Introduction to the special issue: Applying a Caribbean perspective to an analysis of HIV/AIDS

ABSTRACT

This introduction presents a special issue of Global Public Health with a collection of articles that offer multidisciplinary perspectives on HIV/AIDS in the Caribbean. Since the 1990s, poverty, marginalisation, and social stigma have been strong foci of much social science research on HIV/AIDS in the region. These three interrelated phenomena have been offered as explanatory factors contributing to the high prevalence of cases observed in this region. Contributors to this special issue take these emphases in new directions, asking multi-level questions that require unique combinations of epidemiological, social scientific, theoretical, and policy-oriented perspectives and methodologies. Together, they identify several topical areas that intend to create dialogue across disciplines and dialectics, with the fundamental principle that the factors relevant to HIV/AIDS are broad and require intersectional lenses. The articles in this issue offer multi-level interventions into HIV/AIDS in the region, from the varied social circumstances that shape heightened risk factors to patient adherence programmes, with emphases on structural, social, and policy-level approaches. Collectively, this special issue establishes the importance of transdisciplinary approaches to HIV/AIDS that are macro-level in scope, but simultaneously attend to how large-scale dynamics are inflected in situated contexts and histories.

KEYWORDS:

• HIV/AIDS
• Caribbean
• multidisciplinarity
• social epidemiology
• political-economy

Beginning in the nineties, researchers started paying increased attention to the relationship between ‘large-scale social forces – economic, political, and cultural factors–and increased risks for HIV infection’ (Farmer & Kim, 1996, p. xv). This represented a significant shift from the singular emphasis early in the HIV epidemic on biomedical, epidemiological, and clinical factors. The shift occurred in response to findings of vast disparities in risk factors, infection rates, and number of deaths among differently positioned socio-economic and socio-cultural groups. These differences and disparities were becoming and remain particularly acute across national boundaries, and through regions with fewer and greater access to resources. Consequently, poverty and global factors such as neocolonial dependency entered into critical assessments of the distribution of HIV/AIDS (Farmer & Kim, 1996). Over the years, poverty, marginalisation, and social stigma have become the focus of much social science research, with the realisation that these are primary predictors of HIV risk.¹ These three interrelated structural phenomena, separately and in combination, can largely explain the high prevalence observed in Africa and the Caribbean, and have been referenced in numerous assessments of the epidemic (Farmer & Kim, 1996; Gupta, Parkhurst, Ogden, Aggleton, & Mahal, 2008; Howe & Cobley, 2000; Kalipeni, Craddock, Oppong, & Ghosh, 2004; Kippax & Stephenson, 2016; Lurie, Hintzen, & Lowe, 1995), and are rooted in and inflected by legacies of colonialism. Their instrumental effects are the consequences of postcolonial policies of neoliberal development present throughout the Caribbean and Latin America, despite differences in colonial histories, culture, language, and political systems (Biehl, 2008, 2013; Hirsch, 2015; Padilla, 2007; Parker, Easton, & Klein, 2000). According to anthropologist Brooke Schoepf (1993), who was among the first to articulate the need for a structural approach to HIV/AIDS:

Globally, AIDS is best regarded as a ‘disease of development’ and ‘underdevelopment.’ It has struck with particular severity in communities struggling under the burdens of economic crises caused by stagnation in the global economy, distorted internal production structures inherited from colonialism, unfavorable terms of trade, and widening disparities of wealth fueled by the channeling of public funds into private pockets. (p. 55)²

Global Public Health has led the field in foregrounding the macro-level conditions of vulnerability to HIV/AIDS to which Schoepf and others have made reference – including policy and structural interventions that address the root causes of this vulnerability in specific settings – through a series of special issues and symposia, such as prior GPH special issues on ‘HIV Scale-up and the Politics of Global Health’ (Kenworthy & Parker, 2014) and ‘Addressing Social Drivers of HIV/AIDS for the Long-Term Response: Conceptual and Methodological Consideration’ (Auerbach, Parkhurst, & Caceres, 2011). Here, we aim to take cues from this prior work and use similar macro-level and socio-political frameworks to situate the epidemic within the contemporary Caribbean.

