How the Illicit Drug Economy Contributes to HIV Risk in St Vincent and the Grenadines

Abstract

St Vincent and the Grenadines (SVG) is the largest marijuana producer in the Eastern Caribbean. As the European Union has phased out preferred access for its banana crop, marijuana has become one of the main sources of income and a safety net for many young men, in particular. HIV is a problem for youth in SVG where 60% of the population and 50% of cumulative AIDS cases are among individuals under 30 years of age. To explore the relationship between the economic context and HIV, we used rapid appraisal methods including field observations, interviews, and focus groups with 43 key informants. We found that the marijuana-related economy has contributed to social conditions favoring HIV transmission among young people in several interrelated ways. A lively youth culture exists which includes frequent parties, heavy drinking, sex with multiple partners, and the desire to be seen with the best material goods. Men with access to money are able to attract younger partners for parties and sex. Condoms are infrequently used. We conclude that reducing HIV risk will require structural interventions to reduce discrimination and increase economic opportunity.

Background and Introduction

St Vincent and the Grenadines (SVG) is the largest marijuana producer in the Eastern Caribbean. ¹ As the European Union (EU) has phased out preferred access for its banana crop, marijuana has become one of the main sources of income and a safety net for many young men, in particular. HIV is another social problem for youth in St Vincent where 60% of the population and 50% of cumulative AIDS cases are among individuals under 30 years of age. Although they may not appear to be connected, we found that the marijuana-related economy has contributed to social conditions favoring HIV transmission among young people in several interrelated ways.

The nation of SVG is made up of 32 islands and cays and forms part of the Windward Islands, with an estimated population in 2008 of 118 000. ¹ Canouan, Bequia, and Union are the largest and most populated of the Grenadines, while some of the other smaller islands are privately owned. Most of the population resides on the island of St Vincent, with Bequia being the second largest, having approximately 5000 inhabitants. ² St Vincent and the Grenadines was a British colony until independence in 1979. The country now has a democratically elected government which is led by Prime Minister Ralph Gonsalves, who was first elected in 2001 and then reelected in 2005, again capturing 12 of the 15 contested seats. The official language is English, and the capital, Kingstown, is located on the island of St Vincent.

A majority of the population is descendants of African slaves who were brought to the Caribbean to work on agricultural plantations. The remaining inhabitants include East Indians, Carib Indians, and individuals of mixed ethnicity. According to the 2001 population census, almost 60% of Vincentians are under the age of 29, with 30.7% being under 15 years of age, and those between the ages of 15 and 29 representing 27.8%. The age group 30 to 44 years makes up 21.1% and the remaining 20.4% are 45 years and older. ³

The fertility rate in SVG as of 2007 is 2.2 children per woman, and the crude birth rate is 20.1 per 1000, down from 23.6 in 1995. ⁴ Although local health authorities are concerned with what they perceive to be an increase in teenage pregnancies, ⁵ statistics indicate that teenage births are also on the decline. The National Family Planning department released figures indicating that 464 teenaged women gave birth in 2000, but that 398 did in 2003. ⁶ Overall, there were 8166 live births in 2000 to 2003 and 20% were to teenage mothers. ⁷

The annual gross domestic product (GDP) ¹ per capita for SVG is US$3594 as of 2005 and its annual GDP growth is 4.9%. The urban population equates to almost half of all islanders, at 46.7% in 2007. ⁸ Adult literacy ¹ is at 88.1% and the unemployment rate in 2004 was 12%, although unofficial estimates put it more at 14% to 25%, with the English-speaking Caribbean being “plagued with structural poverty.” ⁹ While the level of primary school attendance for males is relatively high at 92% (2006), only 57% of males go on to secondary school in contrast to 71% of females, ¹⁰ even though universal access to secondary education was instituted in 2003. ¹¹

HIV and AIDS in SVG

As of 2005, the AIDS incidence rate per 1 000 000 is 319.3, with more men being described as living with AIDS. The male–female ratio ¹² of AIDS cases being 1.6:1. In its 2008 HIV/AIDS country progress report, the UN General Assembly Special Session (UNGASS) acknowledges that “HIV/AIDS remains a serious health challenge in St Vincent and the Grenadines affecting primarily those who are often socially and economically vulnerable.” ¹³ Those most vulnerable belong to the age group 20 to 49, accounting for 74% of total infected persons identified in 2006 to 2007. This is consistent with AIDS being one of the leading causes of death for those aged 25 to 44 years in the Caribbean region. ¹⁴ The main form of transmission is believed to be through heterosexual contact. The majority of the population in SVG is under 30 years of age and sex is common among younger people; just under a quarter of those aged between 15 and 24 reported ¹³ having sex before the age of 15. According to government figures, ¹³ HIV incidence in the country has been declining since 2004. It is unclear whether some of this trend has to do with HIV-infected people moving off island for treatment and to what degree surveillance figures in the country underestimate the problem.

The Rise of Marijuana Production in SVG

The agricultural industry, particularly banana production and exportation, dominated the economy of SVG since the 1950s. The Caribbean banana growers have enjoyed preferential trade deals from the EU market which has its history in Britain providing assistance to its Caribbean colonies to foster their banana industry, including preferential access to its market. ¹⁵ This regulated market has provided a certain level of stability for the economy of SVG. Such reliance on 1 industry, however, has left the economy vulnerable to banana price and quota fluctuations and has thus made it key to social stability for this and also to other eastern Caribbean countries. ¹⁶

Tariff protections have been eroded due to successful challenges from non-Caribbean countries through the World Trade Organization (WTO), beginning with a complaint from the United States in the 1990s. The unfavorable rulings have forced the EU to reconsider its quota system and reduce import tariffs for all WTO member countries not included in the African Caribbean Pacific (ACP) group, which includes SVG, who trade with the EU tariff free.

