Aug. 14, 2002 – Women committed to a monogamous relationship may be at the greatest risk of contracting HIV or AIDS of any group in the Virgin Islands, according to the findings of a federally funded study.
The study results also suggest that sex workers, who might be considered by some to carry the greatest risk, are well down the list of partners and practices most likely to transmit HIV and AIDS. The term "sex workers" refers to prostitutes, exotic dancers and others for whom sexual activity is a source of income.
Because of the rapid spread of the human immunodeficiency virus in the territory, health care workers have adopted an emergency method of assessing the risk of infection and where and how it is most likely to occur. The federal Centers for Disease Control and Prevention rates the Virgin Islands as reporting the fourth-highest incidence of new HIV infections among all states and territories on a per capita basis.
The study was conducted in 2001, when health experts said about 1 percent of the V.I. population had tested positive for HIV. To slow its spread, researchers say, health advocates will have to raise community awareness, do a better job of reaching teens and gay men, and solicit help from local houses of worship to spread the word about HIV prevention and treatment.
At a recent conference held on St. John, researchers presented the results of a six month study designed to paint the face of AIDS and HIV in the territory. The Rapid Assessment, Response and Evaluation report was designed to identify those groups of people most likely to engage in the kinds of behavior that can lead to HIV infection. The RARE project is part of The Crisis Response Teams Initiative, established as a public health assistance program from the U.S. Department of Health and Human Services.
RARE project coordinator Patricia Odoms told about two dozen health-care workers and counselors attending the conference, "I know everyone at the summit has an interest in improving the care of people living with HIV and AIDS. But there's a lot of work to be done, and much of it will be time consuming and frustrating."
The purpose of the study was to identify what needs to be done in order to get testing, treatment and prevention to the people who need it most. Among the hurdles to achieving that goal, Odoms said, are denial, discrimination and complacency. "We discovered the community is in denial about the existence of AIDS in the heterosexual community," she said.
The crisis team used interviews, field surveys and focus groups to gather information. A total of 82 interviews were conducted on St. Thomas, St. John and St. Croix between March and September of 2001. Questions also were presented to focus groups made up of persons whose activities put them at the greatest risk of contracting HIV and of professionals who test, counsel and treat them.
Interviewers asked who was most likely to get infected, where that contact was most likely to take place, and why people were getting HIV. Through the information gathered, researchers were even able to determine the time of day when an HIV infection was most likely to occur.
Rising incidence of innocent victims
The 35-page report says new infections caused by people engaging in risky behavior with sex and drugs now are spreading into groups of people who may not know they are in harm's way.
Heterosexual women living with a single sex partner are most at risk, the RARE report said, because so many of them are married to or having relations with men who have multiple sex partners, female and/or male, and/or are using drugs injected by needle or obtained in exchange for sex. One of the greatest factors seen at play here was denial — denial by women that their husbands or boyfriends were unfaithful, and denial by the men that the people they were cheating with were having sex with other people, too.
Special concerns were expressed in the report for the risk posed by men having sex with men. "This is a facet of the individual that is a deeply guarded secret, and almost no one will discuss it openly," researchers said, adding that this made it hard to gain the trust of such individuals and collect information from them.
"Because of cultural taboos in openly admitting to or discussing homosexuality and the practice of men having sex with men, this population was extremely difficult to gain access to," the report said. "Nevertheless, they are clearly a significant risk group for the transmission of HIV/AIDS, both among themselves and to the women they may be involved with."
The lack of information available from gay and bisexual men and their partners is apparent in the RARE survey results. Those who were willing to take part in the survey said people who abuse alcohol and drugs facing the greatest risk of contracting HIV. Heterosexual women and sex workers were rated next on the risk hierarchy, although respondents on St. Thomas and St. Croix disagreed over which of the two groups was more in danger.
One of the many contradictions to popularly held ideas that emerged from the survey had to do with the risks facing sex workers and those who patronize them. The findings indicated that "contrary to popular belief, sex workers are more likely to use condoms and are very knowledgeable," Odoms told colleagues at the St. John conference.
Teen-agers, seniors highly at risk
Next on the survey list of HIV-endangered groups are teen-agers, followed by persons over age 50. Researchers said these two groups have one thing in common: the belief that nothing can happen to them. Odoms said use of the drug Viagra is putting seniors at greater risk. Older people having sex are less likely to use condoms, which could protect them from HIV, she said.
The survey's findings on the "where" of contracting HIV in the Virgin Islands were consistent for all three islands. Respondents answered: anywhere there's night life — clubs, bars, strip clubs, brothels and dance halls.
On St. Thomas, beaches, alleyways, around public markets and in abandoned buildings were cited as the hot spots for transmission of the virus. Public service buildings — schools, prisons, hospitals, homeless shelters and churches — ranked next. The researchers said respondents indicated that those engaging in sex and drug use would do so across the street from or next door to a church but would refrain from acting out on church property.
"There appeared to be an unwritten agreement among the drug dealers and the sex workers that the houses of worship were 'forbidden territory' … The illicit activities never took place directly on the church property," the RARE report said. "And the immediate areas surrounding the churches — yards, etc. — were not littered or blocked."
However, it added, "Interestingly, there was no such reverence shown for the cemetery in Christiansted, where drug sales and sexual activity appeared to be the norm among the graves."
Though the survey, the researchers identify the time of day when a risky contact was most likely to occur as between 7 p.m and 3 a.m.
"Lack of knowledge" was the answer frequently given for two of the RARE survey questions:
– Respondents said they thought HIV was spreading because people didn't know how the infection is transmitted.
– They also said they didn't know where they could go to get counseling and treatment if they were infected.
"Very few respondents other than service providers were able to identify existing interventions," the report said. It was less of a problem for people on St. John to know where to go and who to talk to. On the other hand, St. John respondents said because the community is so small, they were concerned about the privacy of their health care information.
The other major factor cited in the spread of HIV in the Virgin Islands was the large number of people passing through the territory as tourists, boaters or
immigrants, legal and illegal.
Strategies for educational outreach suggested at the end of the report include recruitment of churches, because a lot of the risky behavior observed by field workers occurred near churches on St. Thomas, St. Croix and St. John.
"These activities may take place either during church activities, such as evening choir practice, prayer groups and other meetings, or after the church has closed. Churches are uniquely positioned, therefore, as intervention and outreach sites, and should be recruited to participate in prevention activities," the report said.
Another strategy suggested was changing the work hours of health care workers, to raise the chances of their being around at the same time as people living the night life. Researchers also are looking at creating targeted outreach campaigns for gay men and for teen-agers, who often are aware of their risky behavior but are willing to take chances out of a sense that HIV infections cannot happen to them.
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