Following this structural approach, in a review of HIV/AIDS prevalence in Sub-Saharan Africa, Asia, and Latin America, Lurie et al. (1995) focused on policies imposed on national governments by international financial institutions (IFIs) that contributed to socioeconomic conditions of rampant urbanisation, intensification of global and domestic trade, commercial or transactional sex, migratory flows and national and transnational movement of people as principal factors in the epidemiology of HIV. These socio-economic forces disproportionately affect the poor while intensifying economic and social inequality. They are also present across the Caribbean with differential effects on rates of and intensity of poverty, and on the capacities and capabilities of governments to manage the crisis through effective implementation of health policies and practices. Critical questions must be raised in efforts to explain how Caribbean countries, many of which have impressive scores on various international indices of democracy and development, still sustain high rates of HIV/AIDS, without threating regime survival.

This Special Issue of Global Public Health is devoted to multidisciplinary perspectives on HIV/AIDS in the Caribbean that represent a contemporary generation of analyses in the region that take the prior emphasis on global inequality into new domains, asking multi-level questions that require unique combinations of perspectives and methods. Contributors were brought together in 2017 at Florida International University in Miami, Florida, to discuss our collective work as Caribbean-based researchers and scholars across disciplines including anthropology, sociology, epidemiology, history, and clinical and social medicine, among others.³ Our desire was to set a research agenda that facilitated our multi – and trans-disciplinary discussions of HIV/AIDS in the Caribbean, and permitted us to envision new or expanded lines of inquiry that could extend research in this high prevalence region. We determined several topical areas with the intention of creating a dialogue across disciplines and methods, with the fundamental principle being that the factors relevant to HIV are broad, have relevant historical contexts, and require intersectional lenses.

Caribbean countries have the highest prevalence of HIV/AIDS in the world outside of sub-Saharan Africa, with the Bahamas (#17), Haiti (#24), Belize (#27) and Jamaica (#30) ranked globally among the top 30 highest prevalence countries. Other countries in the region are also highly impacted, with Guyana (#32), Suriname (#35) Barbados (#36), Trinidad and Tobago (#39) and the Dominican Republic (#45) among the top 45 highest prevalence countries globally (Central Intelligence Agency, 2016). While prevalence estimates are relatively low compared to sub-Saharan Africa (ranging from 3.30% adult HIV prevalence (aged 15–49) in the Bahamas, to 1% in the Dominican Republic),⁴ they are high by world standards. For example, Ukraine, the European country with the highest rate on the continent (0.90%) is ranked 46th globally. France, which has the highest rate in West Europe, is ranked 70th in the world with a prevalence of 0.40%; notably, Cuba ranks just below France at 71st in the world with an identical prevalence of 0.40%, demonstrating that there are vast epidemiological differences across Caribbean nations (Central Intelligence Agency, 2016).

Among the factors that have explanatory power regarding the disparity in prevalence observed across Caribbean national territories, two, in combination, are quite important in their effect on the capacities and capabilities of governments to provide health promoting conditions for their countries’ populations. The first is a development agenda that legitimises and makes imperative several socio-economic forces associated with high prevalence of HIV/AIDS, which, as described in this volume in Percy Hintzen’s contribution, generate a cluster of development-associated structural risks, including inflows of visitors from overseas, poverty, inequality, and the influence of external actors, health delivery infrastructures, HIV/AIDS treatment access, and prevention and education interventions.

As postcolonial governments adopt development agendas aimed at economic growth, they institute policies such as tourism development (see Colón-Burgos et al.’s contribution to this volume), mineral resource extraction, agricultural export, and high reliance on foreign assistance (see McLean et al.’s contribution to this volume), all associated with significant increases in foreign presences, urbanisation, rural displacement, growing inequality, economic austerity, reduction of government deficits, and devaluation of currency. As described perhaps most vividly in Paul Farmer’s ethnographic work in Haiti (Farmer, 1992), these factors collectively contribute to precarity and structural vulnerabilities associated with increased risks for HIV.

