HIV/AIDS in Latin America and the Caribbean

http://www.christian-aid.org.uk/

Christian Aid: Latin America, Caribbean and Global Division working document

1.2 Rationale for the study
Christian Aid has funded programmes in Latin America and the Caribbean since the early 1970's. The Latin America and Caribbean Team (LACGD) began funding HIV/AIDS programmes in the early 1990s. Since then, HIV prevention and care work has been supported through community-based and HIV/AIDS-specialist programmes in Central America, Brazil, the Southern Cone and the Caribbean. Since 1999, the LACGD has spent in excess of £1 million on HIV/AIDS sexual and reproductive health programmes. In financial year 2001/2 £144,138 was spent on tackling HIV/AIDS in the region out of a total budget of nearly £4.5 million. This represented 3.2 per cent of the annual allocation.

Although evaluations of LACGD-funded HIV/AIDS projects have been conducted on an individual basis, the team has not had the opportunity to reflect on the overall impact of the virus on the region, nor of Christian Aid's response to it. A brief study conducted in 1993 was soon out of date, particularly following the opening of three field offices - in Central America, Haiti and Colombia. Towards the end of 2000, the decision was taken to substantially review the HIV/AIDS situation in the region as part of the team's wider debates on regional priorities, strategies and policies.

1.3 Objective
The objective of the study is to examine the current HIV/AIDS situation in Latin America and the Caribbean (LAC) with specific reference to the country, regional and thematic priorities identified by the team. It is also to make recommendations for programming, advocacy, staff training, fundraising and capacity building as part of the LACGD's regional policy and strategy review. It was agreed that this document would comprise the HIV/AIDS component of the LACGD's process of reflection on regional priorities and strategies, ongoing concurrently.

1.4 Terms of reference
(a) Using internal and external documents, summarise the current HIV/AIDS situation in LAC (rates of infection, vulnerable groups and areas, trends).
(b) Summarise the HIV/AIDS and health programmes of Christian Aid partners in the LAC region in the past three financial years (education, prevention and care, advocacy, campaigning, etc) to highlight type of support given, lessons learnt and obstacles encountered in implementing HIV programmes.
(c) With programme staff, review the country contexts and priorities of the different geographical units (Andes, Brazil, Central America and the Caribbean), and the limitations, opportunities and possible obstacles to integrating HIV/AIDS into their current programmes.
(d) Summarise the role of key actors (including international and national NGOs and governments) influencing HIV/AIDS work in the LAC region with special emphasis on the 11 countries in which Christian Aid has programmes.
(e) Summarise and analyse the activities of the church, ecumenical and faith-based organisations in LAC, including non-traditional or unorganised faiths.
(f) Summarise priority areas of other aid agencies working on HIV/AIDS in LAC, including CAFOD, APRODEV and other major British aid agencies.
(g) Make a preliminary assessment of Christian Aid's partner needs in Southern advocacy on HIV/AIDS with special focus on opportunities, barriers, constraints and capacity, and their relationship to North-led advocacy.
(h) Preliminary review of the possibilities and limitations of access to low-cost integrated and palliative care (food and nutrition, anti-retrovirals (ARVs), testing, etc).

1.5 Limitations of the study
This paper does not aim to establish policy or a strategy for the LACGD's HIV/AIDS work. Rather, it aims to provide a general panorama of HIV epidemiology, provide a background on vulnerable groups and raise issues that the LACGD can discuss in its reflections on future priorities. It was written with two target audiences in mind: LACGD programme and communications staff and the HIV Unit, which has more specific expertise on the issue, but less knowledge of the region and of what Christian Aid has been supporting over the years. Apologies are extended therefore to those who find parts of this document irrelevant or a repetition of what they already know.

HIV/AIDS data collection is still extremely difficult and all the statistics presented here, while revealing clear trends, should be treated with caution. Sentinel surveillance data, the basis of most UNAIDS statistics, tests women only at antenatal clinics. Where the health structures are poorly developed, or where pregnant women lack access, particularly in remote areas, many are not reached. It has been found that sentinel surveillance and other methods tend to reach a higher proportion of middle class and educated people. Furthermore, in conflict areas such as Colombia, HIV data collection is virtually impossible, and doubly so if women have been traumatised by rape or military violence. For this reason, statisticians and researchers usually suggest that the figures presented are underestimates of the real problem.

STD clinics also collect HIV data. Here, men are tested for HIV. However, the same problems apply, namely the number of people reached, what type of people attend and how many visit clinics in times of conflict, and during and particularly after natural disasters. Even under normal circumstances, men, particularly poorer men, are notoriously unwilling to attend to their health problems and can leave medical check ups until quite late.

The statistics presented here reflect data collected mostly by UNAIDS, but also by other local and regional research institutions. They present an picture of epidemiology limited by where the information was collected and who attended clinics. It will provide information for areas where there are no clinics and where people have not been tested. The statistics show trends, but these cannot necessarily be extrapolated to cover the overall population.

At the time of writing, some issues and countries were more difficult to research than others, especially ones where the statistics showed low rates of infection. For example, more research has been done on Brazil and the Caribbean, which have higher rates of infection, than on the Andean countries. Less information is available (although there is evidence that more research is now being done), about sexual practices, about how myths and beliefs affect sexual behaviour, and how intervention programmes should take these into account. More research is needed about the 'world view' of the many minority groups in the region, and its link to their culture's perceptions about health, illness, sexuality, sexual relations and sexual practices. This kind of information is required before programme staff and partners can plan HIV/AIDS interventions in prevention, care or advocacy.

Partners, researchers and other contacts with the experience and ability to make the links between macro socio and political issues and micro behaviour are hard to come by in the region. A few stand out, including GAPA and KOINONIA in Brazil, ENMUNEH in Honduras, increasingly Jamaica AIDS Support, and One Respe in the Dominican Republic. Ecumenical partners that are able to provide HIV leadership and reflection include CREAS and, to a certain extent, the CCC (although there is a limit to what the latter can implement).

Many good contacts are not partners. Nonetheless, there is a tremendous need for more research into HIV and the extent to which its spread across the region is a manifestation of other socio-economic and political factors, which have undermined people's power and ability to control their lives. South-based advocacy and proposals for alternative public policies on health, access to medicines, care, food and nutrition, let alone ARVs, and numerous other issues can only develop against the background of a thorough understanding of the overall socio-political and economic context. This kind of reflection requires much more support and funding. It should be borne in mind that partner capacity for national or international HIV advocacy can increase over time. This often requires training, exchanges, exposure and financial investment, among other things. The document mentions examples of this kind of work where relevant but it should be noted that much more remains to be done.

There is now a tremendous amount of HIV/AIDS information available on the Internet, and there are books and periodicals dedicated exclusively to the subject. These sources sometimes present inconsistent and contradictory information. Care has been taken here to provide reliable data. Any over-emphasis on UNAIDS statistics is due to a lack of other sources or uncertainty about the ones found. The analysis presented also draws as much on qualitative as on quantitative sources. This is due to the availability of the former, and on the researcher's belief that both constitute equally valid sources of information.

A note on terminology
• People living with HIV/AIDS (PLHAs) - refers to people who have been infected with HIV. PLHAs may be completely well (asymptomatic), or have symptoms or illnesses associated with HIV infection.
• AIDS orphans - refers to children who have lost one or both parents to AIDS. The majority of AIDS orphans will not be infected with HIV.
• Prevalence rate - the number of people living with HIV in a particular population at a particular point in time.
• Sentinel surveillance sites - are designated sites, such as antenatal or STD clinics, where anonymous blood samples are tested for HIV.
• Mother-to-child transmission (MTCT) of HIV (sometimes called vertical transmission) - refers to HIV transmission from a mother to her child. This can occur before childbirth (in utero), at the time of delivery or after birth due to breastfeeding.

