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The Caribbean has the highest HIV rates outside of sub-Saharan Africa. In recent decades, tourism has become the most important Caribbean industry. Studies suggest that tourism areas are epicenters of demographic and social changes linked to HIV risk, such as transactional sex, elevated alcohol and substance use, and internal migration. Despite this, no formative HIV-prevention studies have examined tourism areas as ecologies that heighten HIV vulnerability. HIV/AIDS research needs to place emphasis on the ecological context of sexual vulnerability in tourism areas and develop multilevel interventions that are sensitive to this context. From our review and integration of a broad literature across the social and health sciences, we argue for an ecological approach to sexual health in Caribbean tourism areas, point to gaps in knowledge, and provide direction for future research.
Currently, the Caribbean region has the highest prevalence rates of HIV infection outside of sub-Saharan Africa.1 As of 2007, 1% of Caribbean adults are estimated to be HIV positive, with nearly three fourths of the region’s AIDS cases occurring in 2 countries, the Dominican Republic and Haiti, which comprise the island of Hispaniola.1 The primary mode of HIV transmission in the Caribbean is classified as heterosexual,2 despite persistently high prevalence rates among men who have sex with men (MSM).3,4 Although the recent plateau in adult HIV prevalence in some Caribbean nations, such as the Dominican Republic, suggests that prevention efforts have been at least partially successful in the general population, the persistence of high prevalence rates among specific populations, such as MSM and sex workers, suggests that HIV interventions may be missing critical factors in ongoing transmission among vulnerable populations.4,5 Our empirical research in the Dominican Republic and our review of the Caribbean literature demonstrate that HIV prevention policies and programs have neglected much-needed formative research, intervention, and policy development on tourism areas as ecologies of heightened vulnerability.
Throughout the Caribbean, development efforts since the 1970s have encouraged an intensive shift toward large-scale tourism investment, leading to rapid growth in the proportion of gross domestic product due to tourism in nearly all Caribbean societies.6–9 In the Dominican Republic, where we have conducted research on HIV/AIDS and the tourism economy, more than 3 million tourists enter the country annually, most arriving from the United States and Europe.10,11 At the same time, transitions in the local distribution of labor—including a marked decline in the traditional rural agricultural economy and consistent growth in the informal sector and service work—have led many Dominicans to migrate to tourism areas in search of economic opportunities.8 In combination, these demographic and economic trends have resulted in a large-scale convergence of internal migrants and foreign nationals in tourism areas that is historically unprecedented in scope.
Here, we highlight some critical areas of future public health and social science research related to HIV/AIDS and sexual health in Caribbean tourism areas. We define tourism areas broadly as regions that are characterized by a high concentration of tourists, a wide range of tourism-oriented businesses (such as hotels, resorts, bars, restaurants, shops, and discos), and a vibrant market for local service workers who provide the labor for these businesses or engage in informal tourism entrepreneurship. A range of studies strongly suggests that Caribbean tourism areas are geographically, socially, and behaviorally distinct spaces that function as “ecologies of heightened vulnerability” contributing to the transmission of HIV and other sexually transmitted infections (STIs) among mobile populations both within and across national borders.
Globally, the ecological perspective has been increasingly advocated for the analysis of infectious diseases, including HIV/AIDS.12–15 This approach aims to avoid the partitioning of “risk groups” into presumably isolable populations, placing greater emphasis on the environmental and social context of HIV vulnerability and the development of prevention approaches at multiple levels.14 Following recent HIV-prevention models that have advocated for broader systems approaches,16 we argue that future public health research should aim to specify whether and how tourism areas as specific ecological systems shape sexual vulnerability in the Caribbean, and should aim to prioritize formative intervention studies to develop and pilot multilevel prevention strategies tailored to the specific ecological characteristics of these areas.