The second major factor is the stigmatising effects on vulnerable populations of socio-cultural forces harnessed by governments that explain high rates of HIV/AIDS as natural and deserving for certain segments of the population. This, as discussed in the Hintzen contribution to this volume, acts to shift blame from state policies and their derivative documentary practices, understood as the way written constitutions, laws, and statutes are translated into practice in the region. As stigma becomes canonised into laws, differential risks for HIV are literally codified, making HIV an almost inevitable outcome among the most marginalised.

Arturo Escobar (2012) has described some cultural explanations associated with stigma, intensifying the vulnerabilities and precarity of affected groups. Such stigmatisation derives from pervasive notions of respectability and (im)morality that separate governing authorities from their instrument effects (i.e. the far-reaching lived effects of government policies and practices) (Escobar, 2012). These practices lead to an increase in risk factors associated with HIV transmission for those who are most stigmatised. In this volume, an example of how structural stigmatisation in policies and laws connects to differential HIV infection risks is provided by Varas-Diaz et al. in their examination of the manifestation of stigma during clinical interactions, and the inadequacy of physician training on this matter, with potential implications for sub-optimal outcomes throughout the HIV care continuum (timely linkage, retention in care, adequate training of professionals) in Puerto Rico. Stigmatisation of marginalised groups by clinicians can lead to lower health care access, poor treatment adherence, insufficient viral suppression in populations that have been socially placed in high-risk such as men who have sex with men (MSM) and illegal drug users. Indeed, as detailed in a prior special issue of Global Public Health (Kenworthy & Parker, 2014), the de-priorization of clinical training programmes is part of a larger structural phenomenon in which high-level priority setting by policy makers and funders result in lethal deficits in the continuum of HIV care. In what has been referred to as the ‘scale-down’ of HIV/AIDS services – an ironic metaphor when situated historically in reference to the drive toward ‘scale-up’ during the zenith of President’s Emergency Fund for AIDS Relief (PEPFAR) in the early 2000s – many parts of the Global South are increasingly coping with plummeting resources (Cairney & Kapilashrami, 2014).

Hintzen (this volume) discusses the centrality of notions of moral respectability and their relationship to Christianity, the family, and sexual conduct ingrained in popular consciousness in the Caribbean. The social stigma that attaches to violations of these forms of ‘respectable behavior’ and the structural stigma related to their prohibitions are inscribed in the constitutions, laws, and statutes of the countries in the region. These produce instrument effects that increase precarity (Abrahams, 1979; Segal, 1993; Wilson, 1992; Yelvington, 1995). Those who engage in stigmatised, ‘non-respectable’ or socially unacceptable forms of sexual practices that violate heteropatriarchal social cultural norms, are made more vulnerable by constitutionally and legally guaranteed rights and protection are deemed, in practice, not to apply to them. Certain segments of society are deemed unrespectable and are summarily excluded from these guarantees.⁵

There is a mutually constitutive relationship between the ideals of development and regimes of respectability/morality in the region, given the rootedness of the latter in notions of European civilised superiority cultivated under colonialism. As a result, respectability and morality became located at the critical juncture between desirable conduct and the quest for convergence with the industrialised, ‘developed’ West. They are inscribed in the cultural capital of acquired knowledge, information, skills, habits, styles and other modes and manner of behaviour associated with civilised conduct (Bourdieu, 1990). In the Caribbean they are considered prerequisites for developmental convergence and are to be inculcated into the popular. Most importantly, their violations become explanations for the failure of developmental transformation and, therefore, become justifications for exclusionary practices like stigmatisation and social marginalisation.

Precarity is compounded by risks to health and well-being of the stigmatised because of the central role played by the tourist industry as a driver of development policies in the region. Escobar (2012) has also discussed the relationships among ‘textual and work practices’ of institutions of governance – categories of the governed that are either produced, defined, redefined, or employed by those in power – and development policy. In the Caribbean, tourism provides the nexus for these relationships. In innumerable ways, it is seen as the instrumentality through which the reproduction of the economic, political, and social conditions and cultural forms of the industrialised North Atlantic is to be realised in postcolonial development agendas. This has resulted in increasing transnational flows of people in almost all the countries, as discussed directly in this volume in the Hintzen and the Colón-Burgos et al. articles (see also Padilla, 2007; Padilla, Guilamo-Ramos, Bouris, & Reyes, 2010).