The trade liberalization of the banana industry has had a significantly negative impact on the SVG economy as the small-scale banana growers struggle to compete with the larger Latin American banana plantations. Their produce has been exposed as being uncompetitive and overpriced. Subsequently, there has been a shift away from banana production, which is exemplified in the reduction of banana exports. In 1992, St Vincent ¹⁵ exported 77 361 tons compared to only 15 761 tons in 2006. There has been a corresponding 37% agricultural employment decline ¹⁷ from 1991 to 2001.

Tourism in the Grenadines has become an important segment of the economy, along with a growth in construction, a small manufacturing sector, and the presence of an offshore financial sector. ¹⁸ It has been said, however, that even with tourism earning 3 times as much as bananas, “the agricultural dollar goes longer because it is spent locally and that no industry can yet replace bananas in importance.” ¹⁹

There is a lack of alternative income sources for the farmers and this has led to an increase in unemployment, poverty, and social dislocation. ²⁰ Without trade protection, there is little scope to reduce costs for licit agriculture in general. Therefore, a number of farmers have turned to the production of marijuana for survival, either to subsidize their banana crop ¹⁹ or as their only source of income. The move to the cultivation of this illicit crop has become so entrenched in the economy that the sale and export of marijuana has been estimated to equate to one fifth of the St Vincent’s GDP. ²¹ According to the International Narcotics Control Strategy Report for 2008, SVG “is the largest producer of marijuana in the Eastern Caribbean and the source of much of the marijuana used in that region,” ²² with marijuana having become a safety net for many islanders. ²³ “The Caribbean market makes up approximately 45 percent of marijuana consumption from St Vincent and the Grenadines, the US 25 percent, UK 20 percent, and Canada 10 percent.” ²² Marijuana is also often used by people living in SVG. In a national sample survey in 2001, 85% of youth between the ages of 10 and 14, reported that they used marijuana. ²⁴ The Grenadines are thought to be “largely ganja-free” (ganja is the slang term for marijuana often used in the region), with the tourism industry dominating this chain of tropical islands. ²¹ Therefore, the illicit agricultural production is centered on the island of St Vincent.

St Vincent is of volcanic origin and is dominated by the La Soufriere volcano, with most of the farming taking place in its foothills where farmers are able to produce up to 3 crops a year. ²⁵ The obvious attraction being that it can generate about 30 times more profits than bananas. ¹⁵ With this level of return, however, comes substantial risk. “Insecurity is the hallmark of ganja cultivation at every step of the cycle.” ²³ If the crop survives eradication by authorities, growers may be intercepted by thieves or arrested by police before actually delivering their crop to the buyer. There is also a chance that the buyer may not fulfill their promise of payment. If the cultivators do get paid, then there is the threat of having the money stolen, which would leave them with nothing for that production cycle. As well, with the introduction of money-laundering laws, the ability to bank the substantial sum of money is restricted without proof of source, therefore producing a thriving cash economy. This is in contrast to the banana industry that provides guaranteed weekly bankable income and allows for the accumulation of savings. ²³

This level of instability and insecurity for marijuana growers and the families they support creates a feast or famine scenario. So when major US supported marijuana eradication operation, dubbed “Weedeater,” occurred in the late 1990s, the farmers protested the destruction of their crops. The operation conducted in December 1999 was responsible for destroying 5 million plants, 7 tons of cured pot, and 250 drying huts, which accounted for about a tenth of the crop. In all 13 farmers were arrested and 1 killed. The loss of harvest was attributed to the lower sales throughout the Christmas season. ²¹ After such a concentrated eradication effort by multiple law-enforcement agencies, SVG does not have a formal crop eradication program as of 2006. Instead, the local police carry out sporadic manual eradication of marijuana plantations. ²⁶ Also, the United States provides helicopters to the local authorities to patrol marijuana grown in the mountainous terrain. ¹⁶

Officials in SVG have acknowledged the entrenched nature of marijuana cultivation in the economy which has sparked debates on the potential for marijuana legalization. One such advocate is Magistrate Carlisle Dougan, former attorney general and former high commissioner to London. He understands that the people of SVG need a means to make a living, with the demise of the banana industry, and believes that marijuana laws need to be revisited. In his magistrate’s position, he sees no value in charging someone found in possession of a personal amount of marijuana but recognizes that the police have their job to do. ²⁷ On a broader scale, those who are arrested and charged for marijuana possession face additional hardship. It makes it even more difficult for them to find alternative employment in other industries such as the service sector or to emigrate in search of other opportunities. ²⁵ There were 308 persons arrested for cannabis trafficking and corruption related to trafficking in 2006. In addition, 34 831 plants were destroyed and 2121 kg of leaf cannabis were seized. ²⁸

