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Abstract

There is a dire need for interventions that will address the multiple factors—poverty, substance use, early sexual debut, and violence—that influence Haitian youth’s engagement in risky behaviors. The deteriorating socioeconomic and political state of the country has had a deleterious effect on the sociocultural milieu and on the boundaries that have heretofore kept risky behaviors in check. Historically, the lakou system, a community-based approach that supports the family unit, has disintegrated, leading to the disruption of traditional parenting patterns. The unstable economic system has also led to the increasing use of children from poor families, who through the restavek system, are sent to work as servants in other households. The breakdown of traditional systems, coupled with the increasing economic and political instability, has had a significant effect on Haitian adolescents. Among boys, increased levels of substance use have been associated with multiple sex partnerships and very early sexual debut. Among girls, extremely high rates of sexual abuse and forced sex have led to relatively high levels of HIV. While the majority of them have been exposed to behavior change messages, behavior change itself has lagged because many adolescents do not accurately perceive their risk exposure. This review explores the risks of HIV transmission among Haitian youth, with a focus on vulnerability factors, including substance use, culture, and the socioeconomic context, and provides recommendations for intervention. An ecosystemic approach, designed specifically for Haitian youth and that takes environmental context and culture into account, is needed.

Keywords

HIV risk behaviors youth Haiti

Introduction

Haiti is the poorest country in the Western hemisphere and ranks 148th out of 179 countries on the Human Development Index.¹ Political unrest, marked by dictatorships, weak civil governments, and violence that worsened after disputed elections and political boycotts, pose significant barriers to effectively targeting resources where they are most needed.²

To this difficult sociopolitical and economic mix is added the further challenge of HIV, which has reached epidemic levels in the country.^3,4 Multiple factors, including poverty, denial, limited access to health care, and lack of education have led to high prevalence levels.^5,6 Further, cultural factors, such as normative multiple sexual relationships among men, serial monogamy among women, and the continuing belief in the power of the supernatural to cause the disease, continue to weaken the effects of interventions designed to reduce the spread of HIV.^5,7

While the prevalence of HIV in Haiti has declined from an estimated high of almost 6% to current estimates of 2.2%, transmission continues to be an issue throughout this nation which has the highest rate of the disease in the Caribbean region.^3,4,8 Mathematical modeling suggests that the decline in HIV has been in part due to behavior changes, including increased condom use and a reduction in the number of casual sexual partners.^8,9 However, continuing evidence, for example, low condom usage rates among 15- to 24-year-olds (19% among women and 30% among men), suggests that risky behaviors and inaccurate assumptions about HIV transmission may still be common among the general populace.¹⁰

Haitian youth represent a highly vulnerable group. While knowledge of HIV transmission is quite high among young Haitians, behavior change has lagged.^11,12 For example, research has shown that among Haitian youth, the age at first sex is younger and the proportion that is sexually active is higher compared to several years ago.⁸

The high levels of violence, the fact that in urban areas almost two thirds of youth do not live with both biological parents, the challenges of drug abuse, poverty, and lack of access to health care or high-quality education, lead to a situation in which many youth must do what they can to earn money.^2,13 Of those youth who are not in school, nearly one half are unemployed.¹³ Poverty, coupled with lack of economic opportunities, will affect individuals’ decisions to engage in sex with multiple partners or to participate in commercial or transactional sex.^14,15 Many Haitian youth are therefore forced to engage in prostitution, transactional sex, or run with gangs for survival.¹³

This review explores the risks of HIV transmission among Haitian youth and utilizes Bronfenbrenner’s ecological approach^16,17 to explore and provide explanation for the high levels of risk behaviors seen among some Haitian youth. This model suggests that the probability of engaging in risky behaviors in an increasing function of the number of risk factors to which the individual is exposed. The theory explains child development as occurring within the context of a system of relationships that form the child’s environment. The interaction among all the systems, for example, the family, the community, and the wider society, influences the direction of growth of the child; changes in any of the systems will have a ripple effect on the other systems.

Because very little research exists on Haitian adolescents, information on youth in other Caribbean nations and other developing countries, many of whom face similar issues, has been used to supplement the data for this article.

Cultural Context

The political unrest in Haiti has had a broad impact on social norms; levels of violence, particularly against women and young girls, have increased^12,18 (GHESKIO, unpublished). Some sources estimate that over 35 000 women and girls were the victims of sexual violence in the years after 2004; half of the victims were under 18 years of age.¹⁸ This social context therefore creates a situation in which transmission of HIV among the general population may increase.

