Halperin, Daniel T PhD, MS*; de Moya, E Antonio MA, MPH†; Pérez-Then, Eddy MD, MSPH‡; Pappas, Gregory MD, PhD§; Garcia Calleja, Jesus M MD, MPH‖
The island of Hispaniola was the first body of land discovered in the New World, in 1492. It is comprised of 2 nations, the Republic of Haiti and the Dominican Republic (DR). Both countries contain some 8 million inhabitants each and have very large numbers of migrants living abroad, who help support their homeland economies. Macroeconomic conditions in the DR have mainly improved in recent years (although Haiti remains the most impoverished and unstable country in the western hemisphere).1 Some half million Haitian migrants reside in the DR, generally earning very low wages in the sugarcane and other agricultural industries, construction work, and the informal economy.
In 1983, Haiti and the DR became the first countries in the Latin American and Caribbean region to report AIDS cases.2 In 1987, the Dominican government launched a National AIDS Program, and since then various non governmental organization (NGO) and other HIV prevention activities have also been implemented in the country. Despite some predictions that HIV transmission in the DR, and throughout the Caribbean, would continue to increase or even “explode out of control” resulting in an African-like scenario, prevalence has stabilized and in fact probably declined since about the mid-1990s. The UNAIDS estimate of adult HIV-1 prevalence in the DR peaked at 2.7% in 2001.3 After improvements in national surveillance methodology, particularly implementation of the Demographic and Health Survey (DHS+) in 2002, the official country estimate was revised to 1.1% in 2006.4
The main objective of this article is to review and analyze available HIV surveillance data and relevant epidemiological and behavioral information from the DR, so as to better understand the complex dynamics and trends of HIV transmission in the country. For example, as elsewhere in the Caribbean, the DR's epidemic has been officially characterized as being predominantly “heterosexual” in nature.3-5 Although only 3.5% of cumulative AIDS cases have been officially reported as due to homosexual transmission and another 4.3% as being bisexual cases,5 various epidemiological, biological, and qualitative data that we have collected and analyzed suggest that the proportion of total HIV infections due to men having sex with men (MSM) and bisexual transmission is probably substantially higher than has been documented via the official HIV/AIDS case reporting mechanism. In addition, there is no evidence that HIV prevalence in MSM, which remains relatively high, has declined significantly.
In the late 1980s, World Health Organization recommended establishing sentinel surveillance systems to monitor HIV seroprevalence. The DR's surveillance system has functioned relatively well since the early 1990s, and in fact is one of the few countries in the region rated as having a fairly good HIV sentinel surveillance system.6 (Haiti's surveillance system has also been fairly consistent in monitoring HIV prevalence among selected antenatal clients over time.) Both countries have now also conducted population-based household DHS serosurveys,7 which generally provide more accurate national HIV prevalence estimates.8,9 These “DHS+” surveys were conducted in the DR in 2002 and 2007, and both rounds included an oversampling of the residents, largely Haitian migrants and their descendants, of the former “sugarcane plantation” settlements (bateyes).
The data presented in this review are derived from a variety of sources, including surveillance data provided by the National AIDS Program and epidemiological studies of general and high-risk subpopulations. All known studies, including unpublished reports and presentations, concerning HIV-AIDS and related sexual behavior in both general and specific subpopulations were reviewed. The principal data limitation is the general lack of more recent studies of high-risk subpopulations, particularly MSM.
