|
Article Excerpt
The prevalence of HIV infection in the Caribbean is estimated at 2.4%, second only to sub-Saharan Africa (UNAIDS/WHO, 2002). While incidence rates in North America and Latin America have either fallen or levelled off, rates in the Caribbean continue to increase dramatically (Caribbean Epidemiology Centre, 2002a). The disease has reached epidemic levels in the region, where HIV is the leading cause of death among 15-45 year olds (Camara, Lee, Gatwood, Wagner, Cazal-Gamelsy, & Boisson, 2003). The epidemic is now becoming more prevalent among young people, with over 50% of the diagnosed cases occurring in those between 15 and 34 years of age (Camara et al., 2003).
Several sub-groups have been identified as being at high risk of HIV infection in this region. Among these are the homeless, where for example in Trinidad and Tobago research has revealed a higher rate of HIV among this group than among the general population (Hutchinson, 2002). Deren, Kang, Colon, Andia, Robles, Oliver-Velez and colleagues (2003) found that homelessness among Puerto Rican drug injectors was a significant predictor of "shooting gallery" use, behaviour that potentially increases the chances of engaging in unsafe sexual practices. Yet, in disadvantaged populations such as the homeless, high rates of HIV risk factors, and medical and psychiatric problems are frequently associated with a low prevalence of help seeking behaviour and high levels of unmet service needs (Melchior, Huba, Gallagher, Jean-Louis, McDonald, Smereck et al., 2001). This increases morbidity, mortality and the likelihood of transmitting the HIV virus.
The homeless is an understudied group in the Caribbean; however we may be able to extrapolate from research conducted in the U.S. to arrive at some basic hypotheses. In two of the epicentres of the HIV epidemic in the U.S., researchers found that homeless/indigent populations with housing instability, and homeless persons with mental illness and co-morbid substance use problems had significantly higher prevalence rates of HIV than the general population (Robertson, Clark, Charlebois, Tulsky, Long, Bangsberg et al., 2004; Klinkenberg, Caslyn, Morse, Yonker, McCuddden, Ketema et al., 2003). Another study revealed that homeless women who traded sex were more likely to be daily users of alcohol and crack, had higher levels of unprotected vaginal sex and more sexual activities while high on drugs compared with those who were not homeless (Surratt & Inciardi, 2004). These studies underscore the higher level of risk leading to increased vulnerability of infection within this population.
The nexus of drug use and risky sexual behaviours is an especially critical one (O'Leary, Holtgrave, Wright-DeAguero, & Malow, 2003), and particularly relevant to this population. In the Caribbean, where injection drug use is uncommon, crack use has become associated with higher risk for HIV (Djumalieva, Imamshah, Wagner, & Razum, 2002; Gomez, Bain, Major, Gray, & Read, 1996). Studies show that crack smokers have infection rates of HIV similar in magnitude to injection drug users (Edlin, Irwin, Faruque, McCoy, Word, Serrano et al., 1994; Word & Bowser, 1997). Researchers posit that this association occurs through the mechanism of increased unsafe sexual practices precipitated by the use of crack (Castilla, Barrio, Belza, de la Fuente et al., 1999). In Trinidad and Tobago, survey data has shown high HIV prevalence among crack users (Hutchinson & Simeon, 1999), and a study in sexually transmitted disease (STD) clinics found that the strongest predictor for HIV infection was crack cocaine use (Cleghorn, Jack, Murphy, Edwards, Mahabir, Paul et al., 1995). An association between crack use and HIV has also been established in the Bahamas, where cocaine use among patients with an STD was significantly associated with HIV infection (Gomez, Kimball, Orlander, Bain, Fisher, & Holmes, 2002). Crack cocaine use and risky sexual behaviours, both associated with increased risk of medical and psychiatric complications, have been described as common behaviours among the homeless in Trinidad (Reid, 1999).
This paper assesses substance use, HIV status, medical and psychiatric health and access to primary heath care among a sample of homeless, street drug-using populations in the capital cities of two Caribbean states, Saint Lucia and Trinidad and Tobago. The data presented here are derived from the first two countries in a more extensive ongoing research project being conducted in urban areas throughout the Caribbean. The knowledge gained as a result of this research may be used to design and implement appropriate interventions in this high risk group of individuals and therefore reduce transmission of HIV, as well as morbidity and mortality in this population.
METHODS
Seventy-four homeless, out-of-treatment drug users were recruited from drop-in centres in Castries, Saint Lucia (n=26) and Port-of-Spain, Trinidad (n=48). Modified targeted sampling, which involved recruiting participants from identified geographical areas with specific populations of individuals familiar to the researcher, was utilized for this...
|
