HIV/AIDS and tourism in the Caribbean: an ecological systems perspective

"If They Give Their Mind to HIV, They Don't Last as Long": An Explanatory Model of HIV Infection in a Limited-Resource Setting Informs Person-Centered Care

Explanatory models describe individuals’ perceptions of their illness experiences, which can guide culturally relevant care. We constructed an explanatory model of the experience of living with human immunodeficiency virus (HIV) in the Dominican Republic. Following qualitative descriptive methodology, we conducted interviews in Spanish using a semi-structured interview guide developed using Kleinman’s explanatory model framework. Two bilingual researchers coded interview transcripts following conventional content analysis. We used deductive codes from Kleinman’s framework and inductive codes external to the framework to construct the codebook. We arranged codes by shared meaning into categories and constructed themes that reflected shared findings from inductive categories and deductive codes. Twenty-six persons living with HIV participated. They provided rich descriptions of their experiences represented by four cross-cutting themes, which informed the explanatory model. By incorporating this in-depth understanding of patients’ illness experiences into care delivery, nurses can cultivate culturally meaningful and trusting patient-centered partnerships that improve health.

Social networks and condomless intercourse with female partners among male sex workers in the Dominican Republic

Male sex workers (MSW) in the Dominican Republic (DR) have multiple sexual partners, including personal and client-relationships, and are disproportionately affected by human immunodeficiency virus (HIV). We examined the prevalence of condomless anal and/or vaginal intercourse (CI) among MSW in the DR as a function of social network factors. Self-report surveys and social network interviews were administered to MSW recruited through venue-based sampling (N = 220). A generalized linear model was used to complete a Poisson Regression model and identify variables significantly associated with the outcome of interest. CI was more common with female (28.3%) than with male partners (4.9%). Factors associated with CI with the last female partner included older age of MSW, CI with the last male partner, having a stable female partner (a consistent or main partner), and having ≥1 family member in the participants' social network. Partner and social network characteristics associated with CI among MSW suggest the utility of dyadic and network interventions to reduce HIV risk.

Spatial and temporal analysis of the human immunodeficiency virus in an area of social vulnerability in Northeast Brazil

Human Immunodeficiency Virus (HIV) infection still represents an important public health problem, because it involves clinical, epidemiological, social, economic and political issues. We analyzed the temporal and spatial pattern of the HIV incidence in an area of social inequality in northeast Brazil and its association with socioeconomic indicators. An ecological study was carried out with a focus on all HIV cases reported in Alagoas State, Northeast Brazil from 2007 to 2016 using its 102 municipalities as the units of our analysis. Data from the Brazilian information systems were used. Georeferenced data were analyzed using TerraView 4.2.2 software, QGis 2.18.2 and GeoDa 1.14.0. Time trend analyses were performed by the Joinpoint Regression software and the spatial analyses included the empirical Bayesian model and Moran autocorrelation. Spatial regression was used to determine the influence of space on HIV incidence rate and socioeconomic inequalities. There was an increasing trend of HIV rates, especially in the municipalities of the interior. Significant spatial correlations were observed with the formation of clusters with emphasis on the coast of the state and in tourist regions. Spatial regression explained 46% of the dependent variable. The HIV incidence rate was positively influenced by rate of primary health care units (P=0.00), and negatively by Gini index (P=0.00) and proportion of heads of household without or low education (P=0.02). We conclude that the relationship found between indicators of better socioeconomic conditions and HIV infection suggests unequal access to the diagnosis of infection. Prevention and control strategies can be established according to each epidemiological reality.

Social inequalities, sexual tourism and HIV in Cartagena, Colombia: an ethnographic study

Background

Cartagena, Colombia’s main port on the Caribbean Coast, reported an HIV incidence of 7.5 per 100,000 inhabitants in 2007 with 90.0% transmission by heterosexual contact and 70 identified as women with a stable partner. Studies across Colombia illustrate that HIV infection relates to social inequalities; most people with HIV live in poverty and have minimal access to health care, education, and secure jobs. The purpose of this article is to analyse the relationship between social inequalities, sexual tourism and HIV infection in Cartagena, Colombia.

Methods

Data come from a five-year participatory ethnography of HIV in Cartagena in the period 2004–2009, in which 96 citizens (30 of whom were living with HIV) participated in different data collection phases. Techniques included participant observation, in-depth interviews and thematic life histories. Out of this material, we selected three life histories of two women and a man living with HIV that are representative of the ways in which participants expressed how social inequalities make it virtually impossible to engage in safe sex practices.

Results

At stake is the exchange of condomless sex for goods within the widespread sexual tourism networks that promote an idealisation of dark-skinned men and women as better sexual performers. Our results illustrate the complex interplay of social inequalities based on class, skin colour, gender and sexual orientation. Furthermore, they suggest a synergistic effect between poverty, racialization, and gender inequalities in the historical maintenance of social dynamics for a fruitful growth of a sexual tourism industry that in turn increases vulnerability to HIV infection.

Conclusions

Although the convergence of social inequalities has been thoroughly reported in the literature on social studies of HIV vulnerability; distinctive dynamics are occurring in Cartagena, including a clear link between the contemporary globalised sexual tourism industries and a racialised social structure - both having historical roots in the colonial past-.

