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To Truly Prevent HIV, We Need to Let Go of Stigma and Discrimination

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I've been living in Antigua and Barbuda as an intern through CIDA/DFATD's International Youth Internship Program (IYIP) for four months working with an HIV prevention organization and while the weather is balmy and the beaches are sunny, HIV is just as present here as it is elsewhere in the world. In fact, outside of Sub-Saharan Africa, research shows that the Caribbean has the highest HIV prevalence rate in the world. But the discourse of HIV in the Caribbean isn't about access to anti-retrovirals (ARVs) nor is it about children orphaned by AIDS or increasing the number of HIV positive pregnant women accessing testing at antenatal clinics as the discussions often are in many African countries.

In the Caribbean, HIV isn't about visible markers for successful treatment of HIV that the international community can deliver to and measure. In the Caribbean, HIV isn't as much about treatment in fact, it's more about prevention; keeping most at-risk populations (MARPs) HIV negative. And it's entirely different to solicit support and funding from the international donor community, including the Global Fund, to address the structural drivers of an epidemic; drivers that underscores MARPs hesitance to access HIV services that will keep them negative. Though these drivers affect other HIV epidemics internationally, in the Caribbean this is the most critical piece of the HIV response.

In Antigua, institutionalized stigma and discrimination dissuade MSM, a substantial MARP population, from accessing HIV services. Entering a testing facility is not an option for the man who is agonizingly stared at while sitting in the lobby waiting for his test or overhearing his nurse tell another nurse that she suspects he's gay and doesn't want to test him.

When governments and civil society go to design collective responses and interventions to HIV, drawing up strategic plans and national monitoring and evaluation plans full of indicators, they have to carefully navigate this climate of reluctance and hostility with necessary interventions that address these systemic issues.

One of the best practices to transcend these barriers is peer education. The organization that I work for (the Antiguan Resilience Collective Inc. or ARC) champions this model, equipping MSM peer educators to discretely enter the community and educate fellow MSM on HIV transmission; providing them with alternative avenues to get HIV testing, a cornerstone of effective prevention; behaviour change strategies, and lastly condoms. These peer educators are the unsung heroes of the Caribbean epidemic (many sex worker and people living with HIV, the other two primary MARP populations, projects implement the same structure because of its effectiveness).

Assuredly, drawing up a monitoring and evaluation plan that can fit "the number of men who have had their behaviour changed and now feel comfortable going for testing and actually went for testing" in the indicator box is not realistic nor is it measurable. But it is these sorts of interventions that are paramount for reducing the spread of HIV in the Caribbean. It is even further critical that these HIV prevention interventions are valued as much as HIV treatment programs are around the world, and funded as unequivocally as such.

But epidemiologist Elizabeth Pisani put it best, people don't fit in boxes. An MSM individual could also be married to a woman to hide his sexual identity in fear of societal alienation, and inflict gender-based violence on his wife thus spreading HIV. Programs that do little to intersect stigma, discrimination, homophobia, and gender inequalities as well as incorporating the various MARP populations will never undo the societal barriers that drive HIV in the Caribbean, and particularly in Antigua. These programs must work to be transformative, sector-wide, and decentralized interventions that gradually challenge the hetero-normative mindset that fuels homosexual intolerance, inviting MSM and MARPs into the conversation about effective HIV prevention. The international community must renew its effort to support them.

This World AIDS Day, ARC will be participating in the Antigua's annual HIV outreach events. It will participate alongside the government and other organizations in a "Know Your Status" testing drive and call on its peer educators to encourage their clients to come out and get tested. Likely they won't yet, because structurally nothing yet has changed for them in society to invite their trust or comfort; the stigma and discrimination are still present. But this is gradually changing and the peer educator's client intake forms are indicative of this shift.

In the post-MDG 2015 era, the international donor community, including a commitment to replenish the Global Fund, must allocate attention towards assisting the Caribbean in addressing the root causes that perpetuate the spread of HIV, ultimately preventing the spread of HIV for once and for all. The silent societal and structural constraints that drive the Caribbean HIV epidemic are not as audible as the plights of HIV in other countries around the world; but this just commands a different yet pointed response on behalf of civil society and governments but also on behalf the international donor community.

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