1.6 Christian Aid's work in Latin America and the Caribbean
LACGD has programmes through 124 in Peru, Colombia, Bolivia, Brazil, El Salvador, Guatemala, Honduras, Nicaragua, Haiti, the Dominican Republic and Jamaica. A further eight partners address regional issues such as campaigning, ecumenism, gender and health, communications, lobbying and advocacy, going beyond individual country programmes. The team is committed to the eradication of poverty and injustice through the enhancement of the economic, social, cultural, civil and political rights of the region's poor and marginalised people. It is also committed to communicating its work and that of its partners to the rest of Christian Aid and to wider audiences in the UK and Ireland. Programmes are managed through a hybrid structure of three field offices - in Haiti, Central America and Colombia - and three London-based programmes - Brazil, Peru and Bolivia, Jamaica and the Dominican Republic. Regional and UK-based programmes are managed from London by the regional co-ordinator.

1.7 Socio-political and economic overview: Latin America and the Caribbean
1.7.1 Economy
The global political economy is having a profound effect on the region. The neo-liberal agenda of the main international financial institutions has been manifest in a series of trade agreements and trade-related plans for the region, which have been and are still being negotiated. These include the Free Trade Agreement of the Americas (FTAA), the Common Market of the South (MERCOSUR), Plan Puebla Panamα, and Cotonou, the EU's trade agreement with Africa, the Caribbean and Pacific states. Plan Colombia threatens to increase American hegemony not only in Colombia, but the whole region. National sovereignties across the entire region are being subjugated to this agenda of liberalisation and there are signs that this is leading to increased economic insecurity and volatility, as was seen, for example, in Argentina and Venezuela.

Debt remains an important issue. Governments continue to borrow despite the negative effects on the region of loans and debt servicing. The process of 'dollarisation' continues in Latin America, with both Ecuador and El Salvador now fully converted to the US dollar.

These policies have been socially and economically detrimental, reflected in high levels of poverty and marginalisation, continued internal displacement, migration, increased conflict and crime, social disintegration, political and ethnic tensions, and the absence in most countries of a viable political response to the overall problems and possibilities.

1.7.2 Human development indicators
There are 32 Latin American and Caribbean countries listed in the United Nation's Development Programme (UNDP) 2002 Human Development Report. They fall into the 'high', 'medium' and 'low' human development categories, reflecting the great disparity of the region. Haiti is ranked within the 'low human-development' category, 146th of the 162 countries listed. Nicaragua, Honduras, Guatemala, Bolivia are all towards the lower end of the 'medium human-development' scale, ranking 106th, 107th, 108th and 104th respectively ('low human-development' countries start at number 127 out of 162). Brazil is 73rd, Colombia 68th, Peru 82nd, Jamaica 86th, the Dominican Republic 74th, and El Salvador 104th - all medium development countries. A small number of countries covered by regional programmes fall into the 'high human development' category, such as Barbados and Costa Rica, but the vast majority are in the medium to low bracket.

These rankings are reviewed annually and some countries have moved down rather that up the scale in the last five years. Haiti, for instance, was 134 in 2001out the 162 countries listed. The full list is as follows. Countries in which Christian Aid has programmes are in bold.

Table 1 UNDP classification of countries in Latin America and the Caribbean 2002/3

According to all human development indicators, Haiti is the region's, and in fact the western hemisphere's, poorest country. Indicators of health, economic, social and personal development are consistently well below the Caribbean, Central, South and North American average. In the past, Haiti has been stigmatised because of its high HIV-prevalence rate and, during the eighties and early nineties, was incorrectly represented in some regional and international press as being responsible for the spread of the virus in the Americas.

In addition to widespread and ongoing discrimination against Haitians in the region, Haiti remains associated with the spread of HIV. It is important, therefore, that Christian Aid's development and communications work on HIV/AIDS emphasises the link between widespread poverty and the spread of the virus, and not with Haitians per se. There is also extreme poverty in Bolivia, the poorest country in South America, and Guatemala, the poorest in Central America.

The categorisation of countries as 'medium human development' should not camouflage reality. Although their infrastructures, and economies are more developed, and they are better able to trade on the international market, attract foreign investment and create employment, they are also characterised by great income inequality, which leads to other social and economic problems. As a consequence, impoverished groups - in all cases the majority of the population - live alongside people with far greater access to education, health and the overall wealth of their countries. For example, UNDP research on income distribution concluded that, despite having one of the largest economies in the world, Brazil had the fourth most unequal distribution of income out of the 162 countries studied⁴. Ten per cent of Brazil's poorest people have access to only one per cent of the country's wealth. By contrast, ten per cent of the country's wealthiest people own 47 per cent of the land. Of the Latin American countries studied, it had the second most unequal distribution of income, after Nicaragua.

Extreme income inequality is not uncommon in Latin America and the Caribbean. And, as will be discussed later, people are often denied access to social services and wealth because of entrenched discrimination according to, among other things, race, ethnicity, class, gender, sexuality and disability. Christian Aid's LAC Team and its partners therefore recognise the need to address not only the immediate manifestations of poverty, but also the underlying structures and behaviours that prevent specific groups from exercising their rights, and having access to land, wealth and services.

1.7.3 Political and social trends
Collective and individual responses to this overall economic and political climate show a tendency towards social fragmentation, political apathy and increased crime and violence. Internal displacements, and cross-border and inter-island migration, are important issues to consider in the Latin American context, as is emigration out of the Caribbean to North America and Europe. The rights of internally displaced people and migrants are seldom respected in host countries, whether in LAC or elsewhere.
Social violence is on the rise across the region. This is partly due to conflicts, such as the one in Colombia, but levels of violence are also high within poor communities and between different ethnic groups, such as in the Dominican Republic where repatriations and human-rights abuses against Haitians still occur. There is an impact on partners, who become victims of violence, kidnapping and intimidation, as well as on the communities in which Christian Aid partners work.

While the majority of countries in the region are formally democratic, their underlying systems have a tendency towards the anti-democratic. Regimes are prone to militarisation and corruption. There is little political leadership in most Caribbean territories, and in some there are ongoing political tensions. In spite of efforts to increase stakeholder and/or civil society participation in local government, constitutional reform and other state-led development initiatives, in practice these are neither fully participatory nor fully inclusive. Organisations that represent society are, in many parts of the region, weak and fragmented. Nevertheless, there are also signs of growing social movements in some parts of the region, which may well provide future opportunities for change.

1.7.4 US policy
The events of September 11 have had profound implications for the Latin American and Caribbean region. US foreign policy statements have become increasingly hostile towards alternative social and political movements. Plan Colombia's aggressive stance towards the country's 'drug problem' has been strengthened as part of the tougher US foreign policy. There have also been direct economic effects; tourism has dropped markedly throughout the region. Caribbean territories, heavily dependent on this sector, have been badly hit.

1.7.5 Ecumenism
It is not possible to go into detail on ecumenism in Latin America and the Caribbean in this paper. The movement has a very long history. Significant dates are the formation of the Latin American and Caribbean Conference of Churches (CLAI) in 1982, and, in 1973 the establishment of the CCC as a regional ecumenical entity. There are strong links between the two bodies. At the first meeting on the region's ecumenism it was agreed by ecumenical and church representatives that it needed to be as inclusive as possible, and particularly open to the experiences of women, peasant farmers, workers, professionals, artists, Pentecostal movements, base Christian communities, and black and indigenous traditions. In other words, precisely those groups which, hitherto, traditional churches had not necessarily welcomed.

