A Persistent Problem in America's Paradise: Examination of the HIV/AIDS Epidemic in the United States Virgin Islands

Background: For over a decade, the U.S. Virgin Islands (USVI) has consistently had one of the highest prevalence rates of HIV infection in the nation. The USVI had the highest rate of adults and adolescents (per capita) living with a diagnosis of HIV in 2005, the second highest rate from 2006 through 2009, and currently has the third highest rate (685.1), since 2010 (667.1). According to the President’s National HIV/AIDS Strategy (NHAS), the USVI is a geographic hot spot for increased HIV risk. Majority of people living with HIV (PLWH) in the USVI are: AA/Black (56.9%), age 25-54 years (75.6%) and exposed through heterosexual contact (34.6%) or unknown (40.2%). Half are male. The USVI also has the 3^rd highest rate (365.5/100,000) of adults/adolescents living with an AIDS diagnosis in the U.S.  Recent local USVI news reports highlight the territory's alarming rates of some sexually transmitted infections (STIs), including HIV, Chlamydia, and gonorrhea, which are also among the highest in the nation (among females ages 15 to 24 years). Moreover, local experts believe the rates of HIV and STIs in the USVI are significantly higher, but current data are not available to support this due to insufficient testing, data collection and reporting.

Purpose: The purpose of this analysis is to present findings that highlight a persistent HIV/AIDS epidemic in a small U.S. territory by evaluating and analyzing USVI HIV-related data from 2005 – 2010 from two reputable sources: the CDC (2005 and 2009 data) and the USVI Department of Health (2008 and 2010 data).

Methods: U.S. Virgin Islands 2008 and 2010 HIV Surveillance data was evaluated for historical and sociodemographic trends. Additionally, U.S. Virgin Islands Data from CDC Behavioral Risk Surveillance System (BRFSS) 2009 and 2005 Annual Surveys were analyzed using PASW 18.0 software. Descriptive statistics were used to determine the sociodemographics of the population and frequency of HIV testing and HIV risk behavior for 2005 and 2009. Chi-square tests examined associations between age, gender, race/ethnicity and high-risk HIV behavior and logistic regression examined predictors of high risk HIV behavior, using 2005 data. Only data for the U.S. Virgin Islands were included in the analyses. Significance was set at 5% alpha.

Results/Findings: Local USVI data/findings: By the end of 2010, cumulatively, among PLWH, 57.3% identified as Black/AA, 32.9% as Hispanic, and 7.7% as White. Similarly, by the end of 2010, among adults/adolescents living, approximately 59% were AA/Black, 32% Hispanic and 8% White. Approximately sixty percent of cases of HIV infections in the USVI in 2010 were among males and they accounted for approximately 50% of cumulative HIV cases by end of 2010. Of risk categories reported, heterosexual transmission is the most common HIV risk category in the USVI (34.6%); for males (34.5%) and females (82.7%). Male-to-male sexual contact accounted for approximately 13.2% (in 2010) to 22.6% (in 2008). Injection drug use accounted for 8.1% (in 2010). Majority of HIV infections in 2010 (74.2%) and cumulative cases by the end of 2010 (75.6%) were in people 25 to 54 years old.

CDC BRFSS data/findings: 2,509 people surveyed in 2009 and 2,422 in 2005. Majority of the sample were high school graduates (34.1%, n=855) or attended (18%, n=452) or graduated from college (28.3%, n=710). Majority were married (40.9%, n=1026), employed/self-employed (63.0%, n=1581) or retired (18.6%, n=467) and made less than $25,000 annually (30.1%, n=248). However, 29.3% (n=735) made over $50,000/year and 27.6% made $25-50K/year. Majority were Black and non-Hispanic (86.4%, n=2168). More than half (60.6%, n=1154) reported ever having had an HIV test (compared to 53.6%, n=1074 in 2005) and only 5.5% (n=105) reported engaging in high HIV risk behavior (compared to 6.5%; n=130 in 2005). Gender was not significantly associated with high HIV risk behavior (Chi-square=0.28, p=.597), but age was (Chi-square=8.57, p=.0002). Among 18-24 year olds, 19.7% reported high HIV risk (vs 13.5% not at risk) and among 25-44 year olds, 59.1% reported high HIV risk (vs 45.8% not at risk). In a logistic regression model, including race/ethnicity and gender, being 18-24 years (t=2.83, p=.0047) or 25-44 years (t=3.49, p=.0005) old significantly predicted high risk for HIV (Wald Chi-square=631.48, df=4, p=.0001) such that they were 2.5 times (CI 1.3-4.9) and 2.4 times (CI 1.5-3.8) more likely to be at high risk for HIV, respectively. A more comprehensive logistic regression model (education, gender, income, race/ethnicity and age) significantly predicted risk for HIV (Wald Chi-square =779.58, df=20, p=.0001). Age 25-44 years was the only significant predictor (t=2.9, p=.0038) and they were 2.2 times more likely to have high risk for HIV (CI 1.3-3.6).

Discussion/Conclusions: Results indicate an increase in reported history of HIV testing and a decrease in reported high HIV-associated risk behavior between 2005 and 2009. Being a young adult significantly (twice higher) increased the odds of being at high risk for HIV. Local USVI 2008 and 2010 data show that the HIV epidemic in the USVI is primarily among African American, heterosexual men and women between the ages of 25 to 54 years old. More studies are needed to examine the HIV-associated sexual risk behaviors of young adults in the USVI and to facilitate the development of appropriate HIV prevention interventions for this population.