Two Decades Later, We’re Still Not Talking Enough About Sex

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Over the past two decades the region has significantly raised the level of the conversation and awareness around the issue, developing national HIV/AIDS strategies, integrating responses to the epidemic into health systems and ensuring almost universal awareness of HIV risk factors.

But we’re still not talking enough about sex.



Here’s why. As HIV prevalence stabilizes, the region needs to pay more attention to the most-at-risk populations -- men having sex with men, sex workers, injecting drug users, and mobile populations -- rather than the general public. Work with the general public has been essential to raise awareness and cultivate some support for public programs. But so long as most new infections are occurring in specific populations, no major progress is possible until HIV  programs successfully serve these groups.


Even today, only a small fraction of programs are doing so. Efforts are still inadequate to (i) identify those most at risk, (ii) monitor risk behavior, such as patterns of sexual practice and drug use, and (iii) detect and understand the emergence of new HIV cases through surveillance of HIV incidence and behavioral patterns.  Furthermore, cultural taboos, HIV-related stigma and especially homophobia have often restricted frank debate about the sexual and behavioral practices driving the HIV/AIDS epidemic in the Caribbean.  The highly stigmatized environment surrounding these groups has made it difficult to secure buy-in and support for a consolidated response.  This, in turn, has left such groups at ongoing risk.


But despite the challenges countries face in reaching those most at risk, the region can learn from many promising experiences, which can then help shape a policy dialogue that is not shy to talk openly about sex. 


  • Understanding Behavioral Patterns Among Most-At-Risk Populations. The Dominican Republic’s first Behavioral Surveillance Survey was conducted through an innovative participative approach which yielded statistically significant results on the status of the epidemic among those most at risk of HIV/AIDS.  In Barbados, a behavioral sero-status survey of men who have sex with men using the same approach is currently underway.  And in Central America, all countries have now developed a research agenda for second generation surveillance. Together, these surveys and research are raising awareness on the sexual and behavioral practices of those most at risk and generating knowledge to reach these groups more efficiently. 
  • Understanding Sexual Practice among sex workers. Sex workers participating in Brazil’s National HIV/AIDS Program are reporting significantly higher condom use – with both clients and regular partners – than non-participants.  And Jamaica’s prevention efforts have resulted in 90% of female sex workers consistently reporting condom use with their most recent client.  Jamaica has even begun to measure the percentage of female sex workers reporting the use of a condom with their last regular paying partner.  Although this may appear a minor  distinction, it is in fact a crucial one, since condom use is typically lower than with new paying partners.
  • Targeting Prevention Services to Men Who Have Sex with Men (MSM).  Brazil’s National HIV/AIDS Program has provided targeted testing services for gay or bisexual men, among whom the proportion ever-tested for HIV is considerably higher than for the general population.  In St. Vincent and the Grenadines, an important study on MSM has been completed and provides data useful for targeting services to this group. This study is unique in the Caribbean region, given the high level of stigma and discrimination that pervades the region.
  • Targeting Treatment to Most-at-Risk Populations.  With 86% of those in need of ARVs having access to the medication, Barbados has surpassed its national target of 80% and may be seen as a leader in ensuring universal access to HIV treatment to its population.  Behavioral studies are currently being conducted in Barbados among key populations to better understand the drivers of the epidemic and to continue to ensure that those found to be HIV positive also access HIV treatment services.
  • Filling in the Gap to Reach Mobile Populations.  A Central America regional effort reached out to mobile populations who frequently migrate across and between countries and engage in behaviors that increase their risk of HIV/AIDS, such as multiple concurrent partnerships.  Mobile populations represented a gap in the region as no country had prioritized this at-risk group. The regional effort contributed to providing them with access to information and prevention, such as condoms, and to HIV testing in border areas.
  • Engaging Civil Society Organizations to Effectively Reach Those Most at Risk.  Guyana and Eastern Caribbean countries such as St. Kitts and Nevis, St. Lucia, and St. Vincent and the Grenadines have built partnerships with Civil Society Organizations (CSO) in order to reach those most at risk.  From the start of its CSO program, Guyana focused on groups most at risk, resulting in a new website by a CSO which contributed to developing a sense of community amongst MSM.  St. Kitts and Nevis partnered with the Caribbean HIV/AIDS Alliance, an international organization that works with high risk and vulnerable groups in AIDS prevention. Consequently they were able to reach more than twice the number of at risk groups as those identified at the start.  St. Lucia and St. Vincent and the Grenadines also focused on the most at-risk groups for their CSO activities.


These experiences, emerging from the backdrop of a highly stigmatized setting, offer promising opportunities for Latin America, the Caribbean, and its partners to redouble our efforts to reach those most in need.  So let's talk about sex, shall we?


Keith Hansen

World Bank Country Director for Kenya, Somalia, Rwanda and Uganda

Carmen Carpio

Senior Health Specialist for the Africa Region at the World Bank

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