Latin American and Caribbean ecumenism has also tried to better understand the religious diversity in the region. Formally and informally organised religious groups include Santeria, Candomble, Shango, Vodou, and Obeah. There are hundreds of other faith and spiritual traditions of the different minority indigenous groups that live in the region, far too many to name here.

Despite numerous achievements, ecumenism in Latin America and the Caribbean now faces real challenges. Some question to what extent the movement will survive⁵. Many perceive the movement to have insufficient finances and human capacity to face the current threats. These include a severe economic crisis affecting all sectors of society including the middle class, which is the base of traditional churches; the rise of US-influenced neo-Pentecostal and charismatic churches that are suspicious of ecumenism; an erosion of the values that affirm collective efforts in favour of individualism; increased violence; and a migration of people from the region to more developed countries or from rural areas to towns⁶.

Against this background, CLAI member churches rapidly shifting their thinking and strategy. Increasingly, the crisis is also about their own financial autonomy and sustainability. By their own admission, as communities and congregations have become poorer, so CLAI's churches have become poorer. In the Caribbean, the CCC faces very similar challenges. Its quest for financial security is possibly even more acute, as its most important donors, particularly the European Union, have withdrawn support in the past few years. This has forced it to cut staff and restructure.

1.7.6 International aid in the region
While EU and US funding to the region has levelled, DFID is showing a significant interest in Latin America⁷. In particular, it has a growing presence in Central America and has played an important role in the Poverty Reduction Strategy Papers (PRSP) processes in Honduras and Nicaragua. The EU is the most significant aid donor in selected Anglophone Caribbean countries, Haiti and the Dominican Republic. DFID contributions are less significant, ranking third or fourth highest in several territories, except Guyana where it is the most important contributor. Japan, France and Spain are significant donors of aid in other territories. US aid to Latin America and the Caribbean is relatively low, incommensurate with its political and cultural influence in the region.

This is the overall socio-political and economic environment in which HIV is spreading in Latin America and the Caribbean. The extent to which this environment is a causal factor and not just another problem is open to interpretation. Some literature speculates on a possible causal link between the uncertain socio-economic climate and the breakdown of community and traditional values; the search of individuals for quick solutions and quick wealth; and growth in feelings of apathy and powerlessness. It is suggested that people are engaging in risky behaviour as a consequence of external pressures, despite having information about safer practices. What is beyond doubt is that HIV/AIDS is undermining the hard won gains of more than 20 years of development work in the region.

1.8 Current situation of HIV/AIDS in Latin America Caribbean
Of the 40 million people estimated to be living with HIV/AIDS worldwide, 1.4 million live in Latin America and 420,000 in the Caribbean⁸. Latin America has the world's third highest rate of infection - after sub-Saharan Africa, South and South East Asia; the Caribbean has the eighth highest. In 1993, when the LACGD last undertook a regional survey on HIV/AIDS rates, there were 1.5 million people infected with HIV and 240,000 reported AIDS cases.

Latin America's population is roughly 470 million, and the Caribbean's 32 million. Of the five million newly infected people worldwide, 130,000 are in Latin America and 60,000 in the Caribbean. New infections represent 0.02 per cent of the Latin American population, while in the Caribbean they represent 0.18 per cent, proving that HIV is spreading much more quickly there. Another indicator - the adult prevalence rate - shows that 0.5 per cent of Latin America's adult population is HIV infected, as compared with more than two percent of the Caribbean's. Despite its relatively small size, the Caribbean has the second highest HIV prevalence in the world after sub-Saharan Africa. The percentage of HIV-positive women is higher in the Caribbean than it is in Latin America (being 50 per cent and 30 per cent respectively)⁹.

Within the region, there are significant sub-regional differences. In 1993, Brazil had the region's highest rate of infection. There were predictions of a major epidemic, leading to a million infections in that country alone. Initially HIV was concentrated among men who have sex with men (MSM). Later, heterosexual transmission became more common. Trends had been established in certain countries and regions: heterosexual transmission was dominant in the Caribbean and Honduras, whereas in Brazil, Peru, Bolivia, and other Central American countries, homosexual and bisexual men were more at risk. The concerted efforts of governments and NGOs have probably contributed to keeping infection rates below expectations, but there has still been a steady increase in infections in every country in the region. The Andean countries, Bolivia, Colombia, Ecuador, Peru and Venezuela, continue to have the lowest rates of infection.

One of the easiest ways of monitoring the HIV epidemic is through sentinel surveillance - the testing of pregnant women for infection during antenatal care at health clinics. Poorly developed health infrastructures, variable access to health centres, and delayed or under-reporting in many countries mean that the information gathered is inconsistent and has to be treated with caution. Different sources show different trends, making it difficult to produce one completely consistent overview of epidemiology. Other surveys provide useful back-up information. This includes data on sexual behaviour, the rate of sexually transmitted infection (STI), reproductive health and behavioural surveillance surveys. In Nicaragua, for instance, there's no data on HIV prevalence among antenatal women, STI-clinic patients or IDUs. In Guatemala, what little information exists pertains mostly to high-risk groups, particularly sex workers.

Nevertheless, some salient trends can still be discerned, pointing to sub-regional characteristics. Transmission in the Andean region is mostly through unprotected sex, 48.3 per cent homo/bisexual and 47 per cent heterosexual. IDU, haemophiliacs, blood transfusions and prenatal transmission represent fewer than five per cent of reported cases. In the Southern Cone (Argentina, Chile, Paraguay and Uruguay), IDU transmission represents 34.3 per cent of the overall total, and heterosexual and homosexual transmission 24.9 per cent and 32.9 per cent respectively. Because of its size, Brazil is treated as a region in itself in some statistics. There too, IDU represents a high proportion of the overall total - 23.7 per cent, and sexual transmission is divided almost equally between homosexual and heterosexual - 35 per cent and 35.9 per cent respectively.

Central America (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama) and the Caribbean show completely different trends¹⁰. Heterosexual transmission clearly outstrips homosexual, bi-sexual or IDU transmission, representing in both sub-regions almost 80 per cent of transmission. IDU transmission represents less than one per cent of cases in both Central America and the Caribbean (although this is higher in the Latin Caribbean). Homosexual and bisexual transmission represent less than 15 per cent of the total number of cases - a big difference from trends in Brazil and the Southern Cone¹¹.

Owing to stigma, denial, church influence and repressive social attitudes about sexual activity and sexuality, information about individual behaviour is not always freely given. Where taboos against homosexual behaviour are particularly strong, such as in parts of the Caribbean and Central America, there is greater likelihood than elsewhere that men who have sex with women are also having unprotected sex with men without admitting to it. Statistics showing a higher incidence of heterosexual rather than homosexual transmission could conceal the reality of MSM in those regions, and therefore need to be interpreted with caution.

1.9 Some current trends ¹²
There are several organisations collecting and collating epidemiological data in the region. HIV prevalence data from both the general population and specific high-risk groups are presented. There are many inherent difficulties involved in collecting population data, which is why UNAIDS presents high and low estimates, and why the available figures are always an estimation and are most useful in demonstrating trends in HIV prevalence.