To these touristic flows are added the significant presences of expatriates working as officials of foreign governments and multilateral agencies, consultants, employees of foreign private companies, visits by nationals and their families who live overseas and who emigrated to escape poverty, the absence of economic opportunity, and, in some cases, political uncertainty in a quickly transforming global economy (see Robinson, 2014). These transnational flows and bidirectional immigration combine with regimes of morality and respectability to exacerbate risk factors related to the exposure to and spread of HIV/AIDS progression in the region. Colón-Burgos and colleagues (this volume), for example, draw upon tourism theory to explore how the tourism industry in the Dominican Republic creates a two-tiered system of touristic governance that facilitate the behavioural enactment of colonial fantasies of ‘sun, sand, and sex’ that may simultaneously increase health risks for local workers employed in the tourism sector, while exempting foreign tourists from regulation. While notions such as ‘touristic escapism’ are rarely invoked in interpretations of the Caribbean HIV/AIDS epidemic, Colón-Burgos et al.’s ethnographic research and theoretical work in tourism studies provide the rationale for a robust programme of future global health research on the nexus of tourism dependence and the socio-cultural formations that circulate within and around tourism spaces.

Tourism is at the critical centre of development policy and practice in the Caribbean. Its organisation around the ‘nativization of fetishes’ and ‘erotic consumptive patterns’ (Alexander, 2005, pp. 78–80) – which Kamala Kempadoo has dubbed the triad of ‘sun, sex, and gold’ (Kempadoo, 1999; Kempadoo & Doezema, 1998) – has had the effect of insulating tourists and powerful foreign business executives and officials from the regimes of morality and respectability that apply to the local population. It has also excepted them from criminalisation, as documentary practice, in the legal regimes of many of the countries. These practices of exception can increase risks for vulnerable populations forced by need and necessity into relationships with foreign visitors, particularly given the increasing dependence of countries on sex tourism (Alexander, 2005; see contributions to Kempadoo, 1999; Kempadoo & Doezema, 1998; Kempadoo, Sanghera, & Pattanaik, 2015).

The instrument effects of government policy are differently experienced across different groups and in different social geographies. This is true for population flows, which are major determinants of HIV/AIDS prevalence rates in the Caribbean. As discussed further in the Hintzen article in this volume, Bahamas and Haiti, for different reasons, have high transnational flows, the former from tourism and the latter from the significant presences of expatriates and workers in NGOs and in bilateral and multilateral agencies. These differences in the composition of foreign presences stem from differences in the development policies pursued by the two governments and from their capacities to enforce them (Ferguson, 2006; McMichael, 2008). They might explain differences in their prevalence trajectories as well, although epidemiological research is insufficient at this time to make such a claim definitively.

The effects of population flows are predicated upon factors in the political and economic landscape characteristic of particular social geographies. Even though tourist visits to Guyana are significantly lower than in most countries in the Caribbean, the country is ranked 32nd in the world and 5th outside Africa in HIV prevalence (Central Intelligence Agency, 2016). The explanation rests in the negative effects of globalisation on the capabilities of the governing regime to reduce risk and precarity even under conditions of low population inflows. Jamaica, even though highly dependent upon tourism, has a HIV/AIDS prevalence that, though high by world standards (ranking 4th outside Africa), is almost half that of the Bahamas, which has the highest prevalence outside of Africa. As Hintzen argues in this volume, this difference might be explained by differences in conditions of governance associated with the capacities of segments of the population and external actors to use their considerable power to influence policies and practices correlated with risk and precarity (see for example Abrahamsen, 2000). Hinzten’s observations here serve as a suggestive direction for further comparative epidemiological research in the region, rather than an established fact, but it is consistent with numerous social scientific and political-economic analyses.