The Eastern Caribbean Community Action Project

In response to the HIV prevention needs in the Eastern Caribbean region, the US Agency for International Development (USAID) funded the Eastern Caribbean Community Action Project (EC-CAP) in 2007. The overall goal of the Eastern Caribbean Community Action (EC-CAP) project is to work with vulnerable communities to increase access to HIV and AIDS services in 4 islands of the Eastern Caribbean, Antigua and Barbuda, Barbados, St Kitts and Nevis, and SVG. The lead agency on the project is the International HIV/AIDS Alliance which works with its regional linking organization, the Caribbean HIV/AIDS Alliance (CHAA) to accomplish EC-CAP’s 2 main aims: (1) to increase the use of strategic information to promote sustainable evidence-based HIV/AIDS community services in the Eastern Caribbean and (2) to increase access to HIV/AIDS community services in the Eastern Caribbean. The Caribbean HIV/AIDS Alliance (CHAA) has a history of working specifically to mobilize vulnerable communities to carry out HIV prevention, and education activities, counseling and testing, and promoting access to care and support with 3 key populations: men who have sex with men (MSM), sex workers (SWs), and people living with HIV (PLHIV) and AIDS (PLWA). Through the EC-CAP, the CHAA and its partners, the University of California, San Francisco and Intrahealth, support prevention, development, and use of strategic information, rollout of community-based counseling and testing, and provision of care services (palliative and home-based care).

The Role of the Center for AIDS Prevention Studies and CAPS Investigators

At the inception of EC-CAP, IHAA contracted with the University of California, San Francisco Center for AIDS Prevention Studies (CAPS) to lead the strategic information activities associated with the project. In this capacity, CAPS has provided specific expertise and technical support to design a series of special studies to describe HIV risk and health-seeking behavior, conduct studies on implementation and scale-up community-based HIV counseling and testing, train local prevention providers on monitoring and evaluation systems, data use and program planning, provide local organizations with technical assistance in strategic information, package findings and recommendations of the evaluations into best practice publications, and disseminate the publications at the international, regional, and national level. The research carried out under this project assists in building programs which are relevant, culturally appropriate, and effective within the EC-CAP countries, in partnership with National AIDS programs and civil society.

This paper presents the results of a rapid appraisal study of populations at risk of HIV in SVG. The rapid appraisal identified preliminary links between the social dynamics of the marijuana economy and HIV risk, and we suggest possible HIV prevention intervention solutions on the individual, group, and policy levels.

Methods

To explore the relationship between the economic context and HIV, our multidisciplinary team of investigators used rapid appraisal fieldwork methods including a systems-level perspective, an iterative approach to data collection and analysis, and data triangulation. This type of qualitative inquiry was especially suited to our research to develop a preliminary assessment of a situation. ^29,30

The rapid appraisal team comprised 2 CAPS-based researchers, 1 project manager in the field who was a university employee and 2 community-based survey interviewers. The disciplines represented in the 5-member research field team included sociology, anthropology, public health, evaluation, economics, and development studies. This diversity in perspectives ensured a multidisciplinary and more comprehensive assessment. An important additional source of data was provided through the presence of CHAA’s HIV prevention outreach teams in the target EC-CAP countries. The project manager and outreach workers who lived and worked in SVG were able to provide key insights into directing data collection and interpreting results. We made 3 visits to St Vincent and 2 islands of the Grenadines between July and December 2008, first to conduct preparatory work and then to collect data.

Data sources included secondary data, observations and interviews, and focus groups with 43 participants, including community members and staff of government and nonprofit organizations implementing HIV prevention and medical care in SVG (see Table 1 ). Prior to fieldwork, we gathered secondary data available on HIV and populations at risk as well as background economic and political information. This was followed by informal discussions with the program manager and outreach staff based in SVG. These informal discussions provided useful information that helped to refine the research questions and guide the preliminary selection of study participants.

Table 1.

Characteristics of the 43 Participants and Data Collection Methods

Participants	Number of Participants
One-on-one interviews with health care providers	7
One-on-one interviews with government staff (including staff providing direct HIV services and outreach)	5
One-on-one interviews with men who have sex with men	4
One-on-one interview with a bar owner	1
One-on-one interviews with heterosexual women (including 1 informal sex worker and 1 woman living in the Grenadines)	3
One-on-one interviews with people living with HIV/AIDS	2
Focus group with men who have sex with men	6
Focus group with nongovernmental organization staff	5
Focus group with community outreach workers	4
Focus group with male migrant workers in the Grenadines	6
Total number of participants	43

After these initial planning discussions and review of data, we conducted face-to-face semistructured interviews and focus groups with participants selected with the assistance of local staff. Because our intent was to uncover populations at risk of HIV and to understand the context in which risk occurred, we used purposive sampling to include a diversity of participants. The sampling strategy sought to include “information-rich” ³¹ participants, either belonging to different population segments at risk of HIV and/or in different roles providing HIV education and/or services. The sample size was consistent with qualitative methods and the purpose of the study. ³² The criteria for participation were determined together with local staff, including outreach workers conducting HIV prevention and familiar with different population segments in order to ensure a diversity of representation in our participant sample. This type of recruitment strategy is sometimes necessary when researchers cannot identify or access participants because of location and time constraints. ³³

In-depth interviews and focus groups were conducted using semistructured interview guides. During the interviews and focus groups, participants were asked to describe life in SVG, venues where people socialize and where HIV risk behaviors may take place and groups at risk of HIV, and associated risk factors.

Each focus group lasted approximately 120 minutes and individual interviews lasted approximately 60 minutes. All participants provided verbal informed consent to participate. All interviews and focus groups were audio recorded. Community members were reimbursed US$25 for their time and participation in the study.