Bronfenbrenner^16,17 describes this cultural context as one that includes the beliefs, values, and guidelines that a society shares and which influences the social and economic context; this socioeconomic context has a direct impact on the immediate environment of the child. The theory notes that the greater the number of factors that increase risk within this cultural system, the higher the probability that the child will engage in risky behaviors.

Vulnerabilities to Early Sex

Traditional forms of maintaining appropriate behaviors and family control have disintegrated in modern Haiti.^13,19 For example, the lakou system, a communal-based system of cooperative families that functioned together to support parenting and provide economic and emotional assistance, has seen a decline.¹⁹ This trend has had the effect of disrupting parenting patterns and has reduced the effective monitoring of adolescent behavior.

In the Caribbean, early sexual debut is not uncommon, particularly among poor youth who may lack education about the risks of early sexual activity.²⁰ In a study among youth in an outlying area of Port-au-Prince, for example, 78% of the boys and 59% of the girls had had sex.¹² Among the sexually experienced youth, 37% of the boys and 10% of the girls had first sex before the age of 13 years. The Speizer study¹² also found that the majority of female youth (and adult females) had low-risk behaviors but were put at risk of contracting HIV because of the high-risk behaviors (multiple partners) among their male partners. These data indicate the strong need for intervention at an early age among young people in Haiti.

Among youth who are sexually active, protective behaviors are inconsistent. In a school survey in Haiti, among those who were sexually active, only 18% reported always or sometimes using a condom; 27% reported using a condom the last time they had sex.¹¹ Approximately 43% of the sample reported having 3 or more lifetime partners. In another youth sample in Haiti, approximately one half had used a condom at last sex.¹² The total unmet need for contraception is estimated to be approximately 58% among 15- to 19-year-olds in Haiti, suggesting an area of critical need.²¹

In much of the Caribbean, existing cultural practices put individuals at risk of HIV.²² One of the most risky practices for girls is public acceptance of relationships between older men and young girls. A national study in Haiti²³ revealed that among young women and girls 15 to 24 years of age, almost 20% were in relationships with men who were 10 or more years older than they were. Relationships with older men contribute an additional layer of risk among young women and girls because these older men are more likely to have sexually transmitted infections.

Economics and Education

Economic insecurity, lamizè or economic despair in Creole, also plays an important role in engagement in risky sexual behaviors, particularly among females. Research suggests that financial hardship contributes to early initiation of sex and a dependence on sexual relationships for financial support.^5,24 In a study of youth in Haiti, 15% of the boys and 11% of the girls who were sexually experienced reported exchanging money for sex in the past 4 weeks.¹²

Because HIV has reached epidemic levels in Haiti, extensive efforts have been made to educate the general populace about the virus and how it is transmitted, however, many still lack sufficient information. Continuing adherence to traditional vodou belief systems and lack of education contribute to high levels of HIV in the country.⁵ For example, in a large sample of women attending clinics in Port-au-Prince, approximately 50% believed that transmission by supernatural means and by mosquitoes is possible.²⁵ Early engagement in sex, inconsistent condom use, and high rates of multiple partnerships, particularly among boys, indicate the need for immediate and effective interventions among youth in Haiti. These multiple factors put youth at increased risk of contracting HIV and highlight the need for programmers to take into account the impact of the entire ecosystem on youth risk behaviors. Research is therefore needed to develop interventions and to learn about protective factors, such as education, that may improve access to economic opportunities among youth.^26,27

Gender

Cultural traditions in which sex is usually not openly discussed with girls or women, and a cultural belief that promotes early sexual activity for boys are among the factors that may hinder initiation of protective behaviors among females.²⁸ In developing countries, young women are at high risk of HIV infection due to lack of power, early age of sexual debut, and forced sex.²⁹ Estimates are that young women aged 15 to 19, in the Caribbean and sub-Saharan Africa have 3 to 6 times the risk of contracting HIV compared to boys of comparable age.²⁹ Although not sufficient to promote behavioral change alone, prevention components aimed at improving perceived susceptibility to HIV infection are nonetheless integral to comprehensive risk reduction among adolescents and particularly girls.³⁰

Findings from a World Bank report note that girls are at particular risk because they are more likely to drop out of school and to be unemployed.¹³ Among 15- to 19-year olds in Haiti, across urban and rural areas, approximately 7% fewer girls were in school compared to boys.²³ Among females, the unemployment rate is 35% higher than that of males, reducing the chances even further that girls have an opportunity for economic self-sufficiency.¹³