Seroprevalence Data From Pregnant Women
Sentinel surveillance data collected among pregnant women from 1991 to 2006 at hospitals and health centers in urban and some rural sites suggest that there has been an overall decline in HIV prevalence in the general population. Beginning in the mid- to late 1990s, HIV-1 prevalence essentially decreased at all 6 of the country's main antenatal sites although after around 2002 prevalence has stabilized or even increased slightly in some sites. The capital city, Santo Domingo, where about a quarter of the country's population resides and where at least 1000 blood samples have been collected from pregnant women annually since 1991, has been the most regularly surveyed locale. HIV-1 prevalence among antenatal attendees in Santo Domingo declined from a peak of 2.0% in 1995 to 1.1% in 1999, and then it remained essentially stable, with a prevalence of 1.0% in 2006, the last year for which complete data are available.10
As presented in Figure 1, this trend was even more pronounced among the 15-24 age group (dropping from about 2% in the years 1994, 1995, and 1997 down to 0.5% in 2005). This suggests that HIV incidence, or the rate of new infections, was probably also declining considerably during this same general period in Santo Domingo because prevalence in youth can be considered a rough proxy for incidence trends.8 However, in more recent years, the national trend is somewhat less encouraging. At 3 sentinel sites, prevalence has continued to decline steadily; in 2, it has remained stable, and in 2 sites, prevalence has increased recently.10
HIV Prevalence Among High-Risk Populations
HIV-1 prevalence among female sex workers (FSWs) in 2006, the last year for which data are available from several national sites, ranged from 1.4% in Puerto Plata, the third largest city, to 4.1% in La Romana (down from 12.5% in 1996).10 Figure 2 illustrates the generally downward trend in prevalence among FSW at sites in the capital city. Median prevalence at all sites nationally was about 5% in 1991 and had declined to about 3% by 2006, although-as with trends among pregnant women-prevalence reached higher levels during most of the 1990s.5,10,11 One seroprevalence study conducted in 2000 in the semi-urban area of Haina, on the outskirts of the capital, found 0 cases of HIV infection among 98 FSWs along with high rates of reported condom use with their clients (M. Diaz, unpublished thesis, 2001). Syphilis rates in FSWs have also declined or, in more recent years, remained stable (though there has been an increase in hepatitis B, which is also transmitted nonsexually).5,10,11 A recent prospective study found an annual HIV incidence rate of only 0.5% [95% confidence interval (CI): 0 to 2.9%] among a population of FSWs and sexually transmitted infection (STI) patients in Santo Domingo.12
Seroprevalence in 1998 among male patients at an STI clinic in Santo Domingo was 3.3%, down from a high of 8.1% in 1994,10,11 but more recent data from another STI site found a prevalence of 11% in 2004, although this site had declined to 4.4% in 2006.13 Among residents of the chronically impoverished batey informal settlements, most of whom (but not all) are recently or originally of Haitian origin, HIV prevalence in the late 1980s and 1990s was estimated to be similar or even higher than prevalence in Haiti itself or in the 5%-15% range.13-15 The 2002 DHS serosurvey found an HIV-1 prevalence (ages 15-49) in the bateyes of 5.0%; in the 2007 survey, this had fallen to 3.2%, with prevalence in both surveys being generally highest among people in their 30s and older.7 A 2007 analysis of antenatal (n = 1667) and diagnostic (n = 1871) HIV testers at Puerto Plata's largest public hospital found that antenatal testers classified as “Haitians” (n = 263) were over 10 times more likely to be HIV positive than “non-Haitians” (odds ratio = 11.37; 95% CI: 6.23 to 20.73). Although those classified as Haitians made up only 8% of diagnostic testers and 14% of antenatal testers, they comprised 39% and 63%, respectively, of those testing HIV positive at the hospital.16 Among incarcerated men, many of whom are reported to be former injection drug users previously residing in New York City or elsewhere in the United States, high levels of HIV prevalence have also been recorded. For example, a 1995 study found 16% prevalence in a Santo Domingo jail,17 and 19% of inmates surveyed in Puerto Plata in 1991 were infected.13