In addition, we conducted ethnographic observations of locations where populations at risk socialize and where HIV risk behavior may take place (according to study respondents and outreach workers). During our visits, we spent time at the locations identified by respondents as places where people congregated for social networking. These locations included the main square in the capital, beaches, hotels, and bars. We also conducted anonymous informal interviews with taxi and livery drivers and a young man who provided informal tours for tourists hiking up the Mt Soufriere volcano, where marijuana is cultivated.

At the end of each day of data collection, the research team met to review, share, discuss, and compare findings, observations, and interpretations related to the data collected that day. Those debriefing meetings served to identify preliminary themes emerging from the data and new questions to ask participants on consequent days of data collection to further explore those emerging themes.

After data collection, the same team of researchers first listened to the audio recordings of the interviews and focus groups and then prepared written summaries of each interview and group. Those summaries were organized to capture priority issues included in the interview guides and emergent themes arising during the data collection and analysis. During this process of analysis, the research team met (over the phone) to discuss the findings, refine the thematic classifications emerging from the data, and to capture concepts not previously integrated in the summaries. This process of analysis produced the set of main themes included in the results section.

Protection of Human Participants

The study was reviewed and approved by the Committee for Human Research, University of California, San Francisco, and the National Ethics Research Committee of SVG.

Results

We have organized the results into 2 sections. The first section describes populations at risk of HIV and HIV risk behaviors that were uncovered during the rapid assessment. The second section details the connection between the economic environment in St Vincent and HIV risk, particularly risky sexual behavior. In the discussion section, we discuss preliminary links between the economy and HIV risk and propose areas for future research and possible intervention strategies.

HIV Risk in SVG

In SVG, HIV risk is at the confluence of different but overlapping population segments that interact socially and sexually. The population segments identified by our informants as being most at risk of HIV were youth (men and women) and MSM, whether gay or heterosexually identified. While unprotected sex between men may contribute to HIV risk, the number of those men is probably small and would only partially drive the HIV epidemic. Data suggest that a larger proportion of men and women may actually be at risk of HIV. In particular, these may include young adults with low economic resources, who may have multiple partners and may engage in some sort of transactional sex to either cover basic needs or gain access to other material items they would not be able to afford otherwise.

Vincentian Youth are at Risk of HIV

For youth in SVG, HIV risk is intertwined with a lively youth culture that includes frequent parties, heavy drinking, and marijuana smoking. Respondents reported that from an early age, there is emphasis in the culture on enjoying and experiencing life and that there is peer pressure to do so. Many young people spend their free time hanging out in the streets, drinking alcohol, smoking marijuana, and cooking food on barbeques. Young people reported that there were few other options; they spoke of having nothing to do but “hang out, drink alcohol, and smoke pot.” This phenomenon is so common that HIV prevention researchers have coined a term for it. When a group of peers, especially men, congregate in a particular area, they are called “youth on the block.”

Partying—known in much of the Eastern Caribbean region as “liming”—is the common and preferred way for young people to spend their free time. In addition to meeting on the street, there are other venues where young men and women meet including at bars, pubs, parties, through the Internet, and by cell phone, through texting each other to arrange when to meet, for instance, at the main square in the capital city, Basseterre. Between Thursday and Sunday nights, there are activities and socializing in different areas, going back and forth between places that offer drink specials.

Alcohol and Marijuana Use is Prevalent

Alcohol consumption is a key feature of the culture for youth on the block. There is great social tolerance for drinking. Young girls and boys walk around with beer bottles especially at parties. As 1 respondent described it, “it’s a style to walk with a bottle in their hand. There are a lot of crew in the area—5 ladies or more. They give themselves names and drink till they get drunk and then engage in sex. Some drink to an extent … and some drink till they lie down and roll on the ground.”

Mixed drinks are popular mainly among men because of the perception that they provide an increased sex drive and makes them “last longer” when having sex. Energy drinks (Red Bull) mixed with strong rum or vodka are popular. “They mix the strong with the stronger” and after they drink they smoke a “spliff” (spliff is the slang term for a joint or marijuana cigarette most often used in the region). They drink, smoke, and then have sex. Rum is much cheaper to buy for a whole group and lasts longer than buying 1 beer. As 1 young man we interviewed puts it, “considering how much people drink here it is cheaper to buy rum and it could be shared. Guinness [a type of beer] is $5, so you get 3 for $15 while rum is 3 for $10.”

Access to alcohol is not a real problem with many bars selling alcohol and cigarettes to minors. Unless they are dressed in their school uniforms, young people are seldom asked for their identification to prove they are of legal drinking age. Similarly, when asked about accessing marijuana, all of our young respondents said they could get small amounts without any difficulty.

Multiple and Concurrent Sex Partners are Common

Along with socializing and drinking, sexual opportunities are a feature of the limes. According to our respondents, youth culture encourages young adults to start having sex at a young age and both girls and boys start having sex in early adolescence. Young women go out in a “clique, or crew or posse.” They go out to socialize, enjoy themselves, and meet men. Both young men and women place an emphasis on looking good in these situations. The most popular “looks” come straight out of the international hip-hop scene. In the absence of financial resources, youth have become creative in procuring fashionable clothing, shoes, jewelry, cell phones, and other trendy material goods. Having multiple partners or having sex in exchange of money or goods is one way that youth are able to access consumer goods.

