i Distribution Agreement In presenting this Thesis as a partial fulfillment of the requirements for an advanced degree from Emory University, I hereby grant to Emory University and its agents the non-exclusive license to archive, make accessible, and display my Thesis in whole or in part in all forms of media, now or hereafter know, including display on the world wide web. I understand that I may select some access restrictions as part of the online submission of this Thesis. I retain all ownership rights to the copyrights of the Thesis. I also retain the right to use in future works (such as articles or books) all or part of this Thesis. ______________________________________________________________________________ Signature of Student Date ii TROUBLE IN PARADISE: HIV/AIDS IN THE CARIBBEAN BY Samantha Dittrich Degree to be awarded: M.P.H. Career MPH ______________________________________________________________________________ Dabney Evans, PhD, MPH Date Committee Chair ______________________________________________________________________________ Kate Winskell, PhD Date Committee Member ______________________________________________________________________________ Melissa Alperin, MPH, CHES Date Chair, Career MPH Program iii TROUBLE IN PARADISE: HIV/AIDS IN THE CARIBBEAN BY Samantha Dittrich M.P.H., Emory University, 2012 B.S.N., University of Virginia, 2006 B.A., University of Virginia, 2004 Thesis Committee Chair: Dabney Evans, PhD, MPH An abstract of A Thesis submitted to the Faculty of the Rollins School of Public Health of Emory University in partial fulfillment of the requirements of the degree of Master of Public Health in the Career MPH Program 2012 iv Abstract TROUBLE IN PARADISE: HIV/AIDS IN THE CARIBBEAN BY Samantha Dittrich The Caribbean has the world's second highest adult prevalence rate of HIV after sub- Saharan Africa and AIDS-related mortality remains the leading cause of death among 25-44 year olds in the region. Heterosexual sex is the main route of transmission throughout the Caribbean. Women are particularly vulnerable to HIV infection as more than half of the people living with HIV are women. Haiti and the Dominican Republic have one of the highest HIV-positive rates in the Americas whereas the Cuban population has the lowest prevalence rate in the Americas and one of the lowest rates of AIDS-mortality in the Caribbean. The purpose of this project is to examine how and why AIDS mortality rates and transmission patterns vary across three Caribbean countries: Cuba, the Dominican Republic, and Haiti. Additionally, the goal of this project is to show how a small, low-income country like Cuba has managed to have an extraordinary low prevalence rate of HIV/AIDS and how the Cuban response to HIV/AIDS may provide useful strategies to the Dominican Republic and Haiti such as awareness and prevention programs, educational campaigns, and HIV testing and screening. In an effort to address these questions and offer an analysis on how culture and religion, country specific infrastructure, and lack of public health policies and educational resources have contributed to the HIV/AIDS crisis in the Caribbean, a comprehensive review of relevant literature was conducted. The specific data reviewed/examined focused on incidence and prevalence of HIV/AIDS, the origins of HIV/AIDS in the Caribbean, the history of Cuba, the Dominican Republic, and Haiti, characteristics of the Cuban, Dominican, and Haitian populations, as well as case studies and qualitative studies. The main findings showed that the HIV/AIDS epidemic in the Caribbean is still largely concentrated in most-at-risk populations and that new HIV infections now affects men and women equally. As evident in Cuba, the Dominican Republic, and Haiti, many gaps exist in access to prevention and care as well as in efforts to address the HIV/AIDS epidemic in the Caribbean which has been compounded by the social, economic, and political realities of the region. v TROUBLE IN PARADISE: HIV/AIDS IN THE CARIBBEAN BY Samantha Dittrich M.P.H., Emory University, 2012 B.S.N., University of Virginia, 2006 B.A., University of Virginia, 2004 Thesis Committee Chair: Dabney Evans, PhD, MPH A Thesis submitted to the Faculty of the Rollins School of Public Health of Emory University in partial fulfillment of the requirements of the degree of Master of Public Health in the Career MPH Program 2012 vi Acknowledgements First and foremost, I would like to express my great appreciation to my family for all of their unconditional love and support. I am eternally grateful to my parents, Mike and Joyce, for always believing in me and all that I do as well as for their patience, encouragement, and at times much needed motivation. I would also like to thank my brother and sister-in-law, Josh and Stanka, for not only offering academic advice but for their encouragement throughout my studies. Second, I would like to thank my thesis committee. I am very thankful for Dabney, my committee chair, for generously taking me under her wing. Her willingness to give her time and to offer guidance throughout this process has been very much appreciated. I would also like thank Kate for keen insight and assistance along the way as well. Third, I am indebted to all of my amazing friends for their tremendous support and for helping me find that fine balance between work, school, and a little fun. I would like to especially thank Jen, Chris, Jenny, and Duane for always being so loyal and encouraging and to Liz and Dan for all their generous hospitality when I was at Emory for on-campus classes. Lastly, I would like to dedicate this Thesis to Jonathan—my first patient with AIDS who passed away in 2006 from AIDS-related complications. I thank him for inspiring me to continue to help others in need. vii Aire durando Who is it has killed this man and left his voice above ground? There are dead men rising, rising, as their coffins are laid down. This sweat...who caused it to perish? What costs a poor man his breath? Who is it has killed these hands? No man is contained by death! There are dead men who stride taller the deeper their coffins fall. Who felled the length of this man with his upright voice so tall? There are dead men deep as roots who feed the harvest their grace. Who is it has killed these hands, who has killed this sweat, this face? There are dead men rising, rising as coffins sink in their place. Manuel del Cabral viii Table of Contents Distribution Agreement ................................................................................................................. i Approval ........................................................................................................................................ ii Abstract Title Page ...................................................................................................................... iii Abstract ......................................................................................................................................... iv Thesis Title Page ............................................................................................................................v Acknowledgements ..................................................................................................................... vi Table of Contents ....................................................................................................................... viii List of Tables ..................................................................................................................................x List of Figures .................................................................................................................................x List of Abbreviations ................................................................................................................... xi Glossary of Terms ....................................................................................................................... xii Chapter I: Introduction .................................................................................................................1 Introduction ..............................................................................................................................1 Problem Statement....................................................................................................................3 Purpose Statement ....................................................................................................................5 Research Questions ..................................................................................................................5 Chapter II: Methodology .............................................................................................................7 Introduction ..............................................................................................................................7 Data Collection & Analysis ......................................................................................................7 Limitations & Delimitations .....................................................................................................9 Chapter III: The Origins of HIV/AIDS in the Caribbean .......................................................11 Regional Overview .................................................................................................................11 Epidemiological Patterns & Trends in the Caribbean ............................................................12