As previously mentioned, various data suggest that MSM have comprised a substantial proportion of the DR's HIV/AIDS epidemic. In the most recent seroprevalence study of MSM, conducted in 2004 in Santo Domingo, Puerto Plata, and Samaná, 11% of a total of 597 men were HIV positive.18 This prevalence level was identical to that found in the previous serosurvey of MSM, conducted a decade earlier in Santo Domingo,19 whereas a study in the late 1980s found 19% prevalence among male homosexuals.15 However, it should be noted that in the 2004 study, among men self-identified as “homosexual,” 36% were HIV positive and 28% of the “bisexual” men tested positive, whereas 0% were infected among those who self-identified as “heterosexuals” (most of whom were probably exclusively or primarily inserters, as opposed to receivers, of anal intercourse).18
HIV Prevalence in the General Population
Among voluntary blood donors at the Red Cross (n = 72,185), prevalence has, since 1990, consistently remained below 0.2%.11 Among Dominicans applying for resident visas in the United States (n = 139,022), seroprevalence was consistent from 1988 through 1997 (Table 1), averaging 0.28% for all years (95% CI: 0.26 to 0.32).5 In this very large sample, HIV-1 prevalence peaked (as with most DR seroprevalence data) in the mid-1990s, at 0.34% in 1995, and by 1997, the last year for which data are available, had declined somewhat to 0.26%. Analysis of these data, along with the clearly declining trends in antenatal surveillance data noted earlier, suggests that HIV prevalence in the general population of the DR had stabilized, and in fact probably declined, since about the mid- to late 1990s. During the late 1990s, similar or even larger reductions in syphilis and gonorrhea infection rates were observed.11
The 2002 population-based DHS serosurvey found a national adult HIV-1 prevalence of 1.0% (CI: 0.9% to 1.1%), and the 2007 DHS found a somewhat lower prevalence of 0.8% (0.6% to 0.9%).7 However, as the lower- and upper-bound CIs from the 2 surveys overlap, the apparent decline between 2002 and 2007 cannot be considered statistically significant (Fig. 3).
Changes in Sexual Behavior
Analysis of the principal factors behind the overall reduction in HIV levels in the DR suggests that changes in sexual behavior have likely played an important role, along with mortality, which has probably also been a significant factor.20 In attempting to understand the reasons for changes in HIV epidemiology, it is first crucial to pinpoint the most likely period of changes in HIV incidence-which would be most closely associated, temporally, with changes in behavior or other factors likely to affect the rate of new infections.20,21 Because (as in most countries) HIV incidence data are not available in the DR, a rough proxy for incidence trends would be surveillance data of young pregnant women, among whom prevalence began declining in the mid-1990s and continued declining until about 2002. Therefore, the most pertinent changes in behavior would probably be those that occurred during roughly the same period. Between 1996 and 2002, the percentage of unmarried females aged 15-24 reporting premarital sex in the past year increased from 8% to 13%, whereas remaining at 52% for young males.7 During the same period, the median age of sexual debut among females actually decreased by almost a year, from 19.4 to 18.6 (after having declined from 20.4 in the 1991 DHS). These data suggest that it is unlikely that changes in abstinence or premarital sex contributed to the decline of new infections during that period.
Meanwhile, reported condom use at last sex with a nonmarried/noncohabitating partner increased between 1996 and 2002, from 44% to 51% among males aged 15-49 and from 12% to 25% among females.7 (And it further increased between the 2002 and 2007 DHS surveys, to 68% and 40%, respectively, among men and women.) However, condom use remained extremely low (under 3%) among cohabitating or married partners.7
Peer counselor-based and other proactive prevention activities with FSWs, spearheaded by local NGOs (and a Population Council-organized “100% Condom” program), have resulted in generally very high rates of reported condom use for sex work, often in the 90%-100% range (M. Diaz, unpublished thesis, 2001).5,13,22,23 However, condom use is likely to be somewhat lower among male sex workers who have not received nearly as much attention in terms of outreach or other prevention services.24 A study of FSWs conducted in 2002 found that among the 164 FSWs who reported having had clients in the past week, 87% reported using a condom with their last client.13 Of these, 76% reported “always using condoms” with clients in the past 30 days, and an additional 10% said they “almost always” used one with clients.
