bullet to HIV Prevention,” adding that there might be need to find a “magic knife” instead to cut transmission rates. In this regard, he suggested combining different approaches to prevention.
Coming up with a blueprint for confronting the challenge of HIV Prevention in the Caribbean, Professor Figueroa submitted the following: 

* We need to integrate HIV Prevention with other cultural and social programmes
* Place more emphasis on strategic structural changes and put in place, policies that will address the underlying social determinants, and not just the risk factors that are pushing the HIV epidemic.
* We need to model acceptance and support for Persons Living with HIV
* Have anti-discrimination policies and laws governing HIV
* Countries should have the capacity to respond with more training in HIV prevention

In the circumstances, Dr. Figueroa posited that, we in the Caribbean should not be too optimistic and assume that what we are doing in terms of prevention is actually working. “We really have to try and evaluate our approaches better,” he cautioned.

Testimony to the importance of HIV/AIDS as a public health concern in the Caribbean, about ten other HIV/AIDS related topics were slated for the opening day of the Conference.