Introduction to the special issue: Applying a Caribbean perspective to an analysis of HIV/AIDS

This introduction presents a special issue of Global Public Health with a collection of articles that offer multidisciplinary perspectives on HIV/AIDS in the Caribbean. Since the 1990s, poverty, marginalisation, and social stigma have been strong foci of much social science research on HIV/AIDS in the region. These three interrelated phenomena have been offered as explanatory factors contributing to the high prevalence of cases observed in this region. Contributors to this special issue take these emphases in new directions, asking multi-level questions that require unique combinations of epidemiological, social scientific, theoretical, and policy-oriented perspectives and methodologies. Together, they identify several topical areas that intend to create dialogue across disciplines and dialectics, with the fundamental principle that the factors relevant to HIV/AIDS are broad and require intersectional lenses. The articles in this issue offer multi-level interventions into HIV/AIDS in the region, from the varied social circumstances that shape heightened risk factors to patient adherence programmes, with emphases on structural, social, and policy-level approaches. Collectively, this special issue establishes the importance of transdisciplinary approaches to HIV/AIDS that are macro-level in scope, but simultaneously attend to how large-scale dynamics are inflected in situated contexts and histories.

Factors associated with exchanging sex for money in men who have sex with men in Brazil

This study aimed to analyze the association between sociodemographic, programmatic and contextual factors and the receipt of money in exchange for sex among men who have sex with men (MSM). This is a multicenter, cross-sectional study conducted in ten Brazilian cities between 2008 and 2009. Adult MSM recruited through the Respondent Driven Sampling (RDS) were interviewed. Weighted Odds Ratio (ORw) was obtained through logistic regression, retaining the variables associated with the event (p < 0.05) in the final model. Of the total sample, 33.3% reported receiving money in exchange for sex in the last 12 months before the interview. The variables that were independently associated with the event were age less than or equal to 25 years, lower education, lower social classes, previous history of syphilis, using sites or services to find sexual partners in the previous month, very high risk behavior, using illicit drugs in the previous six months, self-identifying as heterosexual or bisexual, having suffered physical violence due to sexual orientation and having suicidal thoughts always or most of the time. It was observed that MSM who received money in exchange for sex had greater socioeconomic, programmatic and contextual vulnerability, potentially increasing the risk of HIV infection than the other MSM in the sample.

An institutional ethnography of prevention and treatment services for substance use disorders in the Dominican Republic

The Dominican Republic is thought to have significant epidemics of illicit drug use but lacks surveillance and formal analyses of the policy context of drug prevention and treatment services. We conducted an institutional ethnography of 15 drug service organisations in Santo Domingo and Boca Chica, Dominican Republic, to explore barriers and resources for drug abuse prevention and treatment. Here, we present a typology of drug service organisations based on their services, methods, and approach. We then draw on interviews with representatives of drug service institutions to describe the primary barriers to drug treatment and prevention services for drug users. We conclude with a focus on the policy priorities that could improve the conditions of health care for marginalised drug users in the Dominican Republic.

An ethnographic study of 'touristic escapism' and health vulnerability among Dominican male tourism workers

Health research on tourism has expanded over the past two decades, focusing on understanding how the social, economic, and political configuration of tourism zones might contribute to health vulnerabilities among the diverse populations that interact in these areas. While there are few studies of HIV and drug use interactions in the region, research has indicated that these two outcomes are often interwoven in tourism zones, potentially producing 'syndemics' of HIV infection and problematic drug use. One framework that has been used in public health research on tourism is one that we refer to as touristic escapism or situational disinhibition that may be heightened for some tourists while on vacation, potentially leading to the abandonment of normative constraints on behaviour and contributing to health risks such as unprotected sex or binge drinking. In this article, we draw upon tourism theory and ethnographic research with male tourism workers employed in two popular tourist areas of the Dominican Republic to explore whether touristic escapism offers insights in understanding health vulnerabilities within tourism spaces.

Precarity and the HIV/AIDS pandemic in the Caribbean: Structural stigma, constitutionality, legality in development practice

The social stigma of sexual immorality is inscripted in constitutions, laws, and statutes in the Caribbean and justified and legitimated through references to Christian doxa. This induces forms of structural stigma through policies and practices of governance. I employ country comparisons to demonstrate the critical effect on rates of HIV/AIDS of structural stigma induced by these inscriptions in Caribbean countries. By comparing rates of HIV/AIDS across selected countries, I analyse the differing patterns of structural stigma against the latter's relationship with structural vulnerabilities associated with poverty, underdevelopment, government incapacities, and population flows. I conclude that significant reductions in rates of prevalence can be achieved when social stigma is minimised or meliorated through effective government action or through the influence of external actors, even in the presence of other forms of structural vulnerabilities. The intensity of population flows into a country can also act independently to increase rates of prevalence, even in the face of reductions in structural stigma related to sexual immorality.

Syndemic Experiences, Protective Factors, and HIV Vulnerabilities Among Lesbian, Gay, Bisexual and Transgender Persons in Jamaica

Syndemics approaches explore the convergence of psychosocial factors that elevate HIV vulnerabilities. Less research has explored syndemics among lesbian, gay, bisexual and transgender (LGBT) persons in contexts where criminalization has downstream impacts on LGBT discrimination, such as Jamaica. We implemented a cross-sectional survey with LGBT persons (n = 911) in Jamaica. We conducted structural equation modeling to examine direct and indirect effects of a latent syndemics construct (binge drinking, depressive symptoms, childhood/adult abuse) on HIV vulnerabilities (lifetime sex partners, perceived HIV risk, condom self-efficacy) and the mediating role of protective factors (social support, resilient coping). Direct paths from syndemics to lifetime sex partners, perceived HIV risk, and condom self-efficacy were significant. Resilient coping and social support partially mediated the association between syndemics and condom use self-efficacy. Resilient coping partially mediated the relationship between syndemics and lifetime sex partners. Interventions can target syndemic issues to reduce HIV vulnerabilities among Jamaican LGBT persons.