As in the rest of the Caribbean, early sexual debut is common among young girls in Haiti, however the number of births to teenage girls, 15 to 19 years, is significantly higher in Haiti, 31% above the Caribbean average.¹³ Among the 20- to 24-year-olds reporting on first initiation of sex, almost 14% reported they had had sex by age 15; 53% had had sex by age 18.²³ Teenage pregnancy and marriage reduces girls’ chances of continuing with their education and delaying sexual debut.¹³

In a study examining the impact of sexual violence on girls under 18 years of age who presented to the Groupe Haitien d’Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) clinics after sexual assault, analyses revealed that, compared to women over 18 years old, younger girls were more likely to be attacked by one known assailant who used force rather than a weapon (GHESKIO, unpublished). The vast majority of the under-18 girls had not had prior sexual experience prior to the assault. This fact, together with the element of force and possible violence that accompanied the assault is more likely to lead to long-term psychological symptoms.

The GHESKIO analyses (unpublished) also indicated that 6% of the assault survivors aged 12 to 14 tested positive for syphilis. This figure is extremely high and presents a significant danger to health but also represents a risk factor for the transmission of HIV. The adolescent girls who had been raped also exhibited high levels of psychological sequelae, particularly signs of depression, posttraumatic stress reactions, and somatic symptoms. Without intervention, many of these girls are at risk of long-term psychological distress. There is therefore a strong need for coping interventions, such as the approach described by Sikkema and colleagues,³¹ which showed positive impact on reducing engagement in risky sexual behaviors among a sample of child sexual abuse survivors. There is also a need to integrate behavioral prevention into HIV/AIDS clinical programs such as represented by the GHESKIO program, particularly given the generalized nature of the HIV epidemic in Haiti.

In the Caribbean, a review²⁰ of risky behaviors reported by youth found that approximately 19% of children had had their first sexual experience at or before age 10. These data strongly suggest sexual abuse as a factor in the first sexual experience for these children. While the impact of sexual abuse and sexual assault as a mode of HIV transmission among young people has been understudied in the Caribbean, several studies in Africa suggest that it may play a significant role. For example, in Cameroon, reportedly 38% of the children and adolescents who were raped or abused seroconverted.³² In Zimbabwe, a significant proportion of sexual abuse cases (50%) were detected only after the children started exhibiting signs of sexually transmitted infections, including HIV.³³ These factors point to the significant impact of the cultural milieu, an important element in Bronfenbrenner’s model,^16,17 as a strong contributor to risk in the lives of female youth in Haiti.

Other Vulnerability Factors

Substance use

Youth who are exposed to the cumulative risks of poverty and high-risk neighborhoods may find it difficult to avoid the pressures to engage in risky behaviors. Among Haitian youth, contextual-level, for example, living in a dangerous area, as compared with individual-level risk factors, for example, being a smoker, appeared to have higher impact on experimentation with alcohol. For example, living in neighborhoods where the level of youth drinking was high was associated with higher risk of experimenting with alcohol compared to individual-level risks.³⁴ These influences are particularly important among adolescent males, for whom the higher the number of risk factors, the higher the probability they will experiment with alcohol.³⁴ These researchers have reported evidence that cumulative stressors contribute significantly to alcohol use. Living in a household with adult problem drinking increased the likelihood of being a regular user of alcohol rather than an abstainer by 3.9 times in Haitian males.³⁴ These findings tie in closely with Bronfenbrenner’s^16,17 supposition that the greater the number of risk factors, the higher the likelihood of engaging in risky behaviors.

The use of drugs and alcohol places adolescents at increased risk of engaging in other risky behaviors. In the study reported by Gage and Suzuki,³⁴ alcohol users were more likely to have witnessed parental violence, to live in neighborhoods with high levels of youth lifetime drinking and to report high-risk behaviors. Regular use of alcohol among male adolescents was highly associated with having been with multiple sex partners in the previous 12 months, initiating sexual activity before age 13, and ever smoking.

In another study among Haitian youth, over 90% of those sampled perceived that injection drug abuse and AIDS were problems in their neighborhood.¹² Approximately 12% of the males and 8% of the females reported injecting drugs within the past year. Almost 4% of the girls reported sexual coercion related to drugs or alcohol. These numbers highlight the need, not simply for education surrounding HIV but for programs that acknowledge and incorporate factors related to the social and environmental context in which these youth must survive. In a study of alcohol use and high-risk sexual behavior in sub-Saharan Africa, Weiser et al,³⁵ offered suggestions for HIV prevention researchers that applied in general to resource-poor countries, noting that the lack of attention to alcohol use in high-seroprevalence countries was of grave concern.

