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In terms of the global AIDS pandemic, the Caribbean is the second-most affected region in the world. With about 240,000 people living with the disease, the average adult HIV prevalence rate is 1.0%, which is higher than all regions except Sub-Saharan Africa. Similar to the crisis of HIV/AIDS in Africa, HIV/AIDS in the Caribbean is a significant public health issue. Several factors influence this epidemic, including poverty, gender, sexuality, sex tourism, and stigma. Different countries have had a variety of responses to the disease, with a range of challenges and successes.

Overview
Although there is no specific data on the exact origins of the disease, the HIV epidemic most likely began in the Caribbean in the 1970s. The first reported case occurred in Jamaica in 1982, followed by a number of cases of gay and bisexual men in Trinidad and Tobago. However, in a short period of time, HIV quickly crossed over into the general population. Contrary to popular belief and the subject of many misconceptions, the primary mode of transmission of HIV in the region is actually heterosexual sex. . In the early days of the epidemic, many more men were affected than women. Now, the number of new HIV infections among women is higher than those among men. Over time, the numbers of men and women living with the disease in the Caribbean seemed to equalize. Currently, though, the Caribbean is the only area outside of Sub-Saharan Africa where women and girls outnumbered men and boys living among people living with HIV.

Among adults aged 15-44, AIDS is the leading cause of death. Between 2001 and 2009, new infections slightly declined. There is a large degree of variation in terms of HIV prevalence between the 21 Caribbean countries. Currently, there are five countries where the national prevalence is over 2%, those being the Bahamas, Belize, Guyana, Haiti, and Trinidad and Tobago. In Jamaica and Barbados, the HIV rate is estimated to be about 1.5%, while in Cuba the rate is under 0.2%. The HIV/AIDS epidemic in Caribbean appears to have been overshadowed by the seemingly more sever problems in Sub-Saharan Africa, Asia, and the countries with more active and highly visible activism.

Social Factors
There are a variety of social factors that have perpetuated the spread and worsened the severity of HIV/AIDS in the Caribbean. Many areas of social vulnerability, including poverty, illiteracy, limited education, and unemployment, put individuals at greater risk for acquiring the infection. Because of these, many have less knowledge, skills, and motivation to practice safe-sex and avoid the disease.

Women
Gender plays an important role in the spread of HIV. Young women are more likely than men to contract HIV in the Caribbean, and most of these women are between 24-44 years old. In Third World countries in general, women are at an extreme disadvantage in terms of the prevention and treatment of HIV. The gender hierarchies found within many societies contributes to the correlation of women and HIV. One of the factors that put women most at risk is sexual violence. The first sexual experience of a girl is often forced, and during unprotected vaginal intercourse, women are more likely than men to contract HIV, because HIV-infected semen has a higher viral concentration than vaginal secretions. The Capability Approach, outlined by Nussbaum’s Central Capabilities, lists bodily health and bodily integrity as crucial components of human dignity, and both of these are violated in the case of HIV transmission through rape. Furthermore, sexual relations between older men and younger women during transactional sex could possibly explain why more teenage girls than boys are HIV-positive in the Caribbean.

Homosexuals
Sexuality has also had a significant impact on HIV/AIDS in the Caribbean. The prevalence of HIV among men who have sex with men (MSM) seems to be high, though there is a lack of reliable data. The average rate across the Caribbean between MSM is about 12%, though these rates range from 11.7% in the Dominican Republic to 18% in Suriname to 33.6% in Jamaica. While unprotected sex between men is undoubtedly a major contributing factor to the epidemic, it remains largely hidden in the data. In many Caribbean countries, gay sexual relations remain illegal. This has led to a heavy stigma associated with same sex relationships. This stigma and widespread discrimination are definite factors in the spread of HIV. In Trinidad and Tobago, one in five MSM were HIV positive, and out of those, one in four said they also have sex with women. Because of the stigma and discrimination, these men hide their same sex behavior and become involved with women who don’t know about their sexuality. This has created a bridge for HIV to pass from the gay community to the general population.