Priority Topics for Health Education to Support HIV Self-Management in Limited-Resource Settings

PURPOSE

The purpose of this study was to identify and prioritize the information that persons living with HIV (PLWH) in a limited-resource setting need to effectively manage their health.

DESIGN AND METHODS

A data sources triangulation method was used to compare data from three separate sources: (a) 107 interviews with Spanish-speaking PLWH being seen at a healthcare clinic in the Dominican Republic (DR); (b) 40 interviews with Spanish-speaking healthcare providers from the same clinic in the DR; and (c) an integrative literature review of English- and Spanish-language articles that assessed the health information needs of PLWH in Latin America and the Caribbean. We compared information needs across sources and developed a prioritized list of the topics important to provide PLWH in a clinical setting.

FINDINGS

Triangulation identified the most important topics for HIV-related health education for PLWH as medication and adherence, followed by transmission, including risks and prevention strategies, mental health management, and knowledge of HIV in general.

CONCLUSIONS

The identification of evidence-based health education priorities establishes a guide that healthcare providers may use to help PLWH effectively manage their health and creates a foundation from which further studies on improving clinical interactions may be generated.

CLINICAL RELEVANCE

Using the priorities identified, nurses and other health educators can improve patient education, and consequently self-management, by making evidence-based choices about what information to provide to their patients.

Molecular Epidemiology of HIV-1 Virus in Puerto Rico: Novel Cases of HIV-1 Subtype C, D, and CRF-24BG

HIV-1 subtype B virus is the most prevalent subtype in Puerto Rico (PR), accounting for about 90% of infection in the island. Recently, other subtypes and circulating recombinant forms (CRFs), including F(12_BF), A (01_BF), and CRF-39 BF-like, have been identified. The purpose of this study is to assess the distribution of drug resistance mutations and subtypes in PR. A total of 846 nucleotide sequences from the period comprising 2013 through 2017 were obtained from our "HIV Genotyping" test file. Phylogenetic and molecular epidemiology analyses were performed to evaluate the evolutionary dynamics and prevalence of drug resistance mutations. According to our results, we detected a decrease in the prevalence of protease inhibitor, nucleoside reverse transcriptase inhibitor (NRTI), and non-NRTI (NNRTI) resistance mutations over time. In addition, we also detected recombinant forms and, for the first time, identified subtypes C, D, and CRF-24BG in PR. Recent studies suggest that non-subtypes B are associated with a high risk of treatment failure and disease progression. The constant monitoring of viral evolution and drug resistance mutation dynamics is important to establish appropriate efforts for controlling viral expansion.

Tourism Labor, Embodied Suffering, and the Deportation Regime in the Dominican Republic

In this article, we use syndemic theory to examine socio-structural factors that result in heightened vulnerability to HIV infection and drug addiction among Dominican deportees who survive post-deportation through informal tourism labor. Through an ongoing NIDA-funded ethnographic study of the syndemic of HIV and problematic drug use among men involved in tourism labor in the Dominican Republic, we argue that the legal and political-economic context of the global deportation regime contributes to structural vulnerabilities among deportees in the Dominican Republic, most of whom are men with histories of incarceration in the United States and/or Puerto Rico. While Dominican laws and institutional practices work conjointly with foreign policies to reconfigure non-criminal deportees as hardened criminals unworthy of full citizenship rights, the informal tourism economy provides one of the few absorption points for male deportee labor, linking the deportation regime directly to the Caribbean tourism industry.

Alcohol Use and HIV Risk Within Social Networks of MSM Sex Workers in the Dominican Republic

To examine how alcohol-related HIV risk behaviors within MSM sex workers' social networks (SN) may be associated with individual risk behaviors, respondent-driven and venue-based sampling were used to collect demographic, behavioral and SN characteristics among MSM sex workers in Santo Domingo and Boca Chica (N = 220). The majority of participants reported problem drinking (71.0%) or alcohol use at their last sexual encounter (71.4%). Self-reported problem drinking was associated with SN characteristics (at least one member who recently got drunk aOR = 7.5, no religious/spiritual adviser aOR = 3.0, non-sexual network density aOR = 0.9), while self-reported alcohol use at last sex was associated with individual (drug use at last sex aOR = 4.4) and SN characteristics (at least one member with previous HIV/STI testing aOR = 4.7). Dominican MSM sex workers reported high alcohol use, which may increase their risk for HIV. A better understanding of SN factors associated with individual risk behaviors can help guide appropriate intervention development.

Factors contributing to food insecurity among women living with HIV in the Dominican Republic: A qualitative study

BACKGROUND

Food insecurity contributes to poor health outcomes among people living with HIV. In Latin America and the Caribbean, structural factors such as poverty, stigma, and inequality disproportionately affect women and may fuel both the HIV epidemic and food insecurity.

METHODS

We examined factors contributing to food insecurity among women living with HIV (WLHIV) in the Dominican Republic (DR). Data collection included in-depth, semi-structured interviews in 2013 with 30 WLHIV with indications of food insecurity who resided in urban or peri-urban areas and were recruited from local HIV clinics. In-person interviews were conducted in Spanish. Transcripts were coded using content analysis methods and an inductive approach to identify principal and emergent themes.