To illustrate our points, we draw on data from a 3-year multimethod ethnographic study of tourism labor and HIV/AIDS in the Dominican Republic.8,17 This study involved a large-sample survey of 200 informally employed men in 2 Dominican cities (Santo Domingo and Boca Chica), 72 qualitative in-depth interviews, and hundreds of hours of ethnographic observation in tourism areas between January 1999 and December 2001. Research was conducted through an international collaboration with a Dominican nongovernmental AIDS service organization, Amigos Siempre Amigos (Friends Always Friends), and was supported by 5 international health organizations and social science foundations. Although most men engaged in a wide variety of tourism jobs, a history of sexual-economic exchanges with either men or women within the tourism area was a criterion for participation. Figure 1 summarizes survey data on the 124 participants who reported engaging in other forms of tourism labor in addition to sex work. A more detailed discussion of the mixed-methods approach and study findings can be found elsewhere.8
This research demonstrated that the political and economic changes brought by the rapid growth of the tourism industry motivated many young men to migrate from rural provinces to coastal tourism areas in search of work.8 As shown in Figure 2, of 200 men surveyed who reported a history of sexual-economic exchanges with tourists, nearly half (98) had migrated to one of the research sites (Santo Domingo or Boca Chica) where they were interviewed. In the south coast research site of Boca Chica—a small beach town with approximately 50000 residents and a primary destination for international tourists to the Dominican Republic—three fourths of the surveyed participants had migrated internally as a means of economic improvement. In qualitative interviews, men in both research sites attributed their migration to the lack of employment opportunities for men in their home communities, and contrasted this with the greater perceived earning potential in the tourism area. Although they only rarely self-identified as “trabajadores sexuales” (sex workers), these men had engaged regularly or situationally in sexual exchanges with tourists and strongly preferred tourists over locals in such transactions because of the perception of greater potential compensation.8 The fact that these men participated in a range of other tourism jobs—such as hotel work, taxi driving, or tour guide services—speaks to the fluidity of informal income-generation activities in tourism areas and the integration of transactional sex into the broader Dominican tourism economy.
Similar findings are reported in studies of female sex workers or women employed in tourism areas in the Caribbean. Studies in Barbados,18,19 Cuba,20,21 the Dominican Republic,17 and Jamaica22–24 have all reported that women and men frequently perceive tourism work as one of their most lucrative employment options, and that such work often overlaps with commercial sexual exchanges with tourists. A growing number of ethnographic studies of female sex workers in the Dominican Republic, where estimates of female sex workers range from 50000 to 250000,25–29 have consistently found a strong preference for tourists, with many women describing hopes of a visa or citizenship abroad as a result of relationships with foreigners.30–32 Studies of Dominican male sex workers, including that conducted by Padilla et al.,17 have similarly found a strong preference for foreign tourists, who are believed to offer financial, migratory, and social status benefits.33–36
Of course, sexual contact with and preference for tourists do not alone provide evidence of a higher risk for HIV transmission in tourism areas. Nevertheless, 4 major sources of evidence suggest that such contacts may involve a particularly high risk: (1) high HIV prevalence rates among sex workers and their clients, (2) high rates of HIV risk behaviors in tourism areas, (3) demographic changes resulting from labor migration, and (4) alcohol and drug use in tourism areas.
Throughout the region, the prevalence of HIV is higher for both male and female sex workers than for the general population.2–4,37,38 Since sex workers often strongly prefer tourists as clients and sex work establishments frequently cluster in and around tourism areas, the risk associated with each act of unprotected sex is likely to be higher in tourism areas. In addition, most of the tourists are from regions such as North America and Western Europe, where HIV prevalence among adults is also high. The United States has one of the highest adult rates of HIV in the Western hemisphere, at 0.6%, and rates in Western Europe have been increasing since 2002.1 According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), France, Italy, Spain, Portugal, and Switzerland continue to have the highest HIV rates in Western and Central Europe, followed closely by the United Kingdom.1 Many of these same countries also contribute a high proportion of the European tourists that enter the Dominican Republic each year. In 2007, a third of the Dominican Republic’s international tourists were from the United States, 17% from Canada, 6% from Germany, 4% from Italy, and 29% from other countries in Europe.39 In terms of its tourist makeup, the Dominican Republic is one of the most diverse tourist destinations in the world. The transnational connections between the Dominican Republic and other countries therefore constitute a highly permeable air bridge through which both people and microbes can move.40
Some behavioral studies of HIV risk behavior have shown that individuals who work in tourism areas or engage in transactional sex with foreigners report higher rates of HIV risk behaviors. For example, studies among MSM,8,33,35,36 female sex workers,32,37,41–48 and hotel and resort employees49,50 in the Dominican Republic have found high rates of sexual contact and sexual risk behaviors with foreign tourists.