Cultural Factors
Several factors exist within Caribbean cultures that play a role in HIV transmission. Firstly, sexual patterns exist in several countries that foster the spread of the disease. There is a high level of sexual activity among the youth, as evidenced by the 22% to 32% of persons in six Eastern Caribbean States reporting having sex before age 15. Furthermore, having multiple sexual partners is very common.

The commercial sex industry, transactional sex, and sex tourism in the Caribbean are likewise important factors. HIV infection rates for these workers are high, ranging from 4% in the Dominican Republic to 9% in Jamaica to 30.6% in Suriname and Guyana. One possible explanation is that the use of condoms in these relationships is less likely. . In addition to the specific industry of sex tourism, studies have shown that the general tourism industry is positively correlated with the HIV epidemic. The perceived connection exists in that there are aspects of the environment of a tourist area that foster higher risks for HIV infection. These include riskier behaviors on the part of locals and tourists, as well as employees of the tourism industry engaging in relations with the tourists.

Injecting drug use also plays a small role in perpetuating the spread of the disease, though it is not very common in many countries. However, two notable exceptions are Bermuda and Puerto Rico. In Bermuda, the prevalence rate is around 43%, while in Puerto Rico almost 80% of HIV infections arise from intravenous drug use.

Economic Factors
The economies of the Caribbean influence the spread of HIV/AIDS as well. Firstly, the actual cost of HIV on many facets of life, outside of simply human well being, was underestimated in the past. The disease hindered both the growth and the development of the island nations that make up the region. Because of rising mortality and falling productivity due to illness, the labor force in several industries has been negatively affected. Several aspects on individual economies will also experience negative impacts of HIV, from agriculture to tourism to finance. There have also been observed correlations between condom use and economic security, with those in more impoverished situations being less likely to practice safe sex.

Studies have tried to identify a relationship between poverty and susceptibility to HIV. Many have indicated that HIV/AIDS can have a negative impact on socioeconomic status, as well as the level of overall employment in a given country. In Trinidad and Tobago specifically, being poor leaves one at a higher risk to contract the disease, but having the disease likewise leaves one more vulnerable to becoming poor and unemployed.

Haiti
Haiti, a nation that shares the island of Hispaniola with the Dominican Republic, has been greatly affected by HIV. Recent studies suggest that the adult prevalence is about 3%, the highest rate in the Americas and the highest outside of Sub-Saharan Africa. Like many other countries, the disease began as being associated with men who have sex with men, specifically men in Haiti who engaged in commercial sex with male tourists. Later, the disease crossed over into the heterosexual community, with the main areas of risk being sex with female sex workers, casual sex with partners infected with AIDS, and blood transfusions. The course of the disease in Haiti has been rapid and aggressive, compounded by high rates of tuberculosis and other diseases of poverty. Furthermore, a large number of children were born to HIV-positive mothers before proper treatment was available, leading to a spike in infant mortality. Negative affects have been observed in the country, one being the impact on the economy due to a shrinking tourism industry.

Prevention
The response of the healthcare in Haiti has been fairly effective. Due to swift identification of the disease, a coordinated response was undertaken relatively quickly. Several measures were taken, such as giving the Haitian Red Cross complete control of the blood bank, launching a national awareness campaign, and setting up local health units that provide HIV treatment with antiretroviral drugs. Although Haiti has undergone civil unrest for several years, a priority was placed on the HIV/AIDS epidemic, and strong relationships were formed with the private health sector. Through both prevention and care, Haiti continues to manage the spread of the disease.

Barbados
Currently, the adult prevalence rate of HIV in Barbados is about 1.5%. When HIV first struck Barbados, the island nation was completely underprepared to handle such a significant and detrimental disease. The first case was recognized in 1984, after which those infected with AIDS were heavily stigmatized.

Prevention
In contrast to system in Haiti, much of the healthcare response in Barbados was carried out by the public sector. Several successes of Barbados in its fight against HIV include universal screening, confidentiality, an AIDS information center and hotline, and special attention focused on at-risk groups. Overall, the achievements should undoubtedly be praised, especially considering the fact that these responses were carried out during an economic depression in 1990s, as well as during a period of severe stigmatization of HIV-positive people.

