Developing world epidemics in the developed world: HIV/AIDS among Caribbean people in the UK, US and the Caribbean Kevin Fenton, M.D., Ph.D. Director National Center for HIV, STD, and TB Prevention Centers for Disease Control and Prevention August 16, 2006

The HIV/AIDS epidemic in the Caribbean AIDS has claimed an estimated 24,000 lives in the Caribbean in 2005, making it the leading cause of death among adults aged years. A total of 300,000 people are currently living with HIV in the region, including 30,000 people who became infected in Estimated national adult HIV prevalence –> 1% in Barbados, Dominican Republic, Jamaica and Suriname –> 2% in the Bahamas, Guyana and Trinidad and Tobago, and exceeds 3% in Haiti.

Driving factors The region’s epidemics are driven primarily by heterosexual intercourse, with commercial sex a prominent factor, against a backdrop of severe poverty, high unemployment and gender inequalities. The overall share of reported HIV infections attributed to sex between men is approximately 12%, but homophobia and the robust socio-cultural taboos that stigmatize same sex relations mean that the actual proportion could be somewhat larger. Injecting drug use is responsible for a small minority of HIV infections currently; only in Bermuda and Puerto Rico does it contribute significantly to the spread of HIV.

The Caribbean Diaspora – Historical context Caribbean emigration occurred in two waves. –The first wave occurred during the post WW II boom in the Western economies in the 1950s/60s due to pull factors like full employment and labour shortages. –The second wave took place in the late 1970s and 1990s as a result of global economic restructuring and economic and social decline in Caribbean countries. The top labour-exporting countries from the Caribbean are Cuba, the Dominican Republic, Haiti, Jamaica and Guyana. The international migration of Caribbean people is largely to North America (the US and Canada) and former colonizer countries in Europe. –The US is the number one destination by a significant margin, and is estimated to account for as much as 75% of the Caribbean-born and first generation diaspora (Segal 1996). –The next largest receiving countries are the UK, Canada, the Netherlands, and France

UK Collaborative Group for HIV and STI Surveillance United Kingdom: Percentage of ethnic groups diagnosed as HIV-infected: 2004 Black AfricanBlack Caribbean Indian/Pakistani/ Bangladeshi White Number aged diagnosed as HIV-infected (SOPHID) Population, aged (Census 2001) Percentage aged living with diagnosed HIV 4.4%0.3%0.03%0.07% Data sources: SOPHID and Office for National Statistics, census 200, England and Wales

UK Collaborative Group for HIV and STI Surveillance United Kingdom: HIV diagnoses among black and minority ethnic populations by ethnic sub-group 1 Numbers will rise, for recent years, as further reports are received. Data source: HIV/AIDS diagnosis reports, England, Wales and Northern Ireland 1

HIV Caribbeans in the UK Between 1997 and 2001, 528 black Caribbean adults were newly diagnosed with HIV; 62 new diagnoses in 1997, rising to 176 in Probable heterosexual acquisition accounted for 335 (63%) infections (161 (48%) males, 174 females), and sex between men 171 (32%). Infection was acquired both in the Caribbean and in the United Kingdom. In 2001, 528 (76%) black Caribbeans accessing services were London residents. Numbers of black Caribbeans accessing treatment and care services more than doubled between 1997 (294) and 2001 (691). Sex Transm Infect Feb;80(1):18-23.

UK Collaborative Group for HIV and STI Surveillance United Kingdom: Ethnic group of HIV-infected MSM accessing treatment and care: 2004 Data source: SOPHID, England, Wales and Northern Ireland

Caribbean MSM in the UK Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in E&W, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% of BME MSM aged in E&W were living with diagnosed HIV in 2002 compared with 3.2% of white MSM (p<0.001). Undiagnosed HIV prevalence in Caribbean born MSM was high. Sex Transm Infect Aug;81(4):

Results -- Estimated HIV Prevalence, United States, 2003 Consistent with NHANES (N=31) among persons ages years of 0.43% ( ). McQuillan, 2006, in press. Total HIV Prevalence: 1,039,000 – 1,185,000 Undiagnosed 24-27% HIV (not AIDS) 42% AIDS 34%

Proportion of HIV/AIDS Cases and Population, by Race/Ethnicity, States* HIV/AIDS CasesPopulation, 33 States * Data from 33 states with confidential name-based HIV infection reporting since at least African American Asian/Pacific Islander 1% White Hispanic American Indian/ Alaska Native <1% 18% 50% 31 % African American Hispanic White American Indian/ Alaska Native 1% Asian/Pacific Islander 3% 70 % 13%

HIV/AIDS and Caribbeans in the United States Caution…  National US surveillance data do not have sub- nationalities or ethnic sub-categories for Black Caribbeans  Misclassification of HIV/AIDS cases in African Americans or Blacks  Geographic heterogeneity of US resident Caribbeans may have disproportionate impact on regional and state-level case rates  Ongoing migration and travel between US and Caribbean may have impact on ongoing epidemic evolution

Risk factors for HIV/AIDS for Caribbeans in developed countries Developed Countries Maintained  Insufficient condom use  Higher prevalence of multiple, concurrent partnerships  Substance abuse: alcohol, crack and cocaine  Cultural and religious taboos Unique  Travel to and from Caribbean and acquisition of new sex partners  Assortative sexual mixing  Poor access to curative services  Higher background prevalence of undiagnosed HIV and STIs  Migrant experiences: Racism, Discrimination, Stigma and discrimination

Summary HIV/AIDS has had a substantial impact on Caribbean countries Members of the Caribbean diaspora also bear disproportionate HIV/AIDS burden in developed countries Increased risk mediated through a variety of risk factors In US, national surveillance data are currently limited to explore disease burden on Caribbeans