Data from M.B. Padilla’s long-term research on Dominican tourism labor provides further support for such findings.8 Male sex workers were asked whether they used condoms with their last male client; 82% of the 168 men with a history of male clients reported that they “always” used condoms during anal penetration with their last male client, 5% reported “almost always” using them, 4% “sometimes,” 1% “rarely,” and 1% “never” (7% of respondents did not engage in penetrative anal sex with their last male client and so this survey item did not apply to them). However, when these findings are compared with condom use rates with the last regular client, the rate changed significantly for those reporting “never” using condoms (other rates varied only slightly). Of the 118 sex workers who indicated that they had regular male clients, 14% said that they never used condoms with their last regular client, a fact that most attributed to a feeling of confianza (trust). This finding is particularly significant given that regular client was defined for the purpose of the survey as a minimum of 3 dates, demonstrating that the dynamics of risk behavior can change considerably after only a few encounters with a client. This association between greater intimacy with regular clients and the cessation of condom use has also been observed among Dominican female sex workers, many of whom refer to clients as novios (boyfriends) after only a few encounters.46
Although the link between regular trusting relationships and a decrease in condom use has been observed in a range of global studies of HIV/AIDS,51–54 further research is needed in the Caribbean to understand how complex relational dynamics influence HIV risk in the transactional sexual exchanges that are negotiated in tourism areas. The growing social science literature on Caribbean sex work has demonstrated that these relationships exhibit wide variations in the context of encounters, relational development over time, the role of gender and sexual identity in structuring interactions, and the subjective experiences of both partners. For example, much of the ethnographic research on sex workers in the region has shown that relationships with tourists could often more accurately be described as “romance tourism” than as sex tourism or prostitution per se.24,30,34,55 This is because the instrumental dimensions of these exchanges are often subtle, may involve gifts rather than direct sex-for-money transactions, and frequently incorporate romance and other forms of “emotion work” that transcend the purely sexual.56 These more intimate exchange relationships may involve regular visits, mutual affection or love, and significant remittances or financial support from abroad.
Although such relationships are often glossed as “sex work,” they provide a very different relational context for the negotiation of risk reduction strategies than do one-time sexual exchanges because of their greater intimacy and potential for more substantial material transfers over time. Given the emotional and economic dependencies of these sustained exchange relationships, local sex workers may confront many of the same barriers to condom negotiation that have been observed for stable or married couples globally.57–60 This, in turn, may contribute to the higher rates of sexual risk behaviors observed in tourism areas, perhaps particularly in the Caribbean, where multiple ethnographic and historical studies have documented the salience of sustained economic exchanges as predominant features of intimate relationships.61–63 It is thus critical that future public health research on Caribbean tourism areas use nuanced and culturally appropriate frameworks for understanding how the very different relational contexts of transactional encounters are linked to sexual risk. This may involve discarding stereotyped categories such as sex worker in the design and targeting of interventions, even when economic transactions are a significant component of the relational dynamic.
As illustrated by Figure 2, the transition to tourism as the backbone of Caribbean economies has contributed to broad demographic changes, including internal migration of local populations seeking economic opportunities in tourism areas. A vast literature in numerous global settings has shown that labor migration frequently increases HIV risk, as measured by both frequencies of sexual risk behaviors and HIV infection rates, and that the stable partners of labor migrants are often at particularly high risk for HIV and other STIs.64–68 These studies have begun to consider how the cultural and social organization of migrant labor areas alters sexuality in ways that may contribute to HIV risk among migrant workers and their partners.
