"This is Tobago"Social and Cultural 'Influencers' of HIV Infections in Tobago

INTRO: In Tobago, HIV rates continue to increase (prevalence rate =5%). Women and youth are increasingly being infected, and heterosexual transmission accounts for most HIV infections. If these trends continue, Tobago's economic and social structure will be in jeopardy. This study has public health significance because it identifies and makes recommendations for incorporating relevant social and cultural factors into HIV prevention programs in Tobago. METHODS: Qualitative methods (participant observations, ethnographic and in-depth interviews) were utilized to unearth (a) pre- and post-HIV infection experiences of People Living With HIV/AIDS (PLWHAs), (b) relevant cultural and social 'influencer' of HIV/AIDS rates, (c) how these factors influence community norms and individual behavior, and (d) appropriate methods/model for incorporating relevant factors into HIV/AIDS prevention programs. PLWHAs, health professionals, community members and leaders were interviewed. RESULTS: 14 PLWHAs, 10 health professionals, 15 community leaders and 25 community members were interviewed. Participant observations occurred in homes, businesses, entertainment events, HIV-related organizations and health facilities. 206 PLWHAs are currently being treated in Tobago (HIV-related medications free to Trinidad and Tobago citizens). Infidelity, sex-in-exchange for resources, abuse and economic need increased PLWHAs' HIV risk. Lack of confidentiality is an issue, and stigma and discrimination are prevalent. There is lack of information about the causes, prevention and treatment of HIV in the general population. Sex is not openly discussed, however youth sexual behavior is common. Serial monogamy coupled with multiple sexual partnering increases general community risk. Consistent and correct condom use is not common, and purchasing or requesting condom use is difficult for women, youth, and married individuals. HIV testing is not common, and pre- and post-test counseling is inadequate. Current HIV prevention programs focus on abstaining, being faithful and using condoms, which do not take into account the complexities surrounding sexual decision making. There is a need for comprehensive HIV prevention programs. RECOMMENDATIONS: A client-centered, risk-reduction model of HIV prevention is recommended. Using the socio-cultural theory of learning, this study highlights the zone of proximal development, the knowledge-in-waiting, knowledge-in-use, agents of change, needed resources, and social environment needed to improve HIV prevention strategies in Tobago