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

3. 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
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).

4. 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

5. 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?)

6. 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).

7. Risk of Transmission

8. 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%)

9. Disclosure

10. 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).

11. Risk of Transmission

12. 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).

13. 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.

14. Thank You