FSWs are a highly mobile population, and further investigation is required to confirm these generally positive findings, particularly among the more informal nonbrothel-based FSWs, among whom consistent condom use may not quite be as high. In the DHS surveys, the percentage of men reporting having paid for sex in the previous year declined from 11% in 1996 to 8% in 2002 to 4% in 2007. In 2002, 74% of clients reported using a condom during their last commercial sex act, and this increased to 83% in 2007.7
In the 1996 DHS survey, a striking 85% of men claimed they had changed their behavior in some manner because of concern over contracting AIDS.25 The proportion of respondents reporting behavioral changes such as reducing their number of partners was about triple the proportion reporting condom adoption.25,26 However, the 1996 DHS did not collect actual behavioral data on reported multiple sexual partnerships, and so, unfortunately a direct comparison with the 2002 DHS is not possible regarding this crucial behavioral indicator.27-29 (More recently, there was no significant change in multiple partner behavior between 2002 and 2007, with 29% of sexually active men on both surveys reporting 2 or more partners in the previous year.7)
However, further retrospective data can be considered from a 1997-1998 behavioral survey of 1400 sexually active Dominican men, of whom, 79% reported they had changed their behavior due to concern over AIDS.5,25,26 Of these, a total of 75% primarily cited strategies related to partner reduction or partner selection, such as a reduction in number of sexual partners or having become monogamous (52%), having sex only with persons one “knows well” (14%), or avoiding relations with prostitutes (9%).26 An additional 15% reported adopting condom use, and only 2% reported having become abstinent. Among all the men surveyed, 51% reported having had only 1 sexual partner, 18% reported 2 partners, 12% reported 3 partners, and 19% reported having more than 3 partners during the previous year.26 These 1997-1998 data (ie, nearly half the men reported multiple partnerships in the previous year) may suggest that such multiple partner behaviors had declined by 2002, when the DHS found 29% of sexually active men reporting 2 or more partners. However, caution must be exercised when comparing data from divergent methodologies. (And although there is no baseline data with which to compare these 1997/1998 findings, a total of 72% of the men reported having fewer or the same number of partners compared with 3 years prior.26)
Furthermore, there seems to be considerable heterogeneity in sexual behavior among different populations. For example, in a 2006 survey of 693 male batey residents, 54% reported having a regular sexual partner in addition to their wife, over the past 12 months.30 This risky level of behavior is particularly notable, considering the important role of such concurrent partnerships for HIV transmission.27-29
In sum, although the available behavioral evidence for the critical period between the mid-1990s until about 2002 is incomplete, the behavioral changes that seem most likely to account for the apparent declining HIV incidence during that time are the high levels of condom use among FSWs and their clients and probably an overall reduction in multiple partnerships among men. Similar changes in behavior have been recorded in a number of other developing countries where HIV prevalence has also declined, including Thailand, Uganda, Cambodia, Kenya, Zimbabwe, Cote d'Ivoire, Haiti, Ethiopia, and urban areas in Malawi.27-29,31,32
A Substantial MSM and Bisexual Subepidemic?