The effect of demographic processes on HIV/AIDS prevalence can be mitigated by state policy and practice. Cuba has been almost singular in the Caribbean in policies and documentary practices that have resisted and eschewed Western-imposed versions of capitalist developmentalism. At the level of official documentation and practice, the Cuban government has, until recently, rejected Christian morality and forms of respectability associated with stigma. Significantly, its decision not to guarantee its population the ‘rights’ that typify liberal democracies has legitimised the curtailment of forms of freedom, such as freedom of movement and migration, freedom of association with foreigners, economic freedom, freedom to emigrate and to return. These curtailments have an ambiguous relationship to HIV/AIDS in Cuba, as they may have contributed to certain government-sanctioned oppressive practices, particularly earlier in the epidemic, which was met with the quarantining of HIV-positive persons; at the same time, however, they may have permitted greater access to treatment and certain protections from an unfettered sex tourism industry (Leiner, 2019). Nevertheless, as Cuba’s economy has leaned inevitably toward tourism since the country’s economic opening in the mid-1990s, sex tourism has dramatically accelerated, a structural change foreboding future increases in HIV incidence (Cabezas, 2009).

Although there may be deficiencies in the surveillance and reporting, Cuba’s prevalence is extraordinarily low for the region (.40%, which is equivalent to France), making it an epidemiological outlier (Central Intelligence Agency, 2016). Recent growth in the power of the evangelical church in Cuba may lead to more stigma and social-marginalisation of higher-risk behaviours and, thus, undermine previous successes in curbing the spread of HIV/AIDS. For example, very recently (2018–2019), the evangelical church protested the inclusion of a constitutional amendment that would have defined marriage as between two people, regardless of sex or gender. When the country’s new constitution was finalised in February, 2019, this amendment was left out. What remains to be seen is exactly how this will affect HIV/AIDS prevalence in Cuba. If other countries are any indication, Christian contributions to documentary practices in Cuba will likely have negative effects on prevalence there.

The United States-Caribbean HIV connection

The Latin American and Caribbean (LAC) region’s close geopolitical connection with the United States (US) makes this issue not only relevant for the region but for the US as well. Indeed, as the foregoing discussion makes clear, it is impossible to situate the region’s HIV/AIDS epidemic, and the socio-structural conditions that shape it, without considering the colonial and neocolonial linkages to the global ‘super-power’ to the north, the US.

The Caribbean’s high HIV/AIDS prevalence comes with significant implications for the United States. Of total tourist visitors to the Caribbean, 44% come from the US (Thomas, 2015), including those engaged in sex tourism (Angulo-Arreola, Bastos, & Strathdee, 2017). In 2014, 22.4 million were stay-over visitors and 20.6 million were cruise ship passengers (Thomas, 2015). Compounding the issue is the significant presences of both documented and undocumented immigrants from the LAC region residing in the US, many of whom engage in forms of circular migration or intermittent visits ‘back home’ to their countries of origin. According to the 2016 census, their numbers totaled 4,286,266, many concentrated in cities such as New York and Miami (U.S. Census Bureau, 2017). If the ‘undocumented’ who are not listed in governmental statistics were taken into consideration, it is estimated that the actual number of immigrants born in the English-speaking Caribbean present in the US would double in size (Hintzen & Rahier, 2003; Zong & Batalova, 2016).

In the US, there is great need for public health focus on social enclaves with heavy Caribbean presence to specifically design and implement interventions to increase testing, clinical prevention, and education among those uninfected, and scale up treatment with migrant-specific adherence supports. In 2010, a U.S. policy disallowing people living with HIV from entering the country was overturned (The Center for HIV Law & Policy, 2010). While this is commendable, it suggests the need for policies and practices focused on immigrant communities from this region in the United States, and an intensification of efforts aimed at treatment and prevention and continuity of care during the migratory process (Cyrus et al., 2017, 2018).