For example, many scholars have discussed the potential risk-taking effects of extended separations from home communities, which may combine with a new normative social climate that encourages sexual risk-taking or substance use within the labor area.69–73 UNAIDS has emphasized the need to understand how HIV risk is shaped by variations in the process and timing of labor migration, such as the periodicity of trips between the home community and the labor area, and the duration of spousal separation during migratory labor.74 Whether internal migration patterns within Caribbean nations follow patterns of migration-related HIV risk in other high-prevalence regions (such as sub-Saharan Africa) and what precisely are the mechanisms connecting migration and HIV risk within Caribbean nations should be high-priority questions motivating future research on HIV/AIDS in the region.
Large-scale HIV studies on the migration–tourism linkage have yet to be conducted in the Caribbean (although we are actively engaged in developing such a program of research), but existing evidence suggests that it is feasible that demographic and structural changes resulting from labor migration to tourism areas contribute to HIV risk among migrants and their stable partners. In such a scenario, migrants entering tourism areas may be more likely to engage in sexual risk behaviors that are pervasive and normative in such environments; later, they return to rural households or adjacent communities where conjugal norms presume fidelity and trust, and where gender inequalities further inhibit risk reduction practices such as condom use and sexual risk communication. Our prior research lends credence to this, demonstrating that Dominican migrant laborers involved in sexual-economic exchanges in tourism areas often cope with the social inequality and stigma they experience by using complex information management techniques to avoid disclosure about clandestine sexual activities to their partners and families.17
Several contributors to a recent issue of the Journal have described similar migration- and gender-related risk scenarios in a variety of global settings, demonstrating that the fictions of fidelity that increasingly define modern notions of marriage, gender-power asymmetries, and the changing social geography of extramarital sex resulting from economic transformations can strongly shape HIV risk for married couples.57–60 An urgent question in need of targeted research is whether and how these dynamics are operative in the Caribbean HIV/AIDS epidemic as a result of large-scale tourism development and resulting patterns of internal population movement.
Some epidemiological evidence suggests that such dynamics may indeed be at work in the evolving Caribbean HIV epidemic. In the most recent Demographic and Health Survey in the Dominican Republic, for example, HIV prevalence levels appear to have stabilized in some larger urban areas such as Santo Domingo, but are apparently increasing in some rural areas.75 Sentinel surveillance reports conducted by the Dominican Ministry of Health and the World Health Organization have similarly found that rates of HIV infection among female sex workers in urban areas are declining,76,77 which UNAIDS has attributed to successful HIV interventions among this population in certain urban areas.78,79 Unfortunately, existing sentinel data in the Dominican Republic do not permit unequivocal conclusions about regional patterns, and may bias prevalence levels in specific sites compared with population-based data.80 Nevertheless, it does appear that the epidemic is undergoing a regional transformation, meriting renewed research on the ecological factors that may be involved. Whether and how the mobility of populations between rural zones and tourism areas is implicated in these changes remains to be examined by future epidemiological and social scientific research.
External migration related to tourism is similarly important. Studies have documented that men and women in the Caribbean may migrate to other islands in search of tourism-related work, and may often engage in sex work while abroad.81,82 In M.B. Padilla’s prior research, nearly one third (30%) of the 200 Dominican male sex workers surveyed had traveled internationally, most commonly to the continental United States or Puerto Rico but also to a number of developing countries in Latin America and the Caribbean.8 An additional 30% of those who had traveled abroad indicated that they had participated in sex work while abroad, with the United States and Puerto Rico accounting for exactly half of reported instances of sex work abroad. Nearly 90% of the sex workers who had conducted sex work abroad affirmed that they had “lived with a client” during this time, and in most cases (62%), these clients were met abroad, that is, after traveling rather than before. It therefore appears that, although for some sex workers international travel may be instigated by relationships with specific clients, such relationships are not necessary precursors to the decision to travel abroad.