RESULTS

Respondents identified economic instability as the primary driver of food insecurity, precipitated by enacted stigma in the labor and social domains. Women described experiences of HIV-related labor discrimination in formal and informal sectors. Women commonly reported illegal HIV testing by employers, and subsequent dismissal if HIV-positive, especially in tourism and free trade zones. Enacted stigma in the social domain manifested as gossip and rejection by family, friends, and neighbors and physical, verbal, and sexual abuse by intimate partners, distancing women from sources of economic and food support. These experiences with discrimination and abuse contributed to internalized stigma among respondents who, as a result, were fearful and hesitant to disclose their HIV status; some participants reported leaving spouses and/or families, resulting in further isolation from economic resources, food and other support. A minority of participants described social support by friends, spouses, families and support groups, which helped to ameliorate food insecurity and emotional distress.

CONCLUSIONS

Addressing food insecurity among WLHIV requires policy and programmatic interventions to enforce existing laws designed to protect the rights of people living with HIV, reduce HIV-related stigma, and improve gender equality.

Early Sex Work Initiation and Violence against Female Sex Workers in Mombasa, Kenya

Between 20 and 40 % of female sex workers (FSWs) began sex work before age 18. Little is known concerning whether early initiation of sex work impacts later experiences in adulthood, including violence victimization. This paper examines the relationship between early initiation of sex work and violence victimization during adulthood. The sample included 816 FSWs in Mombasa, Kenya, recruited from HIV prevention drop-in centers who were 18 years or older and moderate-risk drinkers. Early initiation was defined as beginning sex work at 17 or younger. Logistic regression modeled recent violence as a function of early initiation, adjusting for drop-in center, age, education, HIV status, supporting others, and childhood abuse. Twenty percent of the sample reported early initiation of sex work. Although both early initiators and other FSWs reported commonly experiencing recent violence, early initiators were significantly more likely to experience recent physical and sexual violence and verbal abuse from paying partners. Early initiation was not associated with physical or sexual violence from non-paying partners. Many FSWs begin sex work before age 18. Effective interventions focused on preventing this are needed. In addition, interventions are needed to prevent violence against all FSWs, in particular, those who initiated sex work during childhood or adolescence.

A Framework for Sexual Decision-Making Among Female Sex Workers in Jamaica

The Jamaican government has provided targeted HIV and sexually transmitted infection prevention, treatment, and other services for female sex workers (FSW) since 1989. HIV prevalence among FSW declined from 20 to 12% between 1989 and 1994, then to 9% in 2005, 5% in 2008, and 4.1% in 2011. This article distills the literature and two decades of experience working with FSW in Jamaica. Drawing on the constant comparative method, we put forward an innovative conceptual framework for explaining sexual decision-making and risk behaviors within both transactional and relational sexual situations. This framework helps fill the gaps in existing models that focus on individual behaviors. The model identifies interactions between environmental and structural elements of sex work, and three individual-level factors: risk perception, perceived relationship intimacy, and perceived control, as the four primary mediating factors influencing sexual decision-making among FSW. We propose that other factors such as violence, socioeconomic vulnerability, and policy/legal frameworks influence sexual decision-making through these primary mediating factors. This conceptual model may offer a useful framework for planning and evaluating prevention interventions among sex workers. However, it remains to be tested in order to establish its value.

Methods of mapping ethnographic data on migration, tourism labor, and health risk in the Dominican Republic

This paper focuses on a mixed-method approach to quantifying qualitative data from the results of an ongoing NIDA-funded ethnographic study entitled "Migration, Tourism, and the HIV/Drug-Use Syndemic in the Dominican Republic". This project represents the first large-scale mixed method study to identify social, structural, environmental, and demographic factors that may contribute to ecologies of health vulnerability within the Caribbean tourism zones. Our research has identified deportation history as a critical factor contributing to vulnerability to HIV, drugs, mental health problems, and other health conditions. Therefore, understanding the movements of our participants became a vital aspect of this research. This paper describes how we went about translating 37 interviews into visual geographic representations. These methods help develop possible strategies for confronting HIV/AIDS and problematic substance use by examining the ways that these epidemics are shaped by the realities of people's labor migration and the spaces they inhabit. Our methods for mapping this qualitative data contribute to the ongoing, broadening capabilities of using GIS in social science research. A key contribution of this work is its integration of different methodologies from various disciplines to help better understand complex social problems.

An Exploratory Study of Internal Migration and Substance Use Among an Indigenous Community in Southern Mexico

The primary aim of this study was to explore the association between internal migration experience within Mexico and lifetime substance use among a sample of 442 indigenous persons from Yucatan, Mexico. Adjusting for potential confounding, correlates of lifetime substance use were assessed among participants with and without internal migration experience. Internal migration to a tourist destination was independently associated with higher odds (adjusted odds ratio: 2.1; 95% confidence interval: 1.3-3.4) of reporting lifetime substance use. Findings suggest that environmental contexts of internal migration may be of importance in shaping vulnerability to substance use.

Social determinants of HIV infection, hotspot areas and subpopulation groups in Ethiopia: evidence from the National Demographic and Health Survey in 2011

OBJECTIVE

This study identifies social determinants of HIV infection, hotspot areas and subpopulation groups in Ethiopia.