In light of the liming culture, many men and women, especially when they are young, may have multiple and concurrent partners. Respondents shared the perception that young people change partners often: “The island might be small but some people are ‘fast.’” Many respondents talked about youth engaging in “shutter” behavior, their relationships happen in quick succession, one opens and closes and another begins easily and quickly. Some respondents said their concern about others “sleeping around” (having sex with many partners) and the consequences that multiple partnerships might have, but most said that youth tend to change partners regularly with the attitude that “let me just enjoy my life, lemme just have a fling, lemme just do this tonight and forget about it the next day … that’s sometimes how they [young girls] live here … if they going out tonight they want to lime with this person and the next day you see them with another person.”

Among men, it is common to have a main partner but to have other partners on the side: “As some of them will say that is my empress, which means that is the main woman but that doesn’t mean that they not going to take ‘a little piece’ if something pass by.” Multiple partnerships among women were also noted, although men appeared to have less tolerance for it: “Sometimes is not really you that changing the partners, the girls not behaving themselves so you have to change them.”

Undercover Risk: MSM

Men who have sex with men may also be particularly at risk of contracting HIV. There are several reasons for this. First, most people in SVG are observant of some denomination of the Christian faith; it is a very religious place, even by Caribbean standards. This contributes to HIV risk dynamics in at least 2 ways. Although there is a tolerant attitude toward youth hanging out together and even to young women bearing children out of wedlock, there is little frank discussion of sex and sexuality. This makes it difficult to ensure that appropriate, accurate, and detailed information is available about how to transmit HIV and other sexually transmitted infections. Second, very few men are open about their sexual identity or sexual activities with other men because most church denominations followed in SVG condemn homosexuality as a “sin.” Our informants referred to how difficult and frustrating is to be a gay man—or “battyboy” —because of religious background, stigmatization, and internalized and actual homophobia that would result in ostracism if identified as a man who had sex with other men. In fact, one of our respondents who was “out” reported numerous incidents of verbal abuse and threats. The threat of violence is another key reason that men cannot openly seek information about how to prevent HIV transmission when engaging in sex with other men.

Other contributors also influence the degree to which men can be out about their sexuality. For example, antisodomy or “buggery” laws also officially forbid sex between men, motivating people to hide their behavior. As a result, we heard that while there certainly were MSM on the islands, most do not identify as “gay,” are not open about this sexual activity, and have sex with both men and women. We could not determine whether these men were indeed bisexual in orientation or whether they had sex and relationships with women to be able to “pass” as heterosexual. Considering that for most MSM it is important to pass and not to bring attention to themselves, establishing or maintaining any kind of ongoing intimacy with another man, as understood in most of the Western world, is very difficult.

Condom Use is Inconsistent

Given the degree of multiple partnerships and exchange sex, condoms would be an effective strategy to reduce the risk of HIV transmission. However, social dynamics apparent in St Vincent make their use less than consistent. Condom use is often based on the perception that people have of their partners. Condoms may be used with their “side squeeze” but not with their “main squeeze” either because they trust their partners or because they think their partners are “nice” or “clean.” In cases where men perceived their female partners to be sexually active with many others, or “bad” girls, participants reported that men were more likely to use condoms. They told us that with a partner like this, they would use condoms every time and “not just 1 but 2 condoms at the same time.” Men said that they preferred to have sex with a woman “who goes to church” because they are more likely to be “clean and safe.”

Men felt that if their main partner were to ask them to use condoms they would want to know why. It would raise suspicion for some that perhaps a female partner was being unfaithful. Women agreed that asking a man to use condoms “will bring distrust into the relationship.” They reported that if women are concentrated more on the trust and the relationship, then the way to show their trust and love the guy is not to use a condom: “Using condoms will bring distrust into the relationship, and girls are looking more at the trust and the relationship and that the way to show they trust and love the guy is not to use a condom.” Women also reported that they were less likely to use condoms with their main partners, who were often older men. Participants agreed that with regular partners, after a few months had elapsed, most couples did not use condoms consistently. It was not clear that even with a side squeeze, condoms were used consistently. Respondents said they would make decisions to use condoms depending on how their partner looked, how much they trusted them, how much they knew about them, or just how nice they were perceived to be.

Gender Dynamics Influence Condom Use for Heterosexuals

Among individuals who engaged in heterosexual sex, we heard from respondents that men are typically the ones in control of whether condoms are used. Men reported that they did not like to use condoms because of perceived reductions in sexual pleasure. Women said that even in cases in which a condom was used initially, men were in control of the decision to remove the condom during sex. Women also said they would “go along” with a male partner’s decision not to use a condom because of sharing the feeling that there is more sexual intensity when they have unprotected sex.

Probably they were in a position where as we say locally, “they thief piece of wife,” and at the time, they didn’t have time to take out a condom and put on a condom. It was just all about getting the sex and going home. Or probably they were drunk and the person who they were having sex with was drunk so they just went right ahead and had sex because both parties wanted to have sex. So they just had sex and they forgot about the condoms.

People Living with HIV/AIDS Also Face Barriers to Condom Use

Every new infection involves 1 partner who is already infected. For this reason, prevention providers increasingly draw attention to HIV-risk dynamics among individuals who are infected with HIV/AIDS.