External migration is also relevant for understanding HIV among Haitian migrants who enter the Dominican Republic in search of economic opportunities. Haiti has long had the highest rates of HIV in the Caribbean,78 despite an early decline in Haiti’s tourist industry due largely to political-economic instability combined with an international panic about Haiti as a presumed source of the global epidemic.83 A number of studies have noted that both male and female Haitian migrants engage in sex work while in the Dominican Republic.30,63,84 Haitian migrants often are informally employed in tourist economies in the Dominican Republic, and must contend with a pervasive anti-Haitian sentiment and their tenuous legal status within the country.30,85 The combination of their relative poverty in relation to Dominicans, their relegation to the most exploited sources of labor, and their increasing movement into tourism areas in the Dominican Republic suggests that Haitian immigrants are a critical component of the social ecology of HIV/AIDS.
In recent years, Caribbean tourism areas have fostered a massive growth in the availability of alcohol and drugs, which are important cofactors in HIV transmission. In the Dominican Republic, the estimated amount of alcohol consumed per adult per year increased from 1.18 L in 1961 to 6.11 L in 2001, reaching a peak of 7.71 L per person in 2000.86 Much of this increase can be attributed to the growth of transnational alcohol companies that have marketed and invested heavily in major Caribbean tourist destinations.87,88 Expanding the supply and availability of alcohol in the Caribbean has often been viewed as an important way to support the tourism industry.88 All-inclusive resorts that provide unlimited access to alcoholic beverages further support the industry while contributing to tourist expectations for recreation. Nightclubs, bars, restaurants, and liquor stores frequented by tourists present increased opportunities and points of access where locals may also purchase and consume alcohol.
Globally, a number of studies have documented an increased risk of HIV-related sexual risk behavior associated with alcohol venues, demonstrating that the design and location of many alcohol venues promote easy sexual encounters.79–91 For example, alcohol venues are often characterized by greater availability of commercial sex workers, on-site rooms where sex can occur, or areas where there are nearby buildings, lots, or other spaces to have sex.92 The sex industry thus functions synergistically with alcohol venues in many Caribbean tourism areas, and indeed, in the Dominican Republic research has shown that the liquor store and the centro cervecero (a specialized store that sells and serves beer) have become new sites for the negotiation of commercial sexual transactions.93 These local venues have particular cultural features that remain to be fully studied in relation to HIV.
In addition, the transport of drugs has become an increasing problem in many Caribbean societies, including the Dominican Republic. Today, the Dominican Republic is a primary route for the transport of cocaine from South America to the United States.94,95 Studies have shown that both drug use and HIV prevalence increase along routes of drug transportation.96–99 However, very little research has attempted to examine this in the context of tourism ecologies.
Despite multiple sources of evidence suggesting that tourism areas are important high-risk environments involving vulnerable internal migrants, mobile foreign travelers, transactional sex, high levels of HIV risk behavior, and high levels of alcohol and drug use, no formative HIV-prevention studies have been conducted to examine tourism areas as specific ecologies contributing to HIV transmission. Indeed, the Caribbean Community (CARICOM) and the Strategic Partnership on HIV/AIDS, in their pan-Caribbean agenda-setting initiative, recently advocated for greater attention to tourism areas and the convergence of multiple HIV risks within them, such as transactional sex and mobile populations.100 However, formative HIV-prevention research, programs, and policies in tourism areas have been largely absent or underfunded.
Previous HIV-prevention projects in the Dominican Republic, conducted by organizations such as Centro de Orientación e Investigación Integral (Center for Orientation and Integrated Education), Centro de Promoción y Solidaridad Humana (Center for Promotion and Human Solidarity), and Family Health International, worked with tourist officials and businesses in an effort to develop structural HIV-prevention interventions that subsequently have been evaluated as effective.79 These efforts must be expanded and sustained as part of a prevention research agenda that seeks to address tourism ecologies as areas of heightened vulnerability. In addition, such partnerships will be critical for translating evidence-based strategies and interventions into routine public health practice and policy. The success of structural interventions among female sex workers, many of whom work closely with tourism businesses, further suggests that some of these efforts and models may apply to prevention in tourism ecologies. Because of the significant cultural and linguistic diversity within the Caribbean region, such strategies need to be both disseminated and carefully adapted in specific settings, requiring local formative studies across the region in a variety of tourism environments.