General trends in the whole region
• There has been a three-fold increase in reported HIV cases since 1995 in the whole region
• 50 per cent of infected people in Honduras and 45 per cent of infected people in the Dominican Republic are women between the ages of 15 and 45 (according to 1999 statistics). This is the highest infection rate of the 11 countries.
• In most other countries, including Haiti, more men than women are infected, according to 1999 statistics. However, since 1999 it would appear that women are being infected at a faster rate than men.
• AIDS is the leading cause of death among 15-45 year olds in the English-speaking Caribbean.
• 85 per cent of infected people in the Caribbean come from Haiti and the Dominican Republic combined. (The population of the Caribbean (see definition in footnotes) is estimated at 32 million, based on a UNAIDS definition of the Caribbean. The Haitian and Dominican Republic population combined is just over 16.5 million, representing roughly half of the region total.)
• Haiti, with a population of just over eight million people, has more AIDS orphans than Brazil, which has a population of 170 million.
• According to 1999 statistics, almost as many women in Haiti and the Dominican Republic with a joint population of about 16 million were infected as there were in Brazil, whose population is more than ten times bigger.
• The majority of infected people in Brazil are male.
• 45 per cent of sex workers in Guyana are infected.
• In some countries, men are clearly the more vulnerable group, with very high infection rates. This is the case in Brazil, Nicaragua, El Salvador and all the Andean countries.
• Even where the rates of infection are low, men are still a very vulnerable group with very high rates of infection.

Fig 1 Country Data¹³

Fig 2 Prevalence rate for HIV/AIDS in adults (end 1999) in Latin America and the Caribbean

U.S Cesus Bureau 2000

Fig 3 Age and Sex¹⁴

Fig 4 Estimated prevalence rate in young people, 1999¹⁵

1.10 Vulnerable groups

1.10.1 Men who have sex with men (MSM)
The term MSM is applied to the broad group of men who have sex with men. It includes, but is not limited, to gays and bisexuals who differentiate themselves by identifying as such. As with sex workers, many men engage in sexual activity to which they do not admit. Contrary to perceptions, MSM does not equate homosexuality. Statistics that separate homosexuals from heterosexuals tend to group all MSM together as homosexuals. In reality, the categories are not fixed and movement of men from one to the other is quite fluid. Those who are identified as gay are often a minority within the larger group of MSM. HIV/AIDS programmes therefore have to use language that is broad enough to capture all types of self-identification and activity, including those who may never formally admit to it.

Although the trend is towards heterosexual transmission and more women are being infected, currently there are more HIV positive men than women in Latin America and the Caribbean. While 50 per cent of HIV-positive people in the Caribbean are men, in South and Central America, the proportion is 70 per cent. Homosexual and bisexual transmission account for about half of all infections, making men and particularly young men, a vulnerable group.

The practice of MSM is still taboo in many Latin American and Caribbean societies, although it exists in all of them. Increasingly, 'safe spaces' and 'safer regions' within countries have been negotiated. In some countries, such as Brazil, which have a much longer history of a gay rights movement and more public discussion about sexuality generally, attitudes towards MSM tend to be more liberal. This notwithstanding, homophobia continues to be a problem in all of the region's countries. In some, reprisals against MSM practices can be harsh or even deadly. Jamaican society for example is known for being particularly homophobic¹⁶. In several Latin American and Caribbean countries, homosexuality is still illegal. Those working with MSM often still contend with judgemental and punitive attitudes from different sectors of society, including churches. Many run the risk of being ill-informed about sexual health because of their own silence or denial. Conversely, due to the prejudice and denial of church, government or NGO programmes, they risk excluding MSM as a specific target group. Between self denial and institutional prejudice, MSM - whether gay or not - in many countries are left with insufficient access to information and services. They are therefore more likely to engage in risky behaviour, increasing the danger of infecting both female and male partners.

The problem of MSM silence and denial is so severe in Latin America and the Caribbean that in 1999 UNAIDS devoted an entire conference to the issue, attended by Brazilian, Colombian, Mexican, Guatemalan and Caribbean representatives¹⁷. The conference concluded that everyone in the region has a role to play in counteracting discrimination and in decriminalising MSM, especially as: 'The vulnerability of the group is reduced where political leaders and other key players accept the existence of male-to-male sex and its relevance to HIV programming.' Recommendations included:

• establishing legislation to safeguard the rights of sexual minorities
• making legislation widely known
• establishing coherence between HIV law and laws governing minority rights
• repealing laws that criminalize homosexuality and bisexuality
• targeting specific projects and campaigns at MSM, including at governmental level
• creating supportive environments for HIV/AIDS prevention and care for MSM at community levels
• promoting the case of MSM on the human-rights agendas of progressive organisations, and building alliances
• improving the media awareness of bisexuality and homosexuality and human rights through actions aimed at reducing stigma and discrimination
• promoting and training health workers in order to reduce discrimination against sexual minorities
• distinguishing between heterosexuals and homosexuals in statistical data
• ensuring that programme funds for health education work are targeted at MSM where possible, and that the issue is maintained on public-health and NGO health agendas.

The recommendations aim to raise the level of national and regional debate on MSM to a level where it can be discussed openly without fear of retributions. However, this is far from the case at the moment; MSM can normally only be addressed within safe environments. Unless direct and concerted attention is devoted to the issue and incorporated into HIV and programme planning, it is quite possible that it may never arise in project discussions, particularly at the time of planning. This is particularly true in countries where civil society is not working with a rights perspective and where the debate on homosexuality still evokes strong negative emotions. Although advocacy and support groups for gays, lesbians and bisexuals now exist in all Latin American and Caribbean countries, there is no guarantee that at community level - where ultimately much HIV prevention and care will have to take place and the priority in Christian Aid's strategy - programmes are including targeted MSM interventions. As MSM cannot necessarily be identified as homosexuals, work defined within this category at community level is not likely to reach them all. Furthermore, there is considerable evidence that some churches and ecumenical organisations will continue to undertake care and support work for PLHA without necessarily making any specific reference to this vulnerable group. In the long run, their exclusion will be counterproductive because the virus is particularly prevalent among this group.

1.10.2 Orphans
AIDS orphans are defined as children who have lost either one or two parents to HIV/AIDS. The vast majority will not be HIV positive. There are nearly 200,000 AIDS orphans in the region¹⁸. About 85,000 of these are in the Caribbean and 110,000 in Latin America. Haiti has the highest number of AIDS orphans in Latin America and the Caribbean - and it is poorly equipped to deal with the problem. Unfortunately, there is a shortage of information on AIDS orphans in the LAC region. What little is known is that they tend to be cared for by churches and church-related institutions. In many Latin America countries and the Caribbean, NGOs have accepted responsibility for the care of orphans, especially if they are HIV positive and have been abandoned by family or care institutions. This is often an area of work for which it is difficult to fundraise. For instance, Jamaica AIDS Support was forced to close its Kingston-based hospice several years ago because raising funds for it became impossible.¹⁹

It will be important for the team to monitor the number of AIDS orphans per country and to assess to what extent government and non-governmental organisations are involved. Policy consideration for AIDS will have to be conducted on a country-by-country basis.

1.10.3 Sex workers
The term sex workers (SWs) needs to treated with the same caution as MSM. Firstly, statistical data is not always disaggregated by gender, with the consequence that information is often gathered from women only, although it is commonly known that men are also involved. Neither is it disaggregated by age, although there are reports throughout the region, notably in Central America and the Caribbean, that the involvement of minors in sex work is also on the increase²⁰. As with other sexual practices, men, women and minors engage in sex work without formally admitting to it, moving in and out of it depending on economic necessity, personal circumstances and family responsibilities. By their own silence and denial, they can be difficult to distinguish from sex workers who are formally identified as such. Taboos against male sex workers are just as strong as against MSM, which encourages further denial.