It’s a small country, with just 110,000 in population. Everybody knows everybody. You’ll “catch your royal” to get a job because these employers don’t want people who are HIV positive working in their place because it’s bad for business.

Respondents reported that AIDS is a “stain to a person’s name.” For this reason, most people with the virus try to keep it a secret. This secrecy may lead to absent or inconsistent condom use and a lack of disclosure to sexual partners because of real or perceived fears of rejection, discrimination, and stigmatization.

This discrimination may be even more acute if the person is also a man who has sex with men. Our respondents told us that if a person is living with HIV, but stays healthy and does not manifest symptoms of HIV disease, he or she can pass as an uninfected person and live a relatively unaffected life. Consequently, people living with HIV (PLHIV) may not change any of their behaviors, such as drinking alcohol, smoking marijuana, or initiating condom use for fear of being identified as HIV infected. People will say that that a person is living with “sugar.” However, if an infected person is also a man who has sex with men and people suspect it, the reaction is more aggressive, with some assuming he is spreading the virus. As 1 respondent puts it, “Once they find out you are HIV-positive, the double discrimination comes together … [people say] why do you have to be HIV positive and be a battyman? You’re the ones spreading the virus!”

HIV Testing is Not Well Utilized

In general, in SVG, the uptake for voluntary HIV testing is low. The primary reason our respondents gave for why testing is not better utilized is the lack of confidentiality at the clinics where testing is offered and because people in SVG tend to know or be concerned about each other’s business. Community respondents referred to the fear, whether real or perceived, of confidentiality breaches among health care workers who may disclose someone’s HIV results or status. To avoid that, as illustrated by a respondent in reference to HIV testing, people may use private facilities or hop to a different island for services:

Let’s say in my case, I knew they [health clinic] were having the tests done, I knew they had a drive. If I went to the clinic for another reason and the nurse asked me if I wanted to get tested and I would tell her no. I might be wrong but there’s always this thing going around that the nurses at the public health clinics, if they know something they would talk because they probably like to talk. It’s not confidential … I got my thing done at a private doctor.

Even with confidentiality concerns, perceptions about what it means to use condoms may actually encourage testing. Instead of consistent condom use, some rely upon and perceive HIV tests as a prevention measure. An outreach worker told us the following story about a woman he recently spoke with:

What would happen if she asks him to use a condom all the time? He will think she is probably having an affair and so she is not sure about her status and therefore wants him to use a condom—“you have disease, no?” So she won’t ask him to use condoms … she will depend on the test. She does a test every 3 to 6 months.

Stigma and Discrimination toward PLHIV

Similar to other small Caribbean countries with insular populations and conservative attitudes, perceptions about homosexuals are generally negative and anyone with HIV infection faces likely discrimination if their status becomes known. Respondents reported that discrimination was associated with taking an HIV test, having a positive HIV result, and/or living with HIV and taking HIV-related prescription drugs. Not disclosing a positive HIV status to family, friends, and sexual partners was reported to be common because of fear of being ostracized or discriminated against, and in the case of sexual partners, fear of violence. In the words of 1 respondent, “If I know you have AIDS, I don’t want to eat from you, I don’t want to drink from you, I don’t want nothing to do with you.”

The combination of unprotected sex and lack of disclosure was identified by some respondents as contributing to the spread of HIV: Some persons are identified as being HIV positive even though they are not because they associate with persons who have HIV. There was an incident where a person published his or her negative status in the newspaper to make it clear he or she did not have AIDS:

There was actually someone who was in the newspaper. They published themselves … because people was apparently calling their name and saying they have AIDS and who they thought they slept with to get AIDS. So the person went for a test and then they publish it in the newspaper and tried to make it clear that they didn’t have AIDS. Here in St Vincent because you live in the area you have to face … knowing these people they are small-minded and they are not mature as I am or some of the other persons. So you have to be careful as to how you are going to tell someone here in St Vincent, because it’s all over for you.

The interviewee will not disclose his status to his sexual partners but will use condoms during sex. “No I’m not going to tell them my status. There are certain things you can do during sexual intercourse, there are certain things you cannot do … because of my knowledge in that aspect, I know what to do and what not to do to prevent myself and also to prevent my partner as well.”

Persons who have HIV will not tell others that they are positive. “If you have AIDS right, you not going to tell them that you have AIDS (someone else says in background: they are afraid of discrimination). Everybody who gets it, they just keep away from you. You’re lonely, all by yourself, nobody wants to touch you or give you anything, nobody wants to eat from you.”

Connections between the Economic Environment in St Vincent and HIV Risk

There is a lack of economic opportunity in St Vincent, which influences HIV risk dynamics for young people. Youth culture that includes parties, drinking, and interacting with other young people fuels a general desire to be seen with the best new clothes, shoes, jewelry, and cell phones. Buying nice clothes, alcohol, and other items associated with the limes requires income. However, young people face very limited options for making money in St Vincent. Not all youth attend secondary school because their families cannot afford to pay or because they drop out. Even if they graduate, there are few sustained employment opportunities, and young people often find themselves performing odd jobs or may be unemployed. Many persons living in St Vincent do not have regular or steady jobs. There are no major industries in St Vincent to absorb the thousands of graduating students looking to enter the workforce.

