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Science 28 July 2006:
Vol. 313. no. 5786, pp. 481 - 483
DOI: 10.1126/science.313.5786.481
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News

HONDURAS:
Why So High? A Knotty Story

Jon Cohen

Garifuna culture, discrimination against gay men, massive migration, the Cold War, and ignored prisoners all are theories that attempt to explain this country's serious epidemic

SAMBO CREEK, TEGUCIGALPA, AND LA CEIBA, HONDURAS--As a small group of men and women from this impoverished fishing village watch intently, Daniel Martínez holds up a placard that shows horrific photos of diseased female and male genitals. "Syphilis!" he yells, and the group, which is sitting under a thatched-roof shelter on the beach, looks down at what amount to bingo cards that Martínez has given them. Those who have a syphilis square mark it with an uncooked bean. The HIV/AIDS education game, Lotería Vive, continues with pictures of other sexually transmitted diseases and cartoons of transvestites, a drunken man, and then the Grim Reaper. "Oh!" groans the crowd at the last card, but one man has bingo and yells, "Lotería!" Martínez, who works with the Pan American Social Marketing Organization (PASMO), hands the winner a baseball cap and two condoms.

The residents of this village are Garifuna, so-called Black Caribs who are descendents of shipwrecked Nigerian slaves and who have maintained a distinct culture for more than 200 years. The best HIV studies done in this and three other Garifuna communities--which were conducted by the Ministry of Health more than 7 years ago--found that the adult prevalence was an astonishing 8.4%. Martínez plays Lotería Vive in this and other Garifuna villages in the region several times each week.

In 2005, Honduras in general had an adult prevalence of 1.5%, according to the Joint United Nations Programme on HIV/AIDS. That makes it the hardest-hit country in Central America other than relatively tiny Belize (see p. 483). The spread is mainly through heterosexual sex, which is reflected by a nearly 1:1 ratio of male to female AIDS cases. Yet the virus has also spread widely through the community of gay men, who have a prevalence of 13%--even higher than that of female sex workers, at 9.7%. By November 2005, almost 4500 people were receiving anti-HIV drugs, up from 200 three years earlier. But the national AIDS committee, CONASIDA, estimates that the drugs are reaching only about one-third of those with advanced disease.

Figure 1 Game theory. PASMO dispatches Daniel Martínez to Garifuna communities to teach HIV prevention through the bingolike Lotería Vive.
No convincing studies explain how the virus made so much headway in Honduras, but theories abound. Epidemiologist Manuel Sierra, who headed the Ministry of Health study of the Garifuna and now works at the National Autonomous University, says in most countries in the region, the virus entered through gay men and then "incubated," which means it took a long time to bridge into other communities. The first AIDS cases in Honduras were also gay men, he says, but HIV quickly spread through heterosexual sex, both in the Garifuna community and the country at large. "The main difference between Honduras and the rest of Central America is the incubation period," posits Sierra.

Figure 2 Above and beyond. Honduras has more HIV-infected patients than any country in Central America. They frequently fill the beds at Tegucigalpa's Torax Hospital.
A key distinguishing factor in Honduras, he contends, was the country's role during the Cold War. Sierra notes that when the first AIDS cases were detected in the early 1980s, the Cold War was raging, and U.S. military personnel were flooding into Honduras in an attempt to influence the civil wars in neighboring Nicaragua, El Salvador, and Guatemala. "Honduras was the center used by the United States to fight all the countries," says Sierra. The influx of soldiers--including Nicaraguan contras who staged attacks from Honduras--led to a boom in sex workers, which in turn played a "major role," he says. César Núñez, a Honduran epidemiologist who heads the multicountry PASCA study of HIV prevalence in high-risk groups in Central America (see p. 480), says this is "a good hypothesis."

As in other countries, prisoners are another driver of the epidemic in Honduras. A Ministry of Health study found a prevalence of 7.6% in prisons. "That's the ideal population to spread the virus," says Sierra. "You have spouse visits, lots of homosexual sex, low access to condoms, and lots of HIV." Núñez and Sierra say rampant migration has also played a central role. In particular, the country has a large number of merchant seamen, many of whom travel to Asia and Africa.

Although the Garifuna do not explain the country's high prevalence--they only number about 100,000 out of a population of 7.3 million--they are an important part of a complex story, says Sierra. When he tried to tease out why Garifuna have such a high prevalence, he found no evidence that they were more promiscuous than the ladinos who make up the majority in the country. Yet this has become a common belief, in part because Garifuna more openly discuss their sexual habits. "Garifuna as a group are more innocent, and they'll give you a straight answer," says Sierra. "We ladinos have learned how to lie."

Garifuna, some of whom make their livings as merchant seamen, also frequently migrate to the United States and other countries for work. Sierra notes that many shuttle between the large Garifuna community in New York City, which itself has a high HIV infection rate.

Garifuna have other risk factors, including widespread poverty and less access to health services. The culture also has many myths that make it more difficult for HIV-prevention educators. "They believe a spirit can enter a person and therefore that HIV is an inherited thing," says PASMO's Martínez, who is half Garifuna himself. "And when a person is showing symptoms, they think it's an ancestor asking for a religious ceremony."

Sergio Flores, the top HIV/AIDS doctor in La Ceiba--the nearest city to Sambo Creek--worries about highlighting the high prevalence in the Garifuna, because the population already suffers so much stigma and discrimination. "The community was essentially forgotten about, but when HIV arrived, we put our eyes on them," says Flores. "It doesn't seem right to me. And if you go to the street and ask the people about AIDS issues, many of them think 'AIDS, it's not in my house--it's the house of the Garifuna.' "

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