Psychosocial

Individual psychological characteristics have also been shown to have an impact on risky behaviors among adolescents; however, little research has been conducted in this area in the Caribbean, particularly among Haitian youth. One study conducted among a Caribbean youth sample found that rage, physical or sexual abuse, and risky sexual behaviors were strongly associated with each other.³⁶ Another study that examined the role of psychological vulnerabilities and their relationship to risky behaviors reported findings that high self-efficacy to discuss HIV or use condoms was associated with condom use at last sex, consistent condom use, and fewer lifetime sexual partners among Haitian adolescents.¹¹

In Haiti, approximately only one third of children live with both biological parents, reducing the potentially protective effects of family.¹³ Among male adolescents, witnessing interparental conflict and living away from home for more than 1 month, thereby reducing parental monitoring, were associated with higher probability of experimenting with alcohol.³⁴ These findings strongly support the need to integrate a family support component in risk-reduction interventions for teens. Also, as mentioned earlier, the decline of the lakou system¹⁹ has reduced the effects of parental monitoring, which other studies have shown to have a direct impact on youth’s engagement in risky behaviors. Consequently, surrogate support systems need serious exploration in future HIV prevention research.

Education has been found to be a protective factor in Haiti as it delays the age of starting families and is associated with better health, better jobs, and higher income.¹³ In the context of poverty in which most Haitians live, education is seen as a means of improving one’s situation in life. Access to education may therefore provide a sense of hope that reduces the chances that youth will engage in behaviors that are detrimental to their future aspirations. However, the cost of schooling has been cited as an important barrier to school attendance. Universal public education does not exist in Haiti, even at the primary school level³⁷ (see http://go.worldbank.org/UTZK783TN0) and parents must pay prohibitive fees to send their children to schools that are frequently in severe decay and disorder. In 2008, the World Bank awarded a $6-million grant to Haiti to begin efforts to meet the United Nations millennium goals of universal schooling in the country, starting with primary education (http://go.worldbank.org/ILPLQCPFO0). The educational needs of adolescents, however, have yet to be addressed at the same systematic level.

Interventions

Few intervention studies targeting risk behaviors among adolescents in Haiti have been published under peer review; however, there have been several efforts on the ground. For example, there is the United Nations Children's Fund (UNICEF)–sponsored Right to Know program,³⁸ which is an outreach communication initiative using participatory action research to promote HIV/AIDS prevention among youth in developing countries (http://www.comminit.com/en/node/123035/347). A collaborating partner in the Haitian node of the initiative is Fondation pour la Santé Reproductrice et l’Education Familiale (FOSREF), a multipurpose organization and the largest provider of reproductive health services to youth in Haiti. Their work among vulnerable groups, including incarcerated youth, homeless children, and youth living with HIV, is particularly well known. The organization employs numerous professional and peer workers and offers 15 youth-friendly health centers that provide HIV- and sexually transmitted infection (STI)-testing services, as well as prevention education, and community and school services.

Several studies have been conducted on the effectiveness of components of the FOSREF interventions. One study found that clients who had a low perception of HIV risk did not have lower levels of engagement in risky behaviors.²¹ This intervention study pointed out the need for better quality counseling, the need to ensure that family planning is a part of the counseling discussion, the importance of ensuring consistent supplies of condoms and testing kits, and the need for better integration of services.

The existence of FOSREF reproductive health and prevention services is vital in Haiti; however, studies in outlying areas of Port-au-Prince suggest the importance of broadening the reach and impact of similar services. A study among youth revealed that over 80% of sexually experienced youth had at some point used family planning services, primarily condoms, suggesting that in many cases, it may not be the lack of knowledge that prevents consistent condom use, but rather other factors, for example, finances or opportunity. These data suggest an important area for intervention among Haitian youth.

One comprehensive program, Focus on Youth, being implemented in the Bahamas, involves child and parent intervention components among a large sample of preteens. Early results showed that there were positive changes in knowledge, sexual perceptions, and intentions to use condoms; and at 12-month follow-up, there was reduced likelihood of becoming a quick progressor (to sexual activity) and delayed sexual risk among the children.^39,40

Another program in the Dominican Republic showed that knowledge about HIV/AIDS increased by a factor of 1.72 and current condom use increased by 2.52.⁴¹ These and other studies in the Caribbean can serve as guides to plan effective interventions among Haitian youth.

