Homosexual Aspects of the HIV/AIDS Epidemic in the Caribbean: A Public Health Challenge for Prevention and Control: Homosexual Aspects of the HIV/AIDS Epidemic in the Caribbean: A Public Health Challenge for Prevention and Control Michel de Groulard, Godfrey Sealy, Brader Brathwaite Pauline A. Russell-Brown, Hans-Ulrich Wagner Cheryl O’Neil, Caroline Allen, Emmanuel Joseph


Reported AIDS Cases in CAREC Member Countries, 1982 - 1998: Reported AIDS Cases in CAREC Member Countries, 1982 - 1998


Gender Distribution of Reported Adult AIDS Cases in CMCs 1982-1998: Gender Distribution of Reported Adult AIDS Cases in CMCs 1982-1998


Categories of Transmission in Reported Adult Male AIDS Cases through Sexual Contacts 1992 - 1998: Categories of Transmission in Reported Adult Male AIDS Cases through Sexual Contacts 1992 - 1998


Male Risk Category by Year in Trinidad & Tobago: Male Risk Category by Year in Trinidad & Tobago


Homosexuality in the Caribbean: Homosexuality in the Caribbean Criminal offence in most countries High level of stigmatisation and discrimination Rejected by families and communities Subject to physical violence Individuals and practices driven underground Sexual orientation not fully accepted Individuals remain “in the closet” or adopt socially acceptable heterosexual visible lifestyle


MSM & HIV in the Caribbean: MSM & HIV in the Caribbean High stigma of HIV positive sero status Double stigma for HIV+ and MSM Limited communication with MSM and within the openly gay/bisexual community Nonchalant and fatalistic attitude Culture of silence and secrecy


Methods: Methods Exclusively qualitative research methods Focus groups and in-depth interviews Building mutual trust (investment of time, participating in social interactions) Maintaining confidentiality (fear of being seen and identified)


121 Participants (focus groups and Individuals interviews): 121 Participants (focus groups and Individuals interviews) Trinidad 25 Grenada 9 St. Lucia 22 Barbados 8 Tobago 4 St Kitts 15 Antigua 11 Dominica 6 St Vincent 21


Results: Social Determinants: Results: Social Determinants Communication and social interaction between classes and age groups is limited Lack of trust - within MSM and wider society Social status mediates ability to cope Social class dictates patterns of socialising and sexual mixing Stronger sense of identity among younger and more educated MSM


Results: Sexual Patterns: Results: Sexual Patterns Communities of interest on the basis of sexual preferences, sex practices Multiple meanings of “sex” Negotiated safety of sexual intercourse Partner selection patterns are class related


Results: Sexual Patterns: Results: Sexual Patterns Size of MSM community larger than one would think Increased MSM activity for economic need rather than sexual orientation or preference Trading sex, or sex with tourists for survival Straight-identified men travel to other islands to meet male partners


Results: MSM and HIV: Results: MSM and HIV Safe sex known but hardly practised Condoms reduce sexual pleasure Condom use mitigated by “knowledge” of partner Skills for negotiating condom use at minimum Limited support towards HIV+ MSM Lack of discretion in sharing information on sero- or health status of MSM


Results: Access to Health Care: Results: Access to Health Care Absence of privacy in health care settings for testing and counselling Heath care providers perceived as judgmental and unable to respect confidentiality Preference for private physicians and hospital Reluctance to seek care from heterosexual medical practitioners


Conclusions: Conclusions First study of this kind in the Caribbean Co-existence of heterosexual and homosexual epidemic in the Caribbean Co-existence of underground homosexuality and visible heterosexual lifestyle Co-existence of high level of bisexuality among homosexuals and bisexual practices among heterosexuals


Conclusions: Conclusions Lack of trust and communication Poor dissemination of information Social denial: absence of MSM interventions Unsafe sexual practices High HIV prevalence in MSM Impacts the wider community through the bridge of bisexual practices


Conclusions: Urgent needs: Conclusions: Urgent needs Policy changes for improved access to public health and social services Community based interventions (HIV/AIDS awareness, sexuality, sexual health, safe sex) Operational research (gay issues, behaviour change, HIV prevalence) Legislative reforms to guarantee human rights protection regardless of sexual orientation