DESIGN

The study used data from the 2011 Ethiopian Demographic and Health Survey (EDHS). Sample blood tests from the finger pricks collected on filter paper cards were labelled with a barcode unique to each respondent. Spatial scan statistics and geographic information system tools were used to map hotspot areas of HIV prevalence. Bivariate and multivariable logistic regression models were used to identify social determinants of HIV infection.

POPULATION

A total of 30,625 adults (16,515 women and 14,110 men) were included from 11 administrative states of Ethiopia.

MAIN OUTCOME MEASURES

Laboratory-confirmed HIV serostatus is the main outcome variable.

RESULTS

HIV prevalence reached 10-21% in the central, eastern and western geographic clusters of Ethiopia. Multivariable analysis showed that individuals who were in the middle, richer and richest wealth quintiles had increased odds of having HIV over those in the poorest quintile. Adults who had primary, secondary and higher educational levels had higher odds of being HIV positive than non-educated individuals. The odds of having HIV were higher among adults who had multiple lifetime sexual partners than those with a single partner. An increasing odds of HIV infection were observed among adults in the age groups of 25-29, 30-34, 35-39 and 40-45 years compared with adults in the age group of 45-49 years. Merchants had higher odds of being HIV positive than those who were not employed. The odds of having HIV were higher among urban residents and females than among rural residents and males, respectively.

CONCLUSIONS

This study found statistically significant HIV concentrations in administrative zones of central, eastern and western Ethiopia. Geospatial monitoring and targeting of prevention strategies for specific population groups is recommended.

Alcohol use behaviors among indigenous migrants: a transnational study on communities of origin and destination

The association between international and domestic migration and alcohol use among indigenous communities is poorly understood. We explored migration-related factors associated with alcohol use behaviors among an indigenous Mayan, binational population. From January to March 2012, 650 indigenous participants from the high-emigration town of Tunkás in the Mexican state of Yucatán (n = 650) residing in Mexico and California completed surveys. Multivariate logistic regression identified migration-related factors associated with alcohol use behaviors. US migration of shorter duration (<5 years) was independently associated with at-risk drinking (adjusted odds ratio (AOR) 2.34; 95% confidence interval (CI) 1.09-5.03), as was longer-duration domestic migration (≥5 years) (AOR 2.34; 95% CI 1.12-4.87). Ability to speak Maya (AOR 0.26; 95% CI 0.13-0.48) was protective against at-risk drinking. Culturally appropriate alcohol use prevention interventions are needed for domestic and international indigenous Mexican migrants to address alcohol use behavior in the context of migration.

Short Communication: HIV-1 Subtype B in the Dominican Republic: Evolution and Molecular Epidemiology

The Caribbean region has the world second highest incidence rate of acquired immunodeficiency syndrome. The island of Hispaniola is composed of two sovereign nations: the Dominican Republic and Haiti. Together, they account for more than 85% of HIV/AIDS cases in the Caribbean; and the Dominican Republic alone has approximately 46,000 (33,000-59,000) HIV-1-infected adults and children. Despite this, the magnitude of the genetic variability and evolution of the HIV-1 virus in the Dominican Republic is unclear. In the current study, we analyzed 195 reverse transcriptase (RT) sequences obtained from the Los Alamos HIV database. The data were used to assess the course of the viral epidemic over time in the Dominican Republic, using a coalescent approach. Based on the data, we estimated that the timing of the most recent common ancestor (tMRCA) of local HIV-1 subtype B emerged in 1963, approximately. In addition, the Bayesian analysis provided new information that suggests that the epidemic in the Dominican Republic experienced a significant decrease in relative genetic diversity in the past 2 decades. The results suggest that adherence to antiretroviral therapy, adequate prevention campaigns, and better access to health care may be altering the virus's evolution in the Dominican Republic.

Challenges to successful implementation of HIV and AIDS-related health policies in Cartagena, Colombia

The Caribbean region presents the highest prevalence of HIV/AIDS worldwide after sub-Saharan Africa; leading to serious social, economic and health consequences at the local scale but also at the regional and global levels. In Colombia, a national plan to tackle the epidemic was formulated with little evidence that its implementation in the local context is effective. This study focused on Cartagena - one of Colombia's largest cities and an international touristic hub - that presents one of the highest HIV prevalences in the country, to investigate whether the national plan accounts for local specificities and what are the barriers to local implementation. Based on the Contextual Interaction Theory (CIT), this qualitative research relied upon 27 interviews and 13 life stories of local inhabitants and stakeholders, collected in a first fieldwork in 2006-2007. A follow-up data collection took place in 2013 with 10 participants: key policymakers and implementers, NGO representatives and local inhabitants. Barriers identified by the participants included: local population's understandings and beliefs on condom use; stigma and discrimination; lack of collaboration from the Church, the education sector and local politicians; corruption; high staff turnover; frequent changes in leadership; lack of economic and human resources; and barriers to health care access. The findings suggest that global influences also have an impact on the CIT framework (e.g. international organisations as a major financier in HIV prevention). The participants put forward several feasible solutions to implementation barriers. We discuss how several of the proposed solutions have been applied in other Latin American and Caribbean countries and yielded positive results. However, further research is needed to find possible ways of overcoming certain barriers identified by this study such as corruption, the lack of collaboration of the Church and barriers to health care access.

A new public health context to understand male sex work

Background

Researching male sex work offers insight into the sexual lives of men and women while developing a more realistic appreciation for the changing issues associated with male sex work. This type of research is important because it not only reflects a growing and diversifying consumer demand for male sex work, but also because it enables the construction of knowledge that is up-to-date with changing ideas around sex and sexualities.