In some LAC countries, the selling of sex is often the lowest-status but best-paid job for women whose employment options are limited to domestic work and employment in Free Trade Zones. However, where people are socialised into perceiving themselves as more 'naturally sexual' than others, they could come to see sex work as the most attractive economic option.

For instance, Haiti is much poorer than its neighbour the Dominican Republic and the countries' populations are roughly equal, but there are far more Dominican women sex workers in the Caribbean and in Europe than there in Haiti²¹. This could be related to greater ease of migration for Dominicans than for Haitians or to other factors. However, there is evidence to suggest that the Dominican Republic is internationally known for its "exotic women". Growing up in this environment can lead to early conditioning and, in the context of a lack of economic options, greater numbers becoming involved in sex work.

Moreover, Brazil, Central America and the Caribbean are heavily dependent on tourism as a foreign-exchange earner. Images of exotic Caribbean or Latin sexuality are often used to promote a country's image abroad. These directly or subliminally influence the cultures in which people are developing sexual identities and images of themselves. All of these factors influence the social construction of sexuality which is quite complex in Latin America and the Caribbean, and may explain why there are so many different forms of sex work in the region, sex work that includes men, women and children of all ages, all with varying levels of acquiescence.

The Movement of United Women (MODEMU) in the Dominican Republic is a grassroots group of sex workers. It organises and educates its members and others to defend their rights as women, citizens, workers and human beings. One of its major concerns is the large number of women involved in sex work who don't admit to it. The identity of these women is usually known in poor communities, and they have links with taxi drivers, club owners and other men who bring them clients. Some women are coerced into sex work by male and female relatives, and are often shut away from society. Because of their silence and denial, these women are not in a position to avail themselves of HIV education programmes targeted at those identified as sex workers.

There is increasing evidence of HIV/AIDS programmes run by NGOs that target male sex workers and minors. Jamaica Aids Support (JAS) in Jamaica and the Group of Support to Infected People in Bahia, Brazil (GAPA-Bahia) target these MSM, running condom-distribution, education and information programmes. JAS's programme concentrates on 'beach boys' who work along the tourist belt of the island, and GAPA concentrates on inner-city youth. Outside of these initiatives though, there is still insufficient documentation of the practice of male sex work, how to target those involved in it or encourage safe sex. Even less is said or written about the financial options available to poor men as opposed to women, who can no longer engage in sex work when they are diagnosed HIV positive.

Sex workers are vulnerable where they are unorganised, lack access to information and services and are unable to negotiate safe sex on their own terms. For older, more experienced sex workers (SWs), use of condoms is often standard. There are reports though that younger, less experienced and more impoverished SWs do not know dangerously little about sexual and reproductive health. There are also unconfirmed reports that many choose not to use condoms to command a higher price from clients. Young women who migrate from rural to urban areas are vulnerable, as they often do not have access to information and services. Illiteracy in women further compounds the problem, as materials produced for sex worker education are often written. Unorganised sex workers are also less able to control STDs, which if left unchecked make them increasingly vulnerable to HIV infection.

Female SWs are also vulnerable to violence, either from the police or clients. The women's movement sees this as reasons for the spread of HIV in this group: violence reduces women's self esteem and, therefore, powers of negotiation. Research in Brazil suggests that some sex workers view violence as 'part of the normal working environment'. As a result, they often do not ask for help, and accept not being able to control their environment. Where sex workers are being organised in Latin America and the Caribbean, either through their own groups or via an NGO - notably in Peru, Brazil, Nicaragua and the Dominican Republic - campaigning against violence is often prioritised because it is a pre-requisite for women to control the environment in which they work. HIV/AIDS education has also been an extremely important feature of sex-worker organisation. Governments also tend to ignore the reality of sex work, although there is evidence that that too is changing. Some NGOS in the region have been working specifically with male sex workers, but it is not known if this also includes organising them.

1.10.4 Sex work, tourism, the sexual exploitation of minors
There is a strong correlation between tourism and HIV prevalence, although governments are seldom willing to admit it, and there is no evidence of state programmes that try to educate both the client and the sex worker. More research on the issue is now being conducted.

Central American countries are now targets for the organised child sex trade, owing to the harsher laws being applied to paedophiles in South East Asia, for decades the preferred destination for sex tourists. Nicaragua, Guatemala, El Salvador, Costa Rica and the Dominican Republic are vulnerable, in part because they increasingly rely on tourism as a foreign-exchange earner. According to the Washington Post²², sex tourists are mostly men from North America and Europe, but also from other Latin American countries. Younger children are being targeted, it reports, possibly out of a mistaken belief that older children may already be infected with HIV. A recent UNICEF report on Nicaragua concluded that there has been a significant growth in prostitution of children between 12 and 16 years old, and taxi drivers bring tourists to children. Similarly, a huge number of children in Latin America and the Caribbean live on the streets (the Washington Post suggests that this number could be as high as 40 million for the whole region, but UNICEF estimates are even higher at 50 million²³), and are therefore exposed on a daily basis to the threat of sexual violence and the temptation, whether forced or not, to earn money by selling sex. Unfortunately, this issue is not being fully addressed by Latin American governments who, desiring to have a 'clean international image' choose not to acknowledge that it exists²⁴.

Outside Brazil where GAPA-Bahia includes information for the sex client in its programmes, there is little reference to programmes that target both the demand and supply side of sex work. For good reason, efforts are concentrated on educating sex workers so they can protect themselves. However, in the long run perhaps attention ought to be paid to educating sex buyers to reduce the risk of their infecting other people later on. This is the view held by the Society for Medical Anthropology, which has been reviewing the power relationship between the 'visitor and the visited' in the Dominican Republic. It states that: "The lack of concrete opportunities for young people and the economic power of the foreigner make the relationship between tourism and HIV insurmountable.'

The state response tends to be to try to bring sex tourists to justice, especially paedophiles or sex traders. The Society for Medical Anthropology concludes that lack of political will and economic dependency on tourism as a foreign exchange earner make the local person, ironically, much more vulnerable than the tourist. While the rights of underage sex workers should be protected by laws established in their own countries, it argues, tourists, who probably have greater access to HIV information, should be reminded to engage in safe sexual practices which do not place either themselves or minors at risk.

The highest rates of HIV infection for sex workers in Jamaica are on the north coast's tourist areas. Haiti and the Dominican Republic also have high prevalence rates in tourist areas. Honduras, which has the highest infection rates in Central America, is also most affected on its Caribbean coast, where ships dock along the coastal ports and American visitors use sex workers. Outside of the 11 countries where Christian Aid has direct programmes, Guyana, Mexico, Tobago, Barbados and Argentina also register high prevalence rates for sex workers.

Fig 5 HIV prevalence amongst sex workers in Latin America and the Caribbean. Data is for female sex workers unless otherwise stated

1.10.5 Youth
About one third of the children in Latin America and the Caribbean (about 33 million children) by their own admission have little or no information on sex and sexual health²⁷. The highest incidence of this is in the Caribbean and Andean countries. Lower-income earning groups, rural inhabitants, and black and indigenous peoples were more likely to report feeling uninformed. This indicates a long-established lack of information regarding adolescent sexual health and reproduction in general, even before HIV manifested itself as a problem within that age group. In addition, there are approximately 40 million 'street children' in the LAC region, many of whom would not necessarily be targeted by official prevention and care programmes.