Internally, in the Caribbean region, there needs to be more comprehensive and focused forms of intervention over and above current efforts by the US and multilateral agencies such as the World Bank and the Inter-Development Bank that have funded most regimes of prevention and treatment Future investment, above all, must remain attentive to the structural and socio-cultural regimes that are the fundamental causes of HIV/AIDS in the Caribbean, and to which this special issue pays particularly close attention, particularly in Edwards et al.’s contribution that discusses one possible clinic-based intervention to address such issues.

Structure and overview of the special issue

This special issue consists of seven articles organised into three thematic areas – social epidemiological perspectives, multi-level / multidisciplinary interventions, and political economy. These domains are inevitably overlapping, and one socio-structural factor – social stigma – is a cross-cutting theme; however, this organisation aims to provide structure to our broad and multidisciplinary voices. The tone of the special issue is deliberatively varied, with contributions from clinicians/providers, epidemiologists, social scientists, theorists, and policy makers. Included here are qualitative, ethnographic accounts and quantitative, statistically-driven analyses, as well as more theorised reflections of policy and sociocultural implications of the HIV/AIDS epidemic. While some readers may find the variety of methodologies and analyses unusual, it is meant to reflect the current state of HIV/AIDS experiences, perspectives, and intervention approaches in the Caribbean. Together, the authors make the case for multidisciplinary perspectives to future HIV/AIDS work in the region, with a conceptual emphasis on structural, social, and policy-level approaches.

Part I, Social Epidemiological Perspectives, includes two articles from Haiti and Trinidad and Tobago that address the HIV care continuum and treatment cascade of specific social categories and more private lived experiences of people living with HIV/AIDS and populations who are at greater risk of contracting the virus. Saxena et al.’s contribution, ‘Association between Intimate Partner Violence and HIV Status among Haitian Women,’ explores how intimate partner psychological and physical violence are indicators of heightened risk for HIV/AIDS. As such, the authors find that intimate partner violence should be integrated into prevention strategies, including pre-exposure prophylaxis (PrEP) distribution, in Haiti and elsewhere. Edwards et al. offer epidemiological evidence of determinants influencing disease progression and viral suppression among persons living with HIV in Trinidad and Tobago, and then describe a demonstration project of a cost-effect patient tracking project to address non-viral suppression and lack of engagement in care among those individuals. ‘Determinants of HIV Viral Suppression among Persons Living with HIV in Trinidad’ calls for retention and adherence programmes to urgently target and address higher risk social categories (outlined in the article) in Trinidad and Tobago. These articles identify specific high-risk demographic and social-behavioural factors, as explanatory variables, and help provide pathways toward prevention as well as treatment retention and adherence programming, which are further outlined in the article titled ‘Implementation and Outcomes of a Patient Tracing Program for HIV in Trinidad and Tobago: Implications for MSM and women at high-risk’ (discussed below).

Part II, ‘Multi-level Interventions / Multidisciplinarity,’ – offers three articles on the varied social circumstances that shape heightened risk factors, patient adherence programmes, and consequences of stigma behaviours in health care settings. Colón-Burgos et al.’s ‘An Ethnographic Study of ‘Touristic Escapism’ and Health Vulnerability among Dominican Tourism Workers’ explores the notion of touristic escapism – a theoretical phenomenon derived from tourism studies and public health research on risk behaviours among tourists – and considers ethnographically how such a phenomenon is observable in interactions between tourists and locals in Dominican tourism zones. This article is multidisciplinary, drawing on theories of health, neocolonialism, and global political-economic forces, while incorporating the humanistic method of ethnography to examine how locals experience tourism areas and how this may relate to their vulnerability. Edwards et al.’s translational medicine contribution provides one economic solution to disengagement in care through their contribution, ‘Implementation and Outcomes of a Patient Tracing Program for HIV in Trinidad and Tobago,’ which documents the results of a patient-tracing programme in Trinidad and Tobago from July, 2016 to March, 2017. The authors find that patient tracing programmes are feasible for early and intensive tracing of HIV patients who have recently disengaged from routine HIV care. However, among those retained, MSM, women, and patients of African origin were less likely to restart ART or remain in care. Finally, ‘HIV/AIDS Stigma Intersectionality: Examining Stigma Related Behaviors among Medical Students During Service Delivery’ describes the consequences of interrelated stigmas (i.e. HIV/AIDS related stigmas intersecting with discrimination/stigma of drug use, sexism, and homophobia) and how these interconnected stigmas are manifested behaviourally during clinical interactions in Puerto Rico. As mentioned previously, one of the primary conclusions of this article is the enormous need for culturally validated and institutionalised physician training programmes, which have generally been overlooked in the Caribbean in favour of purely clinical solutions.