Discussion

This paper discusses a range of issues emerging in the male sex industry. Notably, globalisation and technology have contributed to the normalisation of male sex work and reshaped the landscape in which the male sex industry operates. As part of this discussion, we review STI and HIV rates among male sex workers at a global level, which are widely disparate and geographically contextual, with rates of HIV among male sex workers ranging from 0% in some areas to 50% in others. The Internet has reshaped the way that male sex workers and clients connect and has been identified as a useful space for safer sex messages and research that seeks out hidden or commonly excluded populations.

Future directions

We argue for a public health context that recognises the emerging and changing nature of male sex work, which means programs and policies that are appropriate for this population group. Online communities relating to male sex work are important avenues for safer sexual messages and unique opportunities to reach often excluded sub-populations of both clients and male sex workers. The changing structure and organisation of male sex work alongside rapidly changing cultural, academic and medical discourses provide new insight but also new challenges to how we conceive the sexualities of men and male sex workers. Public health initiatives must reflect upon and incorporate this knowledge.

Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission

Male sex workers who sell or exchange sex for money or goods encompass a very diverse population across and within countries worldwide. Information characterising their practices, contexts where they live, and their needs is limited, because these individuals are generally included as a subset of larger studies focused on gay men and other men who have sex with men (MSM) or even female sex workers. Male sex workers, irrespective of their sexual orientation, mostly offer sex to men and rarely identify as sex workers, using local or international terms instead. Growing evidence indicates a sustained or increasing burden of HIV among some male sex workers within the context of the slowing global HIV pandemic. Several synergistic facilitators could be potentiating HIV acquisition and transmission among male sex workers, including biological, behavioural, and structural determinants. Criminalisation and intersectional stigmas of same-sex practices, commercial sex, and HIV all augment risk for HIV and sexually transmitted infections among male sex workers and reduce the likelihood of these people accessing essential services. These contexts, taken together with complex sexual networks among male sex workers, define this group as a key population underserved by current HIV prevention, treatment, and care services. Dedicated efforts are needed to make those services available for the sake of both public health and human rights. Evidence-based and human rights-affirming services dedicated specifically to male sex workers are needed to improve health outcomes for these men and the people within their sexual networks.

Review of HIV in the Caribbean: significant progress and outstanding challenges

This paper reviews the recent literature on HIV in the Caribbean and discusses the challenges faced. HIV incidence in the Caribbean has declined by 49 % in the past decade, coverage of persons living with HIV among those eligible for antiretroviral treatment as per national guidelines was 70 % in 2012, and some countries are meeting the target of virtual elimination of mother-to-child transmission. HIV prevalence in the Caribbean is 1 % with features of both a generalized and concentrated HIV epidemic. HIV prevalence among female sex workers has declined but remains unacceptably high among men who have sex with men. Social and cultural factors, gender norms, and strong stigma associated with HIV and homosexuality contribute to the continued spread of HIV. Caribbean countries and their partners have invested significant resources, creative effort and impressive research in strengthening the HIV response nationally and regionally. However, in order to control the HIV epidemic, leaders at all levels, and the people, must address fundamental structural barriers in society that deny marginalized persons their rights, undermine public health goals, and impede universal access to HIV prevention, treatment, and care.

Illicit drug use and HIV risk in the Dominican Republic: tourism areas create drug use opportunities

While the Caribbean has the second highest global human immunodeficiency virus (HIV) prevalence, insufficient attention has been paid to contributing factors of the region's elevated risk. Largely neglected is the potential role of drugs in shaping the Caribbean HIV/acquired immune deficiency syndrome epidemic. Caribbean studies have almost exclusively focused on drug transportation and seldom acknowledged local user economies and drug-related health and social welfare consequences. While tourism is consistently implicated within the Caribbean HIV epidemic, less is known about the intersection of drugs and tourism. Tourism areas represent distinct ecologies of risk often characterised by sex work, alcohol consumption and population mixing between lower and higher risk groups. Limited understanding of availability and usage of drugs in countries such as the Dominican Republic (DR), the Caribbean country with the greatest tourist rates, presents barriers to HIV prevention. This study addresses this gap by conducting in-depth interviews with 30 drug users in Sosúa, a major sex tourism destination of the DR. A two-step qualitative data analysis process was utilised and interview transcripts were systematically coded using a well-defined thematic codebook. Results suggest three themes: (1) local demand shifts drug routes to tourism areas, (2) drugs shape local economies and (3) drug use facilitates HIV risk behaviours in tourism areas.

Work hard, party harder: drug use and sexual behaviour in young British casual workers in Ibiza, Spain

BACKGROUND

Every summer, young people flock to nightlife-focused holiday resorts around the world to find casual work. Despite being exposed to hedonistic environments, often for several months, little is known about their substance use, sexual activity and health service needs over this extended amount of time abroad.

METHODS

A short anonymous questionnaire examining alcohol and drug use, sexual behaviour and use of health services was administered to young British casual workers aged 16-35 in San Antonio, Ibiza (n = 171).

RESULTS

97.7% of casual workers used alcohol in Ibiza, and the majority (85.3%) used drugs. Almost half (43.5%) of all participants used a drug in Ibiza that they had never used in the UK. Most casual workers arrived in Ibiza without a partner or spouse (86.5%). Of these, 86.9% had sex during their stay and 50.0% had unprotected sex; often while under the influence of alcohol. Only 14.3% of those having unprotected sex with a new partner sought a sexual health check-up in Ibiza, although 84.1% intended to do this on their return to the UK.