Sex education for young people has traditionally been difficult in Latin America and the Caribbean. Many governments now allow it to take place within schools, but this has been a hard-won achievement. There are many constraints and the quality varies widely from country to country. The church continues to have a major influence on the language and tone of sex-education programmes, many of which preach about abstinence and fidelity without reference to a broader understanding of human sexuality, gender relations or of the socio-economic conditions which may encourage or even force young people into early sexual activity. Attitudes vary from country to country, and from church to church within the countries. They depend on the importance of the particular churches, the type of inter-religious dialogue that exists and often the role of influential individuals. Single individuals, whether liberal or conservative, often have influence far beyond their immediate remit. In the Dominican Republic, for instance, the Catholic Cardinal stopped a well-planned government sex-education programme just before it was about to be implemented.

Indicators of adolescent sexual and reproductive health in the region are not good. In the Caribbean, for example, the number of teenage pregnancies per year has always been very high. It is very common for young adolescent girls to enter into dependent sexual liaisons with older men. However, other groups have reported that young people seem to be initiating sexual relations earlier today than they would have a generation before. For example, in Ica, Peru, the Spanish Institute of Foreign Missions (IEME²⁸ )states that while fertility rates for older women have been falling, they are rising among adolescents. Maternal mortality is twice as high for teenage mothers than for mothers over the age of 25. More and more, they say, 'AIDS has a young face in Peru'. In Central America, civil wars and tourism have put young children at risk for years, states Casa Alianza, a Costa Rica-based NGO that works to protect and rehabilitate young children who live and work on the street in Nicaragua, Honduras, Guatemala and Mexico. Young people bear the brunt of economic poverty as well as violence. Casa Alianza sees a close link between the cases of street children who are murdered and those who are HIV positive: they have been abused by strangers, tourists or family relatives, and abandoned by them as well as by the state.²⁹

Statistical information on HIV/AIDS in youths is usually disaggregated by gender. However, studies that focus on sexual behaviour or perception of risk tend to concentrate on either young men or young women, but not both at the same time. The data obtained is therefore not always comparable. For example, according to UNAIDS statistics³⁰, 68 per cent of adolescent girls between the ages of 15 and 19 in Nicaragua think that they are not at risk of HIV infection. In Colombia, Brazil, Guatemala, the Dominican Republic and Haiti, 58 per cent, 52 per cent, 87 per cent, and 76 per cent respectively believe that they are not at risk of infection. Far too little information has been provided by UNAIDS to answer the inevitable questions: was the sample homogenous by class and education, and were the studies conducted in rural as well as urban areas? Nevertheless, the trend seems to be that, with the exception of Brazil, a high percentage of teenage girls in specific countries tend not to think that unprotected sex is a threat to their health. More research is needed to understand the reasons for this. It could be that girls report less awareness than they actually have, or that their access to information and education has been so poor that their awareness is genuinely low. Unfortunately, no comparative data from UNAIDS could be found on the risks perceived by young men³¹.

By contrast, UNAIDS shows that more than 75 per cent³² of adolescent boys know about condoms and where to get them in Brazil, the Dominican Republic, Haiti, Nicaragua, Bolivia and Peru. The statistics for condom use, however, reveal a deep-rooted problem. In Costa Rica 75 per cent of adolescent boys between the ages of 15 and 19 reported using condoms with their most recent non-regular partner. In the Dominican Republic, Chile and Cuba, however, the percentages were 50, 38 and 28 per cent respectively. Although adolescent boys know about condoms, and presumably understand the context in which they are to be used, they tend not to use them. Girls meanwhile, did not demonstrate statistically that they realised unprotected sex could endanger their health, either because there is little information directly targeted at them or enormous pressures on them to appear or to be sexually inactive. These conditions are ripe for the spread of the infection.

Presenters at a recent training workshop on HIV/AIDS in the Dominican Republic³³ also confirmed that adolescents are only mentally ready to perceive and understand the concept of risk quite late in their emotional development. Making a link to their behaviour is also difficult. Given that the age of sexual initiation is getting lower across the region, it seems possible that young people are getting involved in sexual activity long before they are aware of its risks, or emotionally and intellectually prepared for its consequences. Jamaica AIDS Support field-trip reports also show that, while some perceptions of young people may change as a result of educational interventions, ingrained and inaccurate sexual beliefs can persist for a long time, and thereby influence behaviour. It takes years for young people to apply new knowledge to their own behaviour. This suggests that even when risk is understood, there will not necessarily be an immediate significant change in sexual behaviour³⁴.

1.10.6 Migrants
Migration and HIV have been closely linked since the earliest stages of the HIV epidemic. Migrants are often poor, unaware of or denied their rights as migrants and as workers. In some cases, as with Dominico-Haitians in the Dominican Republic, they can exist for years in the host country without the formal identification necessary to avail themselves of public health and education services. Migrants come and go continuously, and are often without family support when they fall prey to illnesses and disease. All of these circumstances make them vulnerable.

Migrant men are also prone to risky sexual practices when travelling. They are far away from home, without the affective support structures. They are usually of a sexually active age. Unsafe sex puts both them and their female partners at home at risk, especially if there are not open discussions about sexual practices during trips abroad.

In the region, Mexico and the Dominican Republic stand out. They both receive migrants and export them, and are transit areas to larger towns. Tecun Uman is a town on the Guatemalan border. It corresponds to a town on the Mexican border called Ciudad Hidalgo. This border zone has a heavy traffic in trailers and women traders from all over Central America heading towards the United States. The migrants are from El Salvador, Honduras, Nicaragua, Costa Rica, Guatemala and Panama. Many are undocumented, and engage in sex work to earn money along the way³⁵. Research on the area shows that sex work is undertaken by migrants formally identified as sex workers, but also by those who aren't. Furthermore, it concluded that HIV awareness and condom use were low. Young migrant women involved in clothing production have also been identified by UNAIDS and other UN bodies as vulnerable to HIV: about 30 per cent of the total migrant populations of Mexico and Central America are employed by companies working in the Free Trade Zone, many of which have questionable working conditions, especially for women. Special HIV-prevention programmes are now being planned, targeting these migrants.

Border towns are important to monitor, not only because they attract large numbers of migrants, but also because they may be one of the few places where services for migrants are concentrated. As a consequence, they are ideal locations for HIV education and awareness programmes. Christian Aid supports human-rights work at various places along the Dominico-Haitian border. Through programmes implemented by the Jesuit Refugee Service (JRS), Haitian migrants learn about their rights and record human rights abuses committed against them by the Dominican military. This is especially important during mass waves of repatriations when Haitians, and at times Dominico-Haitians, are rounded up by the military.

Cases of Haitian women being raped by the military have been reported in the past, but they tend to have been isolated incidents, not the kind of systematic use of women's bodies as instruments of war as is seen in Colombia. On the Haitian side, the Group for Support, Research and Resettlement (GARR) receives and rehabilitates migrants who have been repatriated, many of which would have resided in the Dominican Republic for generations. GARR provides clothing, food, medicine and shelter, and also advocates for the rights of Haitian migrants in the Dominican Republic. It may be useful in the long term to incorporate an HIV perspective into these programmes being implemented along the border, especially as they are now attracting more human and financial resources. JRS felt that this would be possible and appropriate, but that it was not in a position to become specialists in the area³⁶. Clearly, special support would be required to enable partners who are working in geographically strategic areas to incorporate an HIV perspective into their work.

1.10.7 Older people
Because HIV is concentrated in the 15 to 40 age group, it is assumed that older people are not vulnerable. This assumption often leads to their exclusion from HIV/AIDS interventions at the community level. In fact, older people are affected directly and indirectly.