Economic opportunities appear to be slightly better in the Grenadine islands, which benefit from tourism. Tourism is the main source of income in the Grenadines and it presents an attraction for those seeking employment, including for those living on the island of St Vincent, who migrate for work. When those working in the Grenadines return to St Vincent, they are perceived to have benefited: “When you go to the mainland, they feel you now came from New York. They feel that the money down here.” Men who come from the Grenadines express a need to live up to their reputation, in which having money can increase their attractiveness to women. “When you working down here [in the Grenadines], when you go up [to St Vincent] you have to look good. So when you buy your brand shoes and your brand clothes and you go … that is what will catch them … every time I come up there I have on a different shoes … so they want to come down.” We also heard that some women will travel to the Grenadines to engage in sex for money. Such migration between islands may be related to HIV risk because it contributes to some dislocation among families. A respondent from one of the outlying islands told us, “a lot of families get broken up because of persons coming down here to work, the man or the woman. Next thing, they forget their families and they’re in another relationship.”

Transactional Sex Contributes to HIV Risk

Because of the dearth of economic opportunities, young women and men with no job prospects but with the desire for the material expressions of the youth culture, engage in sex in exchange for goods or money. Although there is little evidence of organized prostitution in either St Vincent or the Grenadines, informal sex exchange is an option for both men and women. Respondents reported that the religious culture and punitive law enforcement policies created little room for organized prostitution in St Vincent. Nevertheless, there is a population of men and women involved in transactional sex. Transactional sex or the exchange of goods and/or money for sex takes place on an individual basis, and informally, and the woman or man who receives goods or money may not really think that she or he is selling themselves or having transactional sex but rather considers the interaction as “I want this, I have this to offer, I see no problem with it.” Some “informal” sex work also appears to take place. One of our respondents, a bar owner, reported that there are places that organize ladies for the men. However, she reported that this is not a common practice because it is not legal in St Vincent. She noted it was not uncommon for people to “line up their thing on their own.”

Older, professional men appear to be the main suppliers of goods and money to sex exchangers. For example, 1 of our respondents described the case of a runaway who exchanges sex for a place to sleep. When we talked to our respondent, the young woman was living with 1 man but when his friends expressed an interest in sleeping with her for “a little change” she had no choice but to comply. According to our respondent, no one reports these incidents, so the police do not act. It may also be true that men who happen to be police officers enjoy access to informal sex exchange. Even the policemen have “little girls.”

For young women, intergenerational relationships, which are often of a transactional nature, contribute to HIV risk. It is common that young girls go out with older men who can provide financial security. Well-dressed older men can be seen waiting for teenage girls outside schools. Respondents said that some girls will date an older man, a “sugar daddy,” who will take care of her financially. He may buy her dresses, pay for her to get her hair done, provide pocket money, or pay to have her mobile phone “top up,” or loaded with additional minutes. In some cases, young women become pregnant and there is considerable acceptance of out-of-wedlock child rearing. Respondents reported that in general, families do not object much if a girl is pregnant. The maternal age in the country is quite young and it is not uncommon for mothers and their daughters to be pregnant at the same time. For example, in the case of young women who have an older partner, some will, at the same time also see young men “on the side” for sexual pleasure. Thus, it is not unusual for young women to have concurrent and multiple partners for different reasons.

Men who have sex with men also engage in transactional sex, which may also increase the risk of HIV transmission. Men reported that MSM would either pay for sex or receive compensation for it according to what prevention providers called a “2-way street,” in which the money is an extra perk when someone is willing to have sex with another man.

The money is there as the extra perk of doing it and lots of guys take advantage of the situation, becoming transactional sex. It is a 2-way street because the guys who have the money know that the other guys who do not have the money want it, and the guys who do not have the money know what the other guys want, so it becomes transactional sex. And that is predominant.

Men who exchange sex face increased risk of HIV transmission because they have less choice about using condoms. Bartering sex for money creates power dynamics, which influence HIV risk. Men reported that the participant in the transaction with the cash determined who was the recipient of anal sex, for example, “If there is cash involved, guys will say ‘if I am going to pay, this is what I want.’”

Marijuana is Another Important Source of Income

Some young people have jobs but many have more informal ways to earn income. For example, we heard that young men, in particular, may hunt small animals such as iguanas, armadillos, or opossums to eat or sell, may ask tourists for money, or may sell stolen or used goods. Lacking other economic opportunities and in the absence of steady jobs, many men go up to the hills to make quick cash. These men will say “I am going to the hills” or “going to the bush” which is local parlance for going to work in the cultivation of marijuana. Most of the time, going to the bush involves working for someone else and only receiving “trickle down money” or planting, cleaning, reaping, or transporting marijuana to the boats that ship the crops offshore. Each person typically has a different role and each is paid for only that part of the work. Even with the limited income potential, it is a cash income opportunity for many youth.

Income from going to the bush also contributes to HIV risk when these officially unemployed “alternative agricultural farmers” come down from living and working in the shanties where the marijuana plantations are in the mountains. They spend the quick cash they bring with them from working in the plantations at stores, the supermarket, and use it to party all weekends, including paying or buying things for girls and women, and perhaps other men before going back up to the bush. Respondents said there was little incentive to save money and for any party, any occasion, if a young person has money, “they go to the store, they bring money to the store keeper, they go to the supermarket, they go to the bar and spend a lots of money on entertainment, cases and cases of things, buckets and buckets of things.” She elaborates:

If they have $5,000 [Eastern Caribbean] dollars they get a rental, they are up for the whole weekend and they spend it during the weekend. When the money finishes they go back to the bush. They do not own a house, they do not own a car and officially they are unemployed but they are farmers, alternative agricultural farmers, that is the phrase they tend to use.