When it has mentioned tourism at all, the existing public health literature on HIV/AIDS in the Caribbean has tended to focus exclusively on risk groups, such as MSM or sex workers, and then occasionally to note the behavioral association with tourism, rather than directly examining how tourism areas function as distinct social ecologies creating distinct challenges for HIV prevention for a growing cross section of the population. This lack of contextualized research on tourism ecologies within public health may have much to do with a traditional lack of interdisciplinary communication across social science and public health boundaries, since the Caribbean is now developing a significant social science and ethnographic literature on the effects of tourism on local societies.7,8,24,30,34,82,101,102 To date, little of this literature has informed HIV/AIDS policies and programs, which have traditionally turned a blind eye to the tourism sector. Some analysts have recently attributed this neglect of the tourism sector to policymakers’ fear of contaminating the industry with unappetizing references to HIV/AIDS, thereby jeopardizing the fickle tourism economy.51,103 The lack of empirical research on the linkage between HIV transmission and tourism thereby perpetuates a vicious cycle in which assumptions, stereotypes, or fears trump the development of interdisciplinary collaborations across the social and health sciences. Such collaboration is a critical first step in the creation of evidence-based HIV-prevention programs for some of the most vulnerable Caribbean populations.
In contrast, we recommend that researchers begin to develop interdisciplinary, multilevel frameworks for conceptualizing tourism areas that combine macro- and microlevel influences and aim to identity how ecological factors influence the more immediate determinants of behavior traditionally targeted in interventions. Integrated frameworks that account for how environments are structured in ways that facilitate vulnerability to HIV infection will not only serve to elucidate the pathways between ecological factors and HIV infection but will also begin to identify potential leverage points for interventions at different levels in the ecological system.
As researchers move forward with this approach, ethnographic methods should be used to critically examine the role of context, and to map out how ecological factors shape the more proximate determinants of behavior in specific social spaces. The existing social science and anthropological literature on tourism in the Caribbean should serve as a conceptual starting point for formative research and theory building. Following formative studies, formal analyses of multilevel frameworks that explore both indirect and direct effects can be pursued to understand how the full ecological system influences vulnerability to HIV infection. The end goal of such work will be the development of multilevel prevention strategies that target the specific contextual and individual factors that have the strongest likelihood of reducing the heightened vulnerability associated with tourism areas in the Caribbean. If we are correct in our analysis, further delays in setting such a research agenda may result in a continuing neglect of an underlying association between tourism ecologies and HIV/AIDS.
Agencies and foundations that provided funding for parts of this research included the Wenner-Gren Foundation for Anthropological Research, the Fulbright Institute of International Education (IIE), the US Agency for International Development (Dominican Republic), the Fogarty AIDS International Training and Research Program, and the following institutions at Columbia University: the Vice Provost’s Office of Diversity Initiatives, the Center for the Study of Ethnicity and Race, and the Institute for Latin American Studies. The writing of this article was partially supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA; award no. R21AA018078).
Collaborators based at the Dominican nongovernmental organization Amigos Siempre Amigos (Santo Domingo) deserve special appreciation and gratitude.
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ContributorsM. B. Padilla was principal investigator for the ethnographic project discussed in the article. M. B. Padilla and V. Guilamo-Ramos conceptualized the article, supervised its development, and were primarily responsible for the writing. A. Bouris contributed to conceptualization and literature searches and made editorial comments on the article. A. Matiz Reyes contributed to data collection and analysis for the ethnographic material in the Dominican Republic and reviewed and commented on the text.
Note. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIAAA, the National Institutes of Health, or any of the aforementioned agencies.
Human Participant Protection
This research was approved by institutional review boards at Emory University, Johns Hopkins University (Fogarty AIDS International Training and Research Program site), and the Universidad Autónoma de Santo Domingo (Dominican Republic).
Mark B. Padilla, Department of Health Behavior and Health Education and the Department of Anthropology, University of Michigan, Ann Arbor.
Vincent Guilamo-Ramos, School of Social Work, Columbia University, New York, NY.
Alida Bouris, School of Social Service Administration, University of Chicago, Chicago, IL.
Armando Matiz Reyes, Department of Health Behavior and Health Education, University of Michigan, Ann Arbor.