It is noteworthy that the proportion of reported AIDS cases in the DR accounted for by men remained remarkably constant between 1989-2006, representing nearly two thirds of total cumulative cases throughout those years. By 2006, the proportion remained at 63% or an approximately 1.7:1 male to female ratio.11 However, in the 2002 and 2007 DHS surveys, the male to female ratio of HIV prevalence was nearly 1:1 (in 2002, prevalence was 1.1% in men vs. 0.9% in women).7 Even so, this ratio is substantially higher than one would expect in an overwhelmingly heterosexual epidemic. In sub-Saharan African countries, HIV prevalence is almost always much higher in women than in men, typically from 1.3 to 2.0 times higher than in men.4
In one behavioral survey, 28% of lower socioeconomic class, 18% of middle-class, and 8% of upper-class Dominican men reported having had sex with other men.33 Consideration of such findings should also take into account that this highly stigmatized behavior is likely to be substantially underreported in surveys.34-36 In a 1994 study of 354 MSM in Santo Domingo, only 22% of the interviewees self-identified as being “homosexual,” with over half self-identifying as “heterosexuals” (among whom HIV prevalence was 8%).19 One of the main reasons that MSM tend to have much higher HIV prevalence than the general population is the unusually high risk of receptive anal intercourse, which is estimated to be 10-20 times riskier, per act, than receptive vaginal intercourse.37 In a survey in Honduras, 11% of urban night watchmen reported having had anal sex with other men during the previous 12 months, and these men were over 10 times more likely to be HIV infected than watchmen who did not report MSM activity.38
It is widely acknowledged by both health professionals and lay persons in the DR that, due to the intense stigma surrounding homosexuality, men who at least occasionally engage in MSM activity, especially those who are married or otherwise outwardly heterosexual in orientation, will seek out other male partners in a very discrete or “invisible” manner.34 Most such men, if discovered to be infected with HIV and/or to have AIDS, invariably will self-identify-and thus officially be reported-as cases of “heterosexual transmission.”5,19,33,34 Several clinicians in the capital city and Puerto Plata with many years of experience treating HIV-infected patients reported to the authors that many HIV-positive men eventually have (privately) disclosed being homosexual or bisexual but-due to the pervasive stigma against male homosexuality-prefer to remain “secret” or “disguised.” A study from Honduras reported a similar phenomenon with a follow-up investigation of 100 men with AIDS who were previously classified as “heterosexual” revealing that 53 of them eventually confided as having had sex with other men.39
Many women and men in the DR are evidently not aware of the unusually high risk of HIV infection associated with receptive anal intercourse. In a nationwide survey in the late 1990s, less than 1% of respondents identified anal sex as a specific risk factor for AIDS.40 In contrast, in a more recent survey conducted among residents of a batey community located near the capital, 59% believed HIV can be transmitted through mosquito bites and 54% through use of public toilets.41 Bisexual men, popularly known as bugarrones, have reported especially high rates of anal sex with their female (as well as male) partners, consistent with the pattern in other Latin American countries and elsewhere.24,34,35
Although data remain incomplete, analysis of the existing epidemiological and qualitative evidence supports the hypothesis that the DR's HIV epidemic is probably characterized by a significant “bisexual”-or interrelated MSM and heterosexual-component.19,34,42 Such an explanation would help explain the fairly consistent, approximately 1.8:1 male to female ratio of reported AIDS cases between 1989-2006 (and the near 1:1 ratio of HIV prevalence found in the recent DHS serosurveys). In most other Latin American countries, where MSM comprise an even larger proportion of total HIV transmission than in the DR, the male to female ratio of reported AIDS cases has been even higher: in 1999, the male to female ratio was over 5:1 in Mexico, over 4:1 in Colombia, and for the Latin American and Caribbean region as a whole was 3:1.38,43
The type of “bisexual” pattern that we hypothesize characterizes the DR's HIV epidemic represents an epidemiological situation sharing characteristics of both the endemic, mainly MSM (and injection drug user) epidemics of North America and Europe and the more overwhelmingly heterosexual, often high prevalence HIV epidemics in sub-Saharan Africa. Rather than being of a merely “bridging” or transitional nature, this type of bisexual epidemic more likely represents a self-sustaining ongoing pattern of transmission. The considerable success in increasing consistent condom use among FSWs, along with a reduction in men having commercial (and probably other female) partners, suggests that transmission from female core group transmitters (particularly FSWs) has been significantly reduced. This would further support the hypothesis that a substantial proportion of HIV-positive men have been and continue to be infected by other men, even though many are officially counted as cases of “heterosexual transmission.”5,19,34,42
Consequently, an important question that arises is whether sufficient prevention resources had been targeted to bisexual men and other MSM in the DR. Although one fairly small NGO, “Amigos Siempre Amigos,” has led a dedicated prevention campaign, mainly among the (relatively very few) openly self-identified “gays” in Santo Domingo, most other MSM subpopulations had largely been ignored. These populations include male sex workers,24 transvestites (with 34% HIV prevalence in a study19), prisoners,14,17 boys and adolescents involved in sex work or other MSM activity,24 and men residing in most rural and urban areas located outside the capital city-who form a large part of the apparently substantial population of MSM “hidden” within the general population.19,34 Such populations are particularly challenging to reach and serve, precisely because they are largely hidden. Yet, if a substantial proportion of HIV transmission in fact occurs among MSM, then these populations must be accessed to further reduce new HIV infections in the country.