Jamaica
Jamaica is another island nation that has been hit hard by the HIV/AIDS epidemic, with an adult prevalence rate of around 1.5%. Currently, AIDS is the leading cause of death among two at-risk groups, young children aged 1-4 and young women aged 20-29.

Prevention
Both the public and private health sectors have played important roles in the response to the epidemic. From providing healthcare to seeking international funds, instituting educational programs to providing condoms, the Jamaican government has done much in prioritizing the HIV crisis. Notably, as part of their strategic plan. Jamaica has set of goal of normalizing HIV as part of normal societal discourse. This would undoubtedly help to reduce stigma towards HIV-positive individuals. The relative successes of the Jamaican program are also notable, as the country has managed to secure its blood supply, expand STI treatment centers, introduce proper surveillance of HIV, and make condoms widely available. The country still seeks to strengthen its response, especially in terms of reducing discrimination and expanding prevention and intervention programs.

Cuba
The current HIV adult prevalence rate in Cuba is estimated to be out 0.07%, one of the lowest in the world and certainly the lowest in the region. Three of the major modes of transmissions in other nations, mother-to-child transmission, transmission through blood infusions and through injecting drug use, are virtually non-existant in Cuba. Instead, sexual contact accounts for approximately 99% of all cases. In terms of sexuality, Cuba has followed a trajectory nearly opposite of the norm. Most of the first cases diagnosed were heterosexual men, but the disease then crossed over into the gay community as male-to-male sexual contact began to spread the disease. Today, men who have sex with men (MSM) are one of the most at-risk groups, making up for around 86% of men infected with HIV in Cuba.

Prevention
The response by the Cuban government was swift and effective. With the establishment of the Working Group for Confronting and Fighting AIDS, the government and NGOs were able to create comprehensive measures to fight the disease. Firstly, Cuba strictly banned the importation of all human blood products and destroyed potentially infected supplies, effectively eliminating transmission of HIV through blood transfusions. Next, the country began to provide wide-scale HIV testing for Cubans who had travelled abroad and potentially brought the disease back into the country. The most important measures served to prevent sexual transmission, namely through education programs, medical examinations, and admittance of HIV-positive individuals into specialized health centers called sanatoria. These sanatoria were somewhat controversial, especially in terms of possible human rights violations. Although severely isolated in the late 1980s, the program has since improved significantly, providing outlets for social integration and multiple levels of care. The Cuban response to the HIV epidemic was extremely successful in both prevention and care, attributed to both the Cuban healthcare and socialist government system.

Responses
The responses to the HIV/AIDS epidemic in the Caribbean have varied over time and across countries. Broadly, Jon Cohen establishes that “increased political will, cheaper antiretroviral drugs, stronger NGOs, and the generous donations of bilateral and multilateral donors have combined to vastly improve access to treatment.” Testing pregnant women for HIV and providing antiretroviral drugs has significantly reduced the rates of mother-to-child transmission. Improving awareness of safe sex practices through HIV education and prevention programs, as well as increasing contraceptive distribution, can reduce the rates of sexual transmission. Other responses include screening blood banks to reduce transmission through blood transfusion, increasing HIV screening and testing, and advocacy to establish responsive governmental policies.

Challenges
Several challenges have hindered the response to the HIV crisis. First, many countries have weak national capacities in terms of their ability to manage, control, and address the epidemic. This management also presents technical challenges for developing countries with varying levels of technological advancement. Because of the many regional governments and international aid agencies, the response to the spread of the disease is often uncoordinated and less effective than it could be. The stigma associated with both HIV-positive people and the perceived connection to the gay community is often crippling, resulting in discrimination, low use of testing facilities, and increased transmission of the disease. While this is certainly improving, there is still also a lack of information regarding how HIV/AIDS affected specific groups, like commercial sex workers, men who have sex with men, and IV drug users. Without substantive and concrete information, it remains difficult to completely address the needs of the groups. Lastly, it remains difficult to fully implement HIV interventions in several areas, and in-depth research is needed to truly understand how these interventions function to help HIV-positive individuals.