Part II helps highlight the importance of multidisciplinary and multi-level interventions that consider intertwined social factors as key to prevention strategies, equitable policies, and treatment retainment/adherence programming. When taken together, Part I and II call for the development of intervention programmes that respond to epidemiological findings, thus also exemplifying the use of multidisciplinary yet pragmatic approaches.

Part III, ‘Political Economy’, includes two articles that draw attention to macro-level circumstances, which challenge HIV/AIDS prevention and treatment systems across the region. ‘Austerity and Funding Cuts: Implications for Sustainability of the Response to the Caribbean HIV/AIDS Epidemic’ reviews expenditure and funding landscapes for Caribbean HIV/AIDS treatment and prevention programmes. The study reveals that the region largely continues to depend on external sources of funding, leading to focus on treatment and care programmes as opposed to preventative measures. Nevertheless, the authors also reveal key and significant differences across countries with the hope of informing future spending proposals. A key goal of the article is to identify ways forward for the region to build sustainable responses to the HIV/AIDS epidemic, including: more efficient use of resources at service delivery points, more integrated approaches that utilise non-health sector support, as well as implementing strong monitoring and evaluation systems to ensure that key indicators are well established and measured. Hintzen’s article on ‘Constitutionality, Legality, Injustice, and Precarity: Heightened Risk Factors in the HIV/AIDS Pandemic in the Caribbean’ bookends this introduction with a broad analysis of structural and sociocultural trends in the region. The article explores how, with the possible exception of Cuba, the surveillance and punishment of forms of sexual immorality are deeply inscribed in the documentary practices (i.e. laws, statutes, and constitutions) of Caribbean governments. Hintzen compares the Bahamas, Haiti, Guyana, Jamaica, and Cuba and shows how instrument effects of varying sets of documentary practices create different degrees of vulnerability based on stigmatisation, social discrimination, and social marginalisation. These instrument effects are inextricably linked to the capabilities of development policy, foreign presence of NGOs, or religious groups to seep into the political, social, and economic realities in each country. Together, these structural factors provide a framework, however partial, for the explanation of variance in prevalence across the region.

Taken as a whole, this special issue points to the importance of transdisciplinary approaches to HIV/AIDS in the Caribbean that are structural or macro-level in scope, but simultaneously attentive to the ways that large-scale dynamics are expressed and differently inflected in situated contexts and histories. This kind of dialectic and disciplinary hybridity are appropriate for a region with the vast diversity of the Caribbean, and global health researchers and advocates confronting HIV/AIDS will need to remain broad and critical of the forces that drive vulnerability, while also enabling focused epidemiological and behavioural studies of the ways these forces are enacted at specific times and places.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1 See discussion in Farmer and Kim (1996).

2 Cited in Farmer and Kim (1996, p. xx).

3 We would like to thank the African and African Diaspora Studies Program at Florida International University for their generous support for that meeting.

4 These and all subsequent rates mentioned relate to the percentage of the population of adults aged 15–49 who are infected.

5 By regimes of exception we refer to choices and orientations among regimes and governing institutions to ‘give value or deny value’ to identified categories of people whose members are, as a result, either denied access to rights and protection or are exempted from constitutional and legal prescriptions. This is taken primarily from Aihwah Ong’s work on neoliberalism. Specifically, it refers to the practice of governing authorities to deny segments of the population access to the rights and benefits that they deserve as citizens. It also refers to the exemption of the powerful and privilege from legality and the rule of law. In this case, they are also exempted from the negative consequences of stigmatized behavior and from its punishments, formal or informal, legal or otherwise (Ong, 2006).