In addition, and related, to this issue of MSM and bisexual HIV transmission, some survey and qualitative evidence from the DR34,35 suggest that heterosexual anal sex is also a relatively common practice, consistent with data from other Latin American countries such as Puerto Rico,35,44 Mexico,45 and Brazil.35,46,47 In the 2002 DR DHS, 8% of respondents reported that “anal sex is a customary part” of their sexual relations.7 And qualitative evidence from the region suggests that, consistent with a worldwide pattern, condoms are even less likely to be used for anal than for vaginal sex.34,35 Yet, anal intercourse continues not to be targeted-nor even specifically mentioned-in most prevention campaigns, nearly all of which have focused on heterosexual (which is understood to mean vaginal and, more recently, also oral) routes of transmission. AIDS educators and health promoters in Santo Domingo and Puerto Plata reported to the authors that the most commonly asked questions during prevention talks (charlas) concern the risk of oral sex (which is far less risky for HIV infection than vaginal or anal sex48), whereas the practice of anal intercourse is almost never raised.
Also commonly practiced among many FSWs and other women in the DR (and even more so in Haiti) are “dry sex” practices,49 which some studies have found may increase risk of HIV-1 infection in women.50 One potentially feasible and perhaps less stigmatizing approach for disseminating information about such risky sexual practices would be through emphasizing the high-risk nature of particular behaviors, such as receptive anal intercourse and “dry sex”-as opposed to focusing on those particular groups, that is, “gays” or Haitian immigrants, who are perceived as more likely to engage in such behaviors. The DR's established conservative cultural institutions presumably would not oppose such public health warnings, which would not be inconsistent with their own religious or “moral” ideologies regarding practices such as anal sex.
An additional risk factor for heterosexual transmission in the DR, as in the Caribbean region generally, is the low prevalence of male circumcision (13.5% in the 2007 DHS7). There have been some discussions locally regarding the possibility of providing safe voluntary circumcision services for men in the DR, for example, in batey communities where the prevalence of heterosexually transmitted HIV is especially high. Preliminary qualitative research conducted in 1999-2000 by one of the authors (D.T.H) suggests that acceptance of circumcision as an HIV prevention and male reproductive health intervention may be relatively high in the bateyes, as was similarly found in a recent feasibility study conducted in the capital city of Haiti.51 Interestingly, and unlike the pattern in most of Africa,27,52 HIV prevalence in the DR is highest among the lowest socioeconomic population. For example, prevalence in 2007 was 2.7% among people with no or little education, compared with 0.4% in those with a college education.
A Broader Caribbean Pattern?
