Michel de Groulard, Godfrey Sealy, Brader Brathwaite Pauline A. Russell-Brown, Hans-Ulrich Wagner Cheryl O’Neil, Caroline Allen, Emmanuel Joseph Homosexual Aspects of the HIV/AIDS Epidemic in the Caribbean: A Public Health Challenge for Prevention and Control Let me first acknowledge the Caribbean Epidemiology Center collaborating with the French Cooperation and its Member Countries, and particularly the small communities of very stigmatized MSM in the small Caribbean islands. A special mention to the field investigator of this study, Godfrey Sealy, sitting in this room, without who none of this would ever had happened.

Reported AIDS Cases in CAREC Member Countries, 1982 - 1998 500 1,000 1,500 2,000 2,500 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Years Number of Cases The first case of AIDS in the Region was recorded in Jamaica in 1982. The Region has the highest incidence of reported AIDS cases in the Americas and world wide is second only to Africa in terms of adult HIV prevalence rate (2.1%)

Gender Distribution of Reported Adult AIDS Cases in CMCs 1982-1998 Men play major role in the transmission of HIV Male-Female Sex ratio = 2:1 57% of heterosexual transmission Transmission through heterosexual contact is reported as the main route of transmission (64%), 17% of all reported AIDS cases have not been related to any of the above routes of transmission and are reported as “unknown” or “no risk factor”. More than 80% of the cases reported in this unknown group, are male cases.

Categories of Transmission in Reported Adult Male AIDS Cases through Sexual Contacts 1992 - 1998 In cases reported in men, heterosexual transmission is 60%, Therefore 40% of male cases are not reported to be transmitted through heterosexual contact. The level of HIV prevalence in MSM is not known but there are strong indications, from health care practitioners reporting a large number of young gay men dying from AIDS, that it is high

Male Risk Category by Year in Trinidad & Tobago In the example case of Trinidad and Tobago, it appears clearly that as the proportion of cases reported as homo and bisexual transmission is decreasing, the proportion of “unspecified” increases.

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 The practice of sex between men is a criminal offence in most countries, highly stigmatized, particularly by religious groups, and perceived as delinquent behavior. The society as a whole strongly rejects homosexuals. Recent developments of violence in Jamaica and of criminalization of homosexuality in Dominica indicate the level of fear and passion that the issue emotes in the region. From a public health promotion perspective, a climate of fear and discrimination is counter productive, driving individuals and practices underground and making both invisible. Because of the social and religious pressure, most gay men do not fully accept their sexual orientation, with very little family or peer support. In such a stigmatized environment, men who participate in same sex relationships either remain “in the closet” or, to gain social acceptance, may get married and attempt to conform to the heterosexual norm. They live a double life, which not only place them at risk, but also increase the risk of HIV infection for their female partners and for any resulting children.

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 Regardless of the route of transmission, positive HIV status carries its own stigma. The HIV positive MSM is confronted with a combined social stigma of same sex preference and HIV infection, limiting open communication with MSM and even within the open homo/bisexual community. This gives rise to denial, fatalism and to a culture of silence and secrecy.

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) The research is based on qualitative methods, combining focus groups and in-depth interviews. An anthropological approach based on conversations, personal involvement, and huge investment of time, participating in social interactions, was used to build mutual trust. Difficulty in getting groups together because of fears of being identified stresses the need for strict confidentiality.

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 In 9 islands, 121 participants in the study included openly gay men, closeted bisexuals, young gay and bisexual men The use of two methods for collecting information was expected to minimize the bias created by the interviewer, being both part of the gay community and still an “outsider” coming from a different island/country.

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 Communication and social interaction between class, and between age sub-grouping is limited. The lack of trust within the group as well as between MSM and wider society are factors to take into consideration for public health interventions. Social class differences mediate ability to cope and live a normal life and dictate patterns of socializing and sexual mixing. Younger MSM and those who are perceived to be professionals have a stronger sense of identity. They need to be approached in ways that are different to those of older men and men from the lower social classes.

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 The group is not homogenous. There are several communities, on the basis of sexual preferences, and sex practices. As such, most can be defined as communities of interest. The world “sex” has multiple meanings, from penetrative anal intercourse to erotic telephone conversations, including kissing, oral sex and masturbation. These distinctions should be clearly understood to ensure effective education and communication. Many MSM practice “negotiated safety”, engaging in unprotected sex with a main partner but, for outside partnership, using a condom or limiting relations to non-penetrative sex. Men from higher and middle class travel overseas to meet partners. Less well-off men have less opportunities to be selective in choosing a sex partner.

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 There is a perceived increase in the number of men having sex with other men, which seems to be driven by material and economic needs rather than sexual orientation or preference. Trading sex for money or material things as a matter of survival or upkeep is prevalent in some countries. In some others, sex with tourists is a common practice. In all countries there are men who live straight lifestyles in their home country and travel periodically to other countries to meet male partners.

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 Men are aware of the need for safe sex, but are not always able to practice it. Condoms are considered an obstacle for sexual pleasure and a bother in long-term relationships. The level of support that HIV positive individuals receive from the community is improving but still limited. Communities do not exercise discretion in sharing information about sero- or health status of MSM or other who have AIDS.

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 Men express reluctance to use health services for care or for counseling and testing. They perceive health care providers in the public sector as judgmental and unable to preserve confidentiality and privacy. Private physician and Hospital are preferred sources of testing. Some MSM express reluctance to seek care from heterosexual medical practitioners. The specific reasons for that were not explored.

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 This is the first multi-country study on this subject in the region Epidemiological data clearly indicate that HIV transmission in MSM co-exists with the heterosexual epidemic in the Caribbean. The co-existence of the two faces, one public, the other private, for MSM, presents a major challenge for AIDS prevention.

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 The observed lack of trust and communication, contributes to the poor dissemination of information. The denial of the MSM aspect of HIV transmission results in the absence of interventions targeting MSM. This drives and maintains MSM in unsafe sexual practices resulting in a suspected high HIV prevalence in this community. This needs to be explored further. This impacts the wider community through the bisexual practices imposed by the pressure of society on the gay community.

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 Policy changes are needed at the service delivery level to guarantee confidential and private health and social service to all and the respect of human rights. The need for community based interventions is challenged by the absence of structured communities. The small communities of interest are to be targeted. Additional research should explore more accurately the level of HIV prevalence in MSM, the socio-cultural determinants of sex practices, the effectiveness of educational interventions and assess health seeking behavior. The need for legislative reforms that guarantee the human rights of all members of society regardless of sexual orientation is in the public debate, but not yet on the political agenda.