Older people are sexually active. This fact tends to be overlooked by standard education programmes; so older people could ignore the potential risks of unprotected sex. In Brazil, health ministries have decided to target the over-50s for education campaigns and the distribution of condoms after the infection rate more than doubled in that age group. The infection rate for the 60-69 age group doubled between 1990 and 1998³⁷. Similarly, the Jamaican Ministry of Health has started paying attention to older people for similar reasons, having found that the incidence of HIV infection in men over the age of 50 was twice as high as it was for women, and that, furthermore, it was increasing³⁸. As there is a tendency for older men to become sexually involved with adolescent girls in the English-speaking Caribbean, it is important for this age group to be included in intervention programmes.

Help Age International also stresses that older people are very involved in care at a time when they would have expected to be taken care of by younger members of the family. Contrary to expectations, this is not only a problem in Africa, where the number of people of economically reproductive age who have died of AIDS is so high. In the Caribbean, older people have traditionally had a role in taking care of young people when their parents migrate in search of work. Many older people are unwilling to discuss sex with young people, but continue to have much influence over them. The fact that they are themselves misinformed or uninformed about HIV could in put their grandchildren at risk, especially if they are not getting information from elsewhere.

1.10.8 PLHA

i. Economic marginalisation
People living with HIV/AIDS (PLHA) are often left without the economic resources to survive, and become dependent on communities and families. Women and older people often bear the largely financial responsibility of care. Where PLHA are minorities, they can become very dependent on NGOs and community-based organisations (CBOs) if they do not have an economic alternative. This is a crucial issue for people involved in all areas of commercial activity who may lose income. It is a particularly acute problem for sex workers, who may choose to stop working once infected, and may not have learned any other skills with which to continue earning. Not all will give up working, but those that do face considerable hardship, especially if they were not earning very much before. People may refuse to be tested due to the threat of lost earnings.

Partners such as JAS, One Respe and GAPA have started income-generating programmes, the profits of which can offset some of the costs incurred by care. The little raised is never enough to cover costs. In most cases partners implement such programmes because they do not have budgeted income to spend on care, and partly because the PLHA in their communities are so destitute. Partners who are inexperienced in that area often manage income-generating projects. Many would like to invest in feasibility studies and additional business-management or income-generation training for themselves, but do not have the funds to do so. This is an area in which partners urgently need special support and additional human resources.

ii. Stigma and discrimination
One of the chief problems faced by PLHA is discrimination and prejudice. In order to convince all social sectors of the need for safer sex and hygiene in the handling of blood, it is critical that prejudice and stigma be addressed whenever they are found in programme interventions. This is as important in prevention work as it is in care. PLHA endure not merely ostracism and abandonment by their communities after diagnosis, but also, in some countries, serious abuses of their human, civil and cultural rights. Conversations with partners reveal that PLHA are regularly denied access to food, medicines, and treatment at hospitals and nursing homes. Some extremist churches deny burial to people who have died of AIDS related illnesses or increase the price of funerals beyond people's ability to pay⁴⁰. When the PLHA are migrants, ethnic minorities or sex workers, it can be particularly difficult for them to get the emotional and practical support they need to keep their spirits up and survive opportunistic diseases when they set in. It is believed by those who are in the front lines of care in the community that many more poor people die of loneliness and isolation than of the disease itself⁴¹. All of Christian Aid's partners working on HIV/AIDS at the community level stress the importance of therapeutic, spiritual and emotional accompaniment of PLHA. This kind of one-to-one, or group care is costly.

Stigma and prejudice where reinforced by sexist, homophobic or racist attitudes towards minority groups are particularly insidious and need to be addressed. One of the consequences of such stigma and prejudice is that it often starts a complicated process of denial in the infected person, who may refuse to accept their diagnosis even if it is quite clear⁴². This can lead to further infections later on. This only happens because HIV continues to be treated as a 'sex disease' associated with homosexuality, promiscuity and drug use. It is also one of the consequences of the tendency, which still exists in many countries, to associate HIV with death in educational campaigns or in popular culture. Such messages need to be treated with a great deal of sensitivity so that it can be understood that PLHA can have - if given access to proper, safe and effective treatment, solidarity, emotional support and nutritious food - long and productive lives. Indeed, in many countries they do. It is this access and support that can determine whether people live with HIV or die from AIDS. HIV/AIDS work needs to shift attention from the stigma attached to diagnosis to an understanding of the social, cultural and economic rights of infected people, and of the constraints which prevent them from exercising such rights and gaining access to basic services, which people in more developed countries can get more easily.

2. Framework for understanding the spread of HIV/AIDS

2.1 Rights
Latin America and the Caribbean is a culturally plural, and racially, ethnically and linguistically diverse region. There are hundreds of languages spoken, including many indigenous ones. There are descendants from Europe, the Indian sub-continent, Africa, China, Japan and the Middle East. It is a region also characterised by a multiplicity of spiritual expressions, some of which are black and indigenous and not all of which are Christian. Many spiritual expressions are still not accepted by churches, some governments or mainstream society.

Original inhabitants - or indigenous people - still constitute important populations in Brazil, Peru, Colombia, Bolivia, Guatemala, the Caribbean, Dominica and Guyana. The indigenous population of South America is about 18.5 million and in Central America and Mexico 13 million⁴³. This is just under seven per cent of a total population of more than 505 million. By contrast, there are approximately 100 million Afro-Latin American and Afro-Caribbean people dispersed throughout the region, representing about 20 per cent of the population (depending on definitions, see below)⁴⁴. Definitions of race and identity vary greatly within the region and are open to interpretation. (This will be dealt with in more detail in the section on discrimination against black people.)

Many of the constitutions and laws governing Latin American and Caribbean countries have been conceived according to international conventions governing the rights of all persons. However, in practice, most societies are still structured according to the hierarchies established during slavery, indentureship and colonisation, in which race, colour, class, ethnicity and gender ranked people. In addition, there are contemporary forms of discrimination including age, disability and sexuality. Patterns of systemic inequality, exclusion and deprivation were established according to these principles, which tended to rank people of direct European ancestry at the top, mixed, coloured or 'mestizo' people in the middle, and black and indigenous people at the bottom. In 1992, thousands in Latin America and the Caribbean celebrated 500 years of struggle against all forms of injustice and oppression which started with the arrival of Columbus, but which persist today.

The Quincentennial of 1992 provided an opportunity for black, indigenous, women's, youth and other minority groups in North, Central and South America and the Caribbean to reflect on the impact that the colonial experience had on their peoples. Prior to that, however, minority and oppressed groups throughout the region had been analysing their history and the current patterns of poverty, marginalisation and exclusion, as well as of militarization, state oppression and dictatorship. Resistance to all forms of oppression - political, social, gender, cultural and racial - has been central to this examination of history, as has been the continual search for and articulation of alternative paradigms of economic development, participation and civil society development. Indeed, the historical landscape of the region in the 20th century alone is littered with numerous socialist revolutions (Cuba, Nicaragua, Mexico and Grenada), attempts to overthrow despotic regimes (Argentina, Brazil and Chile) and smaller-scale uprisings of groups claiming their right to better social and economic conditions as well as a fundamental re-ordering of oppressive social structures.

