“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”
HIV/AIDS in Latin America and
Aid: Latin America, Caribbean and Global Division working document
Rationale for the study
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 A brief study conducted in 1993 was soon out of date,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.
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.
Terms of reference
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
(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).
Limitations of the study
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.
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.
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
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
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
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.
note on terminology
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.
Christian Aid's work in Latin America and the Caribbean
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.
Socio-political and economic overview: Latin America and the Caribbean
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 Panamá, 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.
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.
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
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.
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
Ranking out of 162
St.Kitts and Nevis
Trinidad and Tobago
St.Vincent and the Grenadines
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
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
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.
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.
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
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.
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
numerous achievements, ecumenism in Latin America and the Caribbean now
faces real challenges. Some question to what extent the movement will
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
Some current trends
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
has been a three-fold increase in reported HIV cases since 1995 in the whole
• 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
• 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
• 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
• 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
2 Prevalence rate for HIV/AIDS in adults (end 1999) in Latin America and the
Cesus Bureau 2000
3 Age and Sex14
Fig 4 Estimated prevalence rate in young people, 199915
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.
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.
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
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
• 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.
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.
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
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
1.10.3 Sex workers
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
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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.'
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.
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.
5 HIV prevalence amongst sex workers in Latin America and the Caribbean.
Data is for female sex workers unless otherwise stated
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
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.
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.
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
Presenters at a recent training workshop on HIV/AIDS in the Dominican
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.
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.
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.
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.
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.
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
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
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.
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.
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
i. Economic marginalisation
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.
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.
Framework for understanding the spread of HIV/AIDS
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,
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.)
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
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
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).
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
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
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
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.
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
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.
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.
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.
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
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.
also vulnerable and responsible in turn for other reasons. The macho culture
which pervades Latin America a