Caribbean success story - drop in HIV infections in the Dominican Republic

The last decade has seen a sharp drop in HIV infections in the Dominican Republic, resulting largely from reductions in risky sexual behavior, according to a paper in a supplement to the May 1 issue of JAIDS: Journal of Acquired Immune Deficiency Syndromes.

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The good news may be part of a broader downward trend in HIV prevalence in the Caribbean, although there is lingering concern over a likely "bisexual sub-epidemic" of HIV transmission among men having sex with men (MSM) in the Dominican Republic. Daniel T. Halperin, Ph.D., M.S., of Harvard University School of Public Health is lead author of the new report.

Based on a review of the latest information on HIV-AIDS and related sexual behavior in the Dominican Republic, the researchers report an overall decline in HIV prevalence since the mid- to late 1990s. Among women seen at prenatal clinics, the infection rate decreased from two percent in 1995 to one percent in 2006. An even greater decrease was noted among young people aged 15 to 24: from two percent to 0.5 percent.

Reductions in HIV were noted in other key populations as well, including female sex workers and men seen at sexually transmitted disease clinics. There was also a decrease in the high rate of HIV infection among impoverished residents of former "sugarcane plantations" (bateyes), who are largely Haitian migrants.

The reduction in HIV appeared to result from changes in sexual behavior, including increased use of condoms - especially among female sex workers. Surveys suggested that up to 85 percent of men altered their sexual behavior because of concerns about AIDS, especially in reducing their number of partners. Similar reductions in risky sexual behaviors have been reported in African and Asian countries with declining HIV rates.

At the same time, the percentage of AIDS cases among men showed little or no change. This pattern suggests that MSM, or bisexual behavior, probably continues to be an important part of the HIV epidemic in the Dominican Republic. MSM is highly stigmatized in Dominican society - even after becoming infected with HIV, few men would admit to having sex with men. "[A]n important question that arises is whether sufficient prevention resources have been targeted to bisexual men and other MSM in the Dominican Republic," Dr. Halperin and colleagues write.

Downward trends in HIV prevalence have been reported from elsewhere in the Caribbean - including neighboring Haiti. In the early 1980s, Haiti and the Dominican Republic became the first countries in Latin American and the Caribbean to report cases of AIDS. At the time, some predicted that HIV transmission in the Caribbean would "explode out of control." However, over the past two decades, a number of government and other programs have been launched to control HIV in the Dominican Republic and other Caribbean countries.

The new paper suggests that the Dominican Republic is, like Haiti, a "Caribbean success story," having slowed the spread of HIV disease largely through increased condom use and other changes in sexual behavior such as partner reduction. "However, the risk of complacency is real, and it is imperative to continue implementing assertive prevention efforts," according to Dr. Halperin and colleagues. They call for more research to measure how pervasive the "bisexual" epidemic is, and to develop more effective ways of detecting and preventing the spread of HIV among MSM.

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