The MSM and Trans Epidemic in the Caribbean John Waters MD, DSc, MSc, MA(Oxon)

HIV prevalence among MSM and Trans in the Caribbean The Caribbean has an adult HIV prevalence of 1.1% Highest prevalence of 3.2% found in the Bahamas. Although new HIV infections declined by 40% from 2005 and 2013, there were still an estimated 12,000 new HIV infections and a total of 250,000 people living with HIV in the region in 2013. The available data show that HIV prevalence among MSM in the Caribbean region is 25.4 % Much higher than in any other region in the world Sub-Saharan Africa (17.9%) North America (15.4%) Central and South America (14.9%) Beyer C et al (2012a).

The “predominantly heterosexual” Epidemic Epidemic in Caribbean officially characterized as being “predominantly heterosexual” This characterization is based on the fact that only only 3.5% of cumulative AIDS cases have been officially reported as due to homosexual transmission and another 4.3% as being bisexual cases HIV prevalence among MSM continues to grow even as it declines in the general population

Reasons to doubt past HIV estimates and analyses Evidence from Blood banks MSM Mask and Evidence from Risk of Transmission Studies The Dependence on and Reliability of Disclosure Size Estimation Studies for MSM (how common is MSM behaviour?)

Blood banks Blood testing at blood donor clinics indicates that HIV prevalence among the country’s heterosexual population may be as low as 0.2% Much higher countrywide HIV prevalence may be due in large part to HIV prevalence among MSM and their female partners Halperin D et al (2009).

Risk of Transmission

MSM Mask 32% self-identified as gay (Prevalence 10.8%) Serological and behavioural survey in the Dominican Republic 32% self-identified as gay (Prevalence 10.8%) 10% self-identified as transgender (Prevalence 17.2%) 58% self-identified as MSM (Prevalence 4%)

Disclosure

Modes of Transmission (MOT) Modelling Tool New infections in the DR New infections in the Jamaica 33.3% in MSM 2.8% in female partners of MSM 31.9% men with no identifiable sexual risk 32% in MSM 7% in female partners of MSM 32% men with no identifiable sexual risk UNAIDS et al (2010a).

Risk of Transmission

How common is MSM behaviour in Caribbean countries? The evidence is scarce but includes: Spanish speaking Caribbean English speaking Caribbean 1996 DR study in males 17 to 28 years old 8% from the “upper class” 18% from the “middle class 28% percent from the “lower class” Indicated that they had had homosexual experiences 2002 school-based survey of students from 10 to 18 years old in 9 Caribbean countries that were former British colonies 6% of the male students were predominantly attracted to other males Additional 4% were equally attracted to both males and females. De Moya EA and Garcia R (1996).

In Sum…….. Evidence from Blood banks suggests that prevalence in general population is much lower than stated (overall 1.1% versus 0.2% in blood banks) MSM label masks differences between important sub groups of MSM. Risk of infection studies suggest that women are not sustaining the epidemic Evidence from Risk of Transmission Studies that a third of new infections are occurring in men with no known risk behaviour (DL MSM?) The Dependence on and Reliability of Disclosure MSM behaviour may be more common than we admit For all these reasons is it is critical that we more effectively respond to MSM and Trans needs and differences in the Caribbean.

Thank You