CONCLUSION

Substance use and sexual risk taking is widespread among young British casual workers in Ibiza. Such international nightlife resorts represent key settings for substance-related health and social problems, and for the international spread of sexually transmitted infections. Addressing the health needs of casual workers and the environments that permit and promote their excessive behaviour requires collaboration between authorities in home and destination countries and the tourism industry.

Patterns of geographic mobility predict barriers to engagement in HIV care and antiretroviral treatment adherence

Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence.

HIV sexual risk behavior and family dynamics in a Dominican tourism town

Expansion of the tourism industry in the Dominican Republic has had far-reaching health consequences for the local population. Research suggests families with one or more members living in tourism areas experience heightened vulnerability to HIV/STIs due to exposure to tourism environments, which can promote behaviors such as commercial and transactional sex and elevated alcohol use. Nevertheless, little is known about how tourism contexts influence family dynamics, which, in turn, shape HIV risk. This qualitative study examined family relationships through in-depth interviews with 32 adults residing in Sosúa, an internationally known destination for sex tourism. Interviewees situated HIV risk within a context of limited employment opportunities, high rates of migration, heavy alcohol use, and separation from family. This study has implications for effective design of health interventions that make use of the role of the family to prevent HIV transmission in tourism environments.

Taxonomy of Caribbean tourism alcohol venues: implications for HIV transmission

BACKGROUND

Tourism areas represent ecologies of heightened HIV vulnerability characterized by a disproportionate concentration of alcohol venues. Limited research has explored how alcohol venues facilitate HIV transmission.

METHODS

We spatially mapped locations of alcohol venues in a Dominican tourism town and conducted a venue-based survey of key informants (n=135) focused on three facets of alcohol venues: structural features, type of patrons, and HIV risk behaviors. Using latent class analysis, we identified evidence-based typologies of alcohol venues for each of the three facets. Focused contrasts identified the co-occurrence of classes of structural features, classes of types of patrons, and classes of HIV risk behavior, thus elaborating the nature of high risk venues.

RESULTS

We identified three categories of venue structural features, three for venue patrons, and five for HIV risk behaviors. Analysis revealed that alcohol venues with the greatest structural risks (e.g. sex work on-site with lack of HIV prevention services) were most likely frequented by the venue patron category characterized by high population-mixing between locals and foreign tourists, who were in turn most likely to engage in the riskiest behaviors.

CONCLUSION

Our results highlight the stratification of venue patrons into groups who engage in behaviors of varying risk in structural settings that vary in risk. The convergence of high-risk patron groups in alcohol venues with the greatest structural risk suggests these locations have potential for HIV transmission. Policymakers and prevention scientists can use these methods and data to target HIV prevention resources to identified priority areas.

Moderno love: sexual role-based identities and HIV/STI prevention among men who have sex with men in Lima, Peru

Role-based sexual identities structure male same-sex partnerships and influence HIV/STI epidemiology among MSM in Latin America. We explored shifting relationships between sexual roles, identities and practices among MSM in Lima, Peru, and implications for HIV/STI prevention. Patterns of HIV/STI epidemiology reflected differential risks for transmission within role-based partnerships with relatively low prevalences of HIV, syphilis, and HSV-2 but higher prevalences of urethral gonorrhea/chlamydia among activo MSM compared with moderno and pasivo participants. Qualitative analysis of how MSM in Peru integrate sexual identities, roles, and practices identified four key themes: pasivo role as a gay approximation of cultural femininity; activo role as a heterosexual consolidation of masculinity; moderno role as a masculine reconceptualization of gay identity; and role-based identities as social determinants of partnership, network, and community formation. The concept of role-based sexual identities provides a framework for HIV prevention for Latin American MSM that integrates sexual identities, practices, partnerships, and networks.

Emotions and cognitions as correlates of early adolescent sexual behavior among Dominican youth in the United States and Dominican Republic

The present study examined cognitive and emotional correlates of sexual decision-making among three groups of Dominican adolescents: (a) Dominican youth who were born and raised in New York City, (b) Dominican youth who recently immigrated to New York City from the Dominican Republic, and (c) Dominican adolescents who were born and currently reside in the Dominican Republic. Data were collected via self-administered questionnaires from Dominican mother-adolescent dyads in New York City (n = 1,008) and the Dominican Republic (n = 213). Across groups, positive emotion constructs were consistently among the most important correlates of intentions to engage in sexual intercourse while issues related to STIs and HIV showed the lowest correlations. Interestingly, positive correlations with intentions to engage in intercourse were found among Dominican-residing males, as were positive correlations with intentions among Dominican-residing females. The implications for HIV prevention programs for Dominican youth are discussed.

Factors contributing to inconsistent condom use among heterosexual men in Curaçao

This study explored, from a public health perspective, factors that contribute to inconsistent condom use by men in Curaçao through semi-structured face-to-face interviews with 21 heterosexual men. The findings show that there is an important disconnect between what is considered culturally appropriate sexual behaviour for men and women and condom use, that diverging from prescribed notions of masculinity and femininity in order to use condoms consistently is difficult, and that condom use is particularly problematic in the context of concurrent partnerships and sexual economic exchanges. Participants further reported that Caribbean family structures, whereby mothers assume the role as primary caregiver and fathers contribute biologically but, to a much lesser extent socially, also have an impact on condom use. Additionally, consistent condom use was reported to be impeded by a cultural taboo on talking seriously about sex and sexual health. In their totality, findings provide important input from men for the development of sexual health promotion interventions that are cognizant of the cultural context in which inconsistent condom use occurs, and that are geared not only to the individual level but also to the interpersonal and structural levels.