The defence of human, civil, cultural, social, economic and sexual rights, as well as the rights of immigrant workers, women, young people, and indigenous and black people is based on well-established traditions of struggle which have always emphasised the primacy of organised collective responses over individual ones. HIV/AIDS cuts across all barriers, but affects specific groups more and usually exacerbates their vulnerability. As a consequence, the response to HIV/AIDS of minority groups in the region has been to try to increase prevention and get access to improved care and treatment, but on top of that to emphasize a critical link between people's vulnerability to HIV and overall patterns of inequality which were established long before the advent of the disease. Defenders of rights would normally go beyond abstinence and fidelity as a solution to the HIV crisis, seeing these as individualistic solutions to a problem that is inherently social and structural. They emphasise instead that abstinence and fidelity are options which people take only if they are relatively well informed, empowered, satisfied in their basic needs and confident enough to be able to make conscious choices. The majority in Latin America and the Caribbean are either poor or extremely poor, and may experience discrimination for all sorts of reasons, not necessarily linked to HIV. They are often ill informed about their rights. One of the realities of living in middle-income countries is that the poorest often live in close proximity to very wealthy people. Tensions created by this can be exacerbated by the media, which often depicts images of plenty and reinforces a culture "getting rich quickly". Growing up in this kind of environment with a perception that one has few opportunities for upward mobility often leads to the development of fatalistic expectations and short term strategies in poor people. These are not good conditions for informed decision-making, personal development or life-preserving activities, such as using condoms. HIV is not another social problem, but a manifestation of society's unresolved tensions. Defenders of rights would therefore tend to argue for structurally based, collective solutions that go to the root of the problem, going far beyond the normal ABC approach (abstinence, be faithful and use of condoms if all else fails).

A rights-based approach to HIV understands that people's inability to protect themselves from HIV, and their lack of access to care, treatment or services, are manifestations of deeper and endemic problems of poverty, dependency, inequity and marginalisation. These erode their individual and collective rights - human, cultural, social, economic and sexual. A rights-based approach seeks to go beyond palliative measures of HIV prevention and care to tackle the structural reasons for the persistence of vulnerability. It suggests that a defence of human rights in their broadest sense will in the long term increase people's ability to protect themselves and live with HIV instead of dying from it. The LACGD is committed to a rights-based perspective on HIV, as it has been for other departmental priorities.

Minority or identity-based struggles do have disadvantages, however. Some groups are sometimes accused of using exclusive strategies themselves: blacks tend to argue for the rights of blacks, adult female sex workers tend to ignore male sex workers or younger men and women involved in the trade, minority ethnic groups tend to fight for the rights of their 'own kind', etc. When considering financial support, care has to be taken to assess if minority groups consider all rights beyond their own specific concerns. However, supporting only those groups that articulate positions - and implement programmes - which are non-racist, non-sexist, non-homophobic, poverty focused, and are willing and able to form broad-based alliances can be an extremely difficult proposition. This is especially true at the initial stage of partnership where partners may not have developed strong institutional positions. They may have had to overcome numerous obstacles and compromise in order to develop strong institutions and make their voices heard⁴⁵. Often donor agencies and their own support base tend to want exclusive target groups. But it is important that in principle minority groups can undertake work that is non-racist, non-sexist, non-homophobic, and poverty focused, and are able to take part in broad-based alliances. Where this is not the case initially, it is important that Christian Aid is very clear about its own position in terms of its relationship with the partner.

2.1.1 Unequal gender relations
The consequences for women of male machismo in Latin American and Caribbean societies are well documented. Indicators of domestic violence are high in the region, with both women and children being victims of many forms of abuse, including psychological. Women's inability to negotiate safer sex, use of condoms, fidelity, and sexual and reproductive health is linked to their economic dependence on men and the threat of physical violence. This is often exacerbated by societal and family expectations that women ought to marry and raise children at whatever cost as proof of their femininity. Traditional and economic factors therefore conspire to give women few options, which in the long run increases their vulnerability to HIV/AIDS. Poor women in Latin America and the Caribbean tend to earn less than men, and are often economically dependent on men from a young age. Many have the considerable burden of social, family and care responsibilities which force them to make decisions inconsistent with traditional values, such as involvement in sex work, involvement with older men, sexual liaisons with tourists and abortion.

The statistics now bear this out. In Latin America, 30 per cent of HIV-positive adults are women. In the Caribbean the figure is 50 per cent⁴⁶. The data does not show any differentiation between heterosexual and homosexual women, so there is no statistical data to show if one group is more vulnerable than the other. However, heterosexual women are generally considered to be more at risk due to the high concentration of the virus in semen and the greater physical vulnerability of female in relation to male genitalia.

Feminist organisations in Latin America and the Caribbean continue to emphasise the economic and social vulnerability of women. Programme responses have tended to focus on empowerment programmes, education and services, access to training in sexual and reproductive health and some income-generating activities for women. These are useful in as much as they emphasise the relationship between macro and micro issues and the power inequities, which place women at risk.

A review conducted by the Latin American Health Network of the results of the last eight years of feminist activism on sexual and reproductive health and rights in Latin America and the Caribbean concludes that in many areas of advocacy, there have been real gains⁴⁷. Thousands have received information, participated in workshops, organised themselves and represented their communities and countries at international forums. Feminist organisations have lobbied governments for laws to improve women's access to health services, and pertaining to prenatal and postnatal care, domestic violence and the right to proper preventive health. They have also fought for improved access to information for adolescents on sexual and reproductive health. Unfortunately, however, the report also found that educational and training activities are often limited to too few women and that increased efforts are needed to provide access to a broader spectrum of women, particularly women from rural areas.

It is not clear how much depth educational workshops go into in their prevention programmes, nor to what extent programmes equip women with the range of skills and techniques needed to initiate and develop dialogue with male partners. In the HIV/AIDS brochures and pamphlets reviewed in this research, there is far too little mention of how exactly women can go about raising the subject of sexual health and sexual responsibility with male partners. Few explicitly provide women readers with helpful hints or suggestions on how she could start discussing condom use, family planning or just the initiation of sexual activity with men. Brochures on HIV/AIDS often 'medicalise' and sensationalise HIV/AIDS by showing pictures of infected genitalia and listing health-related problems. While it is true that condoms are always featured, they are spoken of as if the act of putting them on occurs in a completely neutral gender, cultural and social context.

Where health work seems to avoid any mention of sexual or reproductive health, it is the role of programme staff to ascertain what the obstacle is. Dealing with these sensitive issues may cause embarrassment to staff especially if they lack exposure to specific training. Some NGOs choose to emphasise the easier post-infection HIV/AIDS issues such as care, accompaniment and solidarity. They can be quite good at encouraging compassion and empathy in others, but may lack the skills and confidence required to raise issues that are seen to attack traditional beliefs. Another difficulty is that even if training for health workers on sexual and reproductive rights is done thoroughly, trainees often have great difficulty in applying information to real situations back in their communities when the training is finished. Prevention of further infection also requires a hard-nosed, pragmatic, unemotional approach to sexuality and sexual activity. Women have to be taught from an early age to be very pragmatic about their bodies and sexual health, and to prepare in advance of sexual encounters by being honest about the fact that they could happen. As people usually engage in sexual activity without talking honestly about it, and as adolescent girls, unmarried or young women 'ought not to be doing it anyway', it is unlikely that many live in environments which make that kind of open dialogue possible. Similarly, materials produced for education about sexual activity need to be couched in sensible, informative and useful language, which emphasises in non-alarmist ways that sexual activity, as with so many other aspects of life, needs to be prepared for and negotiated.

2.1.2 The rights of men
World Aids Day 2001 focused its attention on the role men have in HIV prevention. In Latin America and the Caribbean, strongly characterised by machismo, homophobia or denial of MSM and poor sex education, men's experiences are characterised by vulnerability on the one hand and responsibility for spreading the virus on the other.

MSM are also vulnerable and responsible in turn for other reasons. The macho culture which pervades Latin America a