Discussion

Drugs, the Economy, and HIV Risk in SVG

Although some of the social mores and discrimination certainly predate the growth of the marijuana-related economy, our data suggest that it has contributed to social conditions favoring HIV transmission among young people in several interrelated ways. It is clear that marijuana is an important source of income for young people in SVG, particularly young men. The income that marijuana and other informal income-generating strategies provide allow men to purchase alcohol, cell phones, nice clothes, shoes, and jewelry—which in turn make them attractive sex partners. However, while it may be lucrative, being involved in illicit trade can compromise more legitimate opportunities to make money. We were only able to provide preliminary insights into how the government’s response to marijuana cultivation—primarily focused on eradication and law enforcement—influences the options of young people living in SVG. However, it does appear that few legitimate job opportunities exist for young people—primarily young men—after they are convicted of marijuana-related crimes. For this reason, they may face increasing pressure to exchange sex for money or goods.

Women may be under even more pressure to engage in transactional sex because they do not have access to “quick cash” through odd jobs connected with the marijuana economy. In order to have access to the best new clothes, shoes, jewelry, and cell phones, women may exchange sex in the context of relationships or just chance encounters. Older professional men appear to be the main suppliers of goods and money to sex exchangers. Partying or liming is only one of the cultural norms that drive sexual contact between young men and even younger women, creating situations for risky behavior and increasing HIV transmission risk. There are also the norms that promote or tacitly accept the cultivation of younger women for parties or sex by older men or the complicity of both parties for the purpose of transactional exchange, status, or socioeconomic security.

HIV risk and preventive behaviors are complicated by severe discrimination toward PLHIV and MSM. Just as using condoms is sometimes associated with being gay, people with HIV fear withdrawing from risky behaviors as well—such as partying and engaging in youth culture “on the block.” One of our staff respondents knew of HIV-infected youth who felt they could not disclose their status and continued to drink alcohol and smoke marijuana because any change in their habits would have been an indication to their peers that there is was something wrong with them. Condoms are infrequently used because they are not perceived as masculine or are associated with highly stigmatized gay sex.

Interventions Should be Offered at Multiple Levels

When taken together, economic conditions and the cultural aspects of human sexual behavior in SVG create a complex system of HIV risk dynamics. For this reason, HIV risk is unlikely to change with simple interventions. Any attempt at interrupting transmission risk will need to consider interventions targeting multiple levels.

At the individual level, basic HIV prevention interventions are needed to provide HIV knowledge and to increase condom use and HIV testing. The Caribbean HIV/AIDS Alliance and others have collected strategic information to guide intervention development. Although much of the research into effective interventions has been completed in the United States, the field of “translational” intervention research is becoming more sophisticated and there are examples emerging of evidence-based HIV prevention interventions being successfully translated and utilized in international settings. ^34,35

At a societal level, interventions are needed that address stigma and discrimination specifically related to HIV testing, the fear of potential disclosure of HIV results, lack of confidentiality in health care settings, homophobia, and discrimination towards PLHIV/PLWA. Changing norms to favor condom use in particular will help protect young people engaged in transactional sex, MSM, and young women who have older men as sexual partners.

Another important societal-level intervention would be to engage in economic development so that young people have access to jobs and income. This is important for the underemployed young population in general, but it is particularly important for young people who earn income from marijuana production and sale. Without alternative options for income, marijuana farmers and the young people they employ will not be able to shift their focus to legal jobs. ³⁶

At a policy level, 2 key interventions are needed. The first is to overturn the “buggery” or sodomy laws that give official government sanction of homophobia. The decriminalization of consensual sex among adults was proposed during the Eighth Annual General Meeting of the Pan Caribbean Partnership against HIV/AIDS (PANCAP), but homosexual behavior is still effectively a crime in 7 countries. ³⁷ Increasingly, leadership bodies such as Joint United Nations Programme on HIV/AIDS (UNAIDS) are calling for the overturning of such laws, arguing “such measures have a negative impact on delivery of HIV prevention programs to individuals at high-risk for HIV and access to treatment by people living with HIV. Not only do they violate human rights of individuals and sexual minorities, but further stigmatize these populations.” ³⁸ Similarly, the Global Forum on MSM and HIV calls for national strategies that integrate community input into HIV prevention and services for MSM, the reform of laws against sodomy and related policies that may limit HIV outreach and services to MSM, and the promotion of human rights for sexual minorities. The Global Forum also recommends that governments who limit the human rights of MSM be accountable to donor countries and to international human rights and health bodies. ³⁹

The second policy intervention that would support HIV prevention goals is to overturn the penal orientation toward drug crime in SVG. As noted above, when young people are convicted of drug-related crime, their access to legitimate employment opportunities is diminished, leaving them with few other options than continued illicit behavior. There does appear to be some hope for policy solutions. According to one of our respondents, the police have recently become more tolerant of personal use of marijuana and now allow persons to carry small amounts (according to this person, “one joint”) of marijuana without facing a criminal charge. In addition, there has been some discussion at the government level of legalizing marijuana in order to boost tax revenue. Reducing HIV risk may require shifting the orientation of the legal framework surrounding the marijuana growing economy from retribution to rehabilitation and engaging structural interventions such as better job training and increased economic opportunity.