A similarly downward trend in HIV-1 prevalence has been reported in neighboring Haiti.31 Based on surveillance among antenatal clinic attendees, national adult prevalence in Haiti was estimated to be 6.2% (CI: 5.9% to 6.5%) in 1993, 5.9% (5.7% to 6.1%) in 1996, 4.5% (3.0% to 6.0%) in 2000, and 3.1% (3.0% to 3.2%) in 2004 (when more rural sites were included, which would have lowered the average overall prevalence).53 However, prevalence among young pregnant women has not been decreasing at the same rate. A population-based DHS serosurvey in 2005/2006 found a national adult prevalence of 2.2% (2.3% among women and 2.0% among men). Officially reported syphilis rates have followed a similarly declining trend in most urban populations in Haiti (although rates may be increasing somewhat in youth).53
Along with the role of mortality in an older AIDS epidemic such as Haiti's, another principal reason for the declining HIV prevalence seems to be behavioral change.31 Analysis of DHS and other data indicates that the proportion of men reporting multiple partners has declined somewhat, and condom use has increased, especially for sex work.54 In Behavioral Surveillance Surveys conducted in 1999 and 2003 among youth in the Haitian capital, Port-au-Prince, the proportion of males aged 15-19 and 20-24 reporting casual sexual partners fell from 50% and 60% in 1999 to 12% and 20% in 2003, respectively. Among females of the same age groups, this reported behavior dropped from 31% and 52%, respectively, in 1999 to only 2% for both age groups in 2003, and some modest increases in reported condom use were also found in this youth study.54 Although such dramatic changes in reported behavior may be exaggerated due to self-report bias, they suggest that at least some level of partner reduction has taken place in Haiti, as seems to have similarly occurred in the DR.
Surveillance data from Jamaica indicates that adult HIV-1 prevalence decreased from an estimated 2.0% in 1996 to 1.5% in 2005.4,55,56 Successful prevention trends have also been reported in some other Caribbean nations where disturbing increases in prevalence had previously been reported, such as in the Bahamas.56,57 The number of HIV infections in Haiti and the DR probably represent at least 75% of the total number of infected persons in the greater Caribbean Basin region. Thus the prevalence declines in those 2 countries, along with similarly declining or stable trends in several other Caribbean countries,42,43 strongly suggest that (with some possible exceptions) the overall HIV epidemic in the region is declining. However, further information is required to more thoroughly assess the regional situation.
HIV prevalence seems to have generally declined in the DR, placing it among a relatively small but steadily growing list of other developing countries, including Uganda, Thailand, Kenya, Cambodia, Zimbabwe, Rwanda, Ethiopia, and Haiti, which have achieved some success in reducing their epidemics.6,27-29,31,32 The reduction in the rate of new HIV infections in the DR seems to have resulted in part from changes in sexual behavior, particularly increased condom use among FSWs and their clients and probably an overall reduction in multiple partnerships among men. It is likely that prevention programs have helped contribute to these successful behavioral changes.5,23,26
However, the risk of complacency is real, and it is imperative to continue implementing assertive prevention efforts. Indeed, some recent data, for example among pregnant women in a couple sites, suggest that HIV prevalence may no longer be declining, and might even be increasing, at least in some populations in the DR.13 Recent small increases in HIV prevalence and probably incidence in Uganda, for example, along with some negative trends in behavior (ie, a considerable increase in multiple partnerships among men), demonstrate that prevention gains can eventually be eroded.29,32
The available data also suggest that, as in most other Latin American countries, a substantial proportion of HIV infections in the DR is probably due to male-male and bisexual transmission. HIV prevalence remains relatively high in MSM, with no evidence of a significant decrease to date. The unusually risky practice of anal intercourse, whether male-male or male-female, similarly remains a neglected aspect of prevention programs and health messages. To investigate more rigorously the hypothesis of a substantially MSM or “bisexual” epidemic in the DR, further research is required, including improved sentinel and behavioral surveillance studies, which ideally would include (considering the great reticence to disclose MSM and anal sex behaviors) more rigorous biological research, such as clinical inspections for evidence of anal trauma or anal STIs. Such research could also provide early warning of a possible resurgence of HIV or STI transmission among vulnerable populations, including the various MSM groups, batey residents, incarcerated populations, and the more informal and street-based sex worker populations.
We thank Martha Butler, Jean William Pape, Elizabeth Gomez, Maria Castillo, Allison Herling Ruark, Tito Coleman, Clifton Cortez, David Losk, Glenn Post, Leonardo Sanchez, Michael Cassell, Robert Bailey, Elisa Ruiz, Zac Kaufman, Peter Figueroa, and 2 anonymous reviewers.
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