On being gay in Barbados: "Bullers" and "Battyboys" and their HIV risk in a societal context of stigma

Limited research exists about gay men in the Caribbean region. A qualitative study was conducted to characterize gay men in Barbados, their HIV risk, and the impact of stigma on their lives. The 2 main groups of gay men ("bougies" and "ghetto") reflect social class and level of "outness" in broader society. Homophobia, stigma, and buggery (sodomy) laws increase their HIV vulnerability. The need for anti-discrimination legislation and tools for self-development were identified for gay men to realize their strengths, develop their self-worth, and protect themselves from HIV.

Genetic diversity in the merozoite surface protein 1 and 2 genes of Plasmodium falciparum from the Artibonite Valley of Haiti

Describing genetic diversity of the Plasmodium falciparum parasite provides important information about the local epidemiology of malaria. In this study, we examined the genetic diversity of P. falciparum isolates from the Artibonite Valley in Haiti using the allelic families of merozoite surface protein 1 and 2 genes (msp-1 and msp-2). The majority of study subjects infected with P. falciparum had a single parasite genotype (56% for msp-1 and 69% for msp-2: n=79); 9 distinct msp-1 genotypes were identified by size differences on agarose gels. K1 was the most polymorphic allelic family with 5 genotypes (amplicons from 100 to 300 base pairs [bp]); RO33 was the least polymorphic, with a single genotype (120-bp). Although both msp-2 alleles (3D7/IC1, FC27) had similar number of genotypes (n=4), 3D7/IC1 was more frequent (85% vs. 26%). All samples were screened for the presence of the K76T mutation on the P. falciparum chloroquine resistance transporter (pfcrt) gene with 10 of 79 samples positive. Of the 2 (out of 10) samples from individuals follow-up for 21 days, P. falciparum parasites were present through day 7 after treatment with chloroquine. No parasites were found on day 21. Our results suggest that the level of genetic diversity is low in this area of Haiti, which is consistent with an area of low transmission.

A syndemic analysis of alcohol use and sexual risk behavior among tourism employees in Sosúa, Dominican Republic

The Dominican Republic has high rates of HIV infection and alcohol consumption. Unfortunately, little research has been focused on the broader sources of the synergy between these two health outcomes. We draw on syndemic theory to argue that alcohol consumption and sexual risk behavior are best analyzed within the context of culture and economy in Caribbean tourism spaces, which produce a synergy between apparently independent outcomes. We sampled 32 men and women working in the tourism industry at alcohol-serving establishments in Sosúa, Dominican Republic. Interviewees described alcohol consumption as an implicit requirement of tourism work, tourism industry business practices that foster alcohol consumption, and an intertwining relationship between alcohol and sexual commerce. The need to establish relationships with tourists, combined with the overconsumption of alcohol, contributed to a perceived loss of sexual control, which participants felt could impede condom use. Interventions should incorporate knowledge of the social context of tourism areas to mitigate the contextual factors that contribute to HIV infection and alcohol consumption among locals.

HIV Risk Behavior among Youth in the Dominican Republic: The Role of Alcohol and Other Drugs

Existing literature related to HIV in the Dominican Republic has tended to neglect the unique role of tourism areas as distinct ecologies facilitative of sexual risk behavior, particularly HIV vulnerability and transmission. Furthermore, limited attention has focused on Dominican adolescents living in close proximity to tourism areas who have become increasingly exposed to alcohol due to the expanding tourism industry in the Dominican Republic. While most previous analyses of the effects of alcohol on adolescent sexual risk behavior have focused on the transient effects of alcohol on judgment and decision making, the effects of chronic alcohol use on sexual behavior has been a neglected area of research. Our study explores the relationship between chronic alcohol use, the parent-adolescent relationship, affective factors such as self-esteem, and intentions to engage in sex. We examine the above factors within the context of tourism areas which represent a unique ecology of alcohol availability and consumption and HIV risk. We discuss implications for developing applied family-based programs to target Dominican adolescent alcohol use and sexual risk behavior in tourism areas of high alcohol exposure.

Internet use, recreational travel, and HIV risk behaviors in men who have sex with men

Previous studies have documented higher rates of HIV risk behavior in gay and bisexual men traveling for leisure. Most of these studies collected data in high-risk tourist areas known for promoting alcohol and other substance use. The present study sampled a broader range of men by collecting data at a Gay Pride celebration, and asking participants about vacation experiences over the past 12 months. We also collected information about men's use of the Internet to find sexual partners before they traveled. Overall, two-thirds of participants reported recreational travel in the previous year. Of these men, 17% reported having sex with a new partner during their most recent vacation. Forty-three percent of the respondents were sexually active during their vacation. Sexually-active participants reported a mean of 2.01 unprotected anal sex acts during their brief vacation stay (M = 6.2 days). Close to half of the sexually-active men reported having sex with a partner of unknown HIV status. Alcohol and drug use were associated with unprotected sex. Men who used the Internet to set up dates prior to travel reported significantly more sexual partners and were significantly more likely to report having sex with a new partner. Many gay and bisexual men on vacation report behaviors that may place their health at risk, including substance use and unprotected sexual activity. Interventions designed to reduce risk behaviors in this population are needed.