Interventions with proven effectiveness among Haitian American youth may also provide some guidance for work among Haitian youth. An HIV prevention study conducted among adolescents of Haitian origin in Miami demonstrated significantly improved outcomes in HIV knowledge and attitudes and intentions to use condoms, and improved ability to use condoms.⁴² A meta-analysis of behavioral prevention studies among adolescents in the United States has also been instructive, detailing the positive effects of interventions on behavioral risk in general and increased condom use, specifically.⁴³ These studies may provide some guidance for the development of programs targeting Haitian youth.

Conclusions

Haitian adolescents are an understudied group. Interventions for these youth are crucial to prevent further increases in the HIV incidence, especially among females. Bronfenbrenner’s model suggests that treatments that target emotional/behavioral issues, particularly those that change environmental factors, have the highest potential for impact on youth.^16,17 The priority in Haiti should be on an ecosystemic approach that not only takes into account individual level behaviors and choices but also attempts to address the cultural factors that encourage these behaviors.

Disruption of the traditional lakou system and the collectivist approach to parenting has had a negative impact on parental monitoring. Economics also certainly play a role in the disruption of family structures. These factors strongly suggest that interventions must take a multifactored approach to ensure effective implementation of any prevention program. Interventions should be tailored to the needs of Haitian youth and take culture and environment into account. To do otherwise would increase the risk that these interventions will lack relevance and therefore be largely ineffective for the population.

Government has a critical role to play in developing and enforcing policies that protect youth.²² These may include policies to protect girls and women, promote economic independence, and improve equitable and enhanced access to health care by all.⁴⁴ On a national level, researchers have noted that not enough funds are being spent on prevention (eg, Henderson et al⁴⁵), even though prevention dollars often have more impact than money spent on treatment. Other researchers have noted that while much research has been conducted on assessing the prevalence of risky behaviors among Caribbean adolescents, more emphasis is needed on designing and testing interventions.²⁰

Sexual coercion appears to be an important factor in the initiation of sexual activity, particularly among girls in the Caribbean. This fact speaks to the broader cultural context that permits this behavior. Government has a role to play to ensure that there is a safe place for youth to report and be protected from these behaviors and to enforce laws that hold perpetrators accountable for these actions. Young girls may not be able to protect themselves from sexual coercion—only society can do this. Awareness campaigns should be initiated to address societal perceptions. An intervention such as the MEMA kwa Vijana project in Tanzania, for example, found that changing the norms and beliefs of adults, particularly men, led to the increased effectiveness of youth-targeted behavioral change programs.²⁹ This program may provide a valuable model for Haitian interventions.

At the same time this work is being done to improve the cultural context in which these risky behaviors occur, interventions in and around schools and at venues that are frequented by youth should be developed. But as already noted, this will require dramatic improvements in school environments and better access to education in general. Innovations are needed on how to combine strategies of improving family access to quality school education with youth prevention programs that include HIV/STI education, condom distribution, and testing services. Providing condoms is particularly important among youth who may have limited finances. In one study in Haiti, for example, almost 70% of the venues identified as meeting sites for sexual contacts reported they would agree to distribute condoms, suggesting an effective area for intervention.¹² Substance abuse is also becoming an increasing problem, particularly in the urban areas. Researchers suggest that because substance use increases with age, it will be important to target younger adolescents before they start experimenting with drugs.¹³

Interventions should be gender specific—with very special emphasis placed on protection and education for girls, teaching safe sex communication skills, and stressing the importance of noncoercion among boys. The 2009 Population Council report on Haitian adolescents notes that current youth policies frequently target those who are already better off. The most vulnerable adolescents are often neglected, particularly girls and youth that are younger or out of school. In addition, as was mentioned earlier, there is often a gap between knowledge and behavior change. An effective program should therefore focus on methodologies to translate knowledge into sustainable behaviors.

The recent earthquake of January 2010 that devastated Haiti has also added to the risks that adolescents face. Reports acknowledge the existence of vast numbers of unaccompanied minors caused by the death or displacement of one or both parents, leaving children vulnerable to predation by adults.⁴⁶ There is also a reported increase in sexual abuse and sexual violence against girls and women in the camps established for displaced persons, with some girls forced to trade sex for shelter.⁴⁷ These factors underscore the crucial need for short-term and longer-term interventions for adolescents.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: National Institute on Alcohol Abuse and Alcoholism (NIAAA), grant R01AA018084, “Intervening with Haitian HIV+ Alcohol Abusers: An Environmental Psychosocial Framework.”

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