FRIGATE BAY, St. Kitts
TO DRAMATIZE the terrible force of the HIV/AIDS pandemic we usually look to the most vivid counts of people infected with the human immunodeficiency virus, such as the 25 million in Africa who carry HIV. But here in the small islands of the Caribbean, HIV/AIDS has also taken a strong hold on local populations. Though the numbers of the infected seem sparse because the general populations are so small, the ramifications pose just as severe economic and human consequences as anywhere else.
Some 17 of the sun-drenched islands that stretch from Cuba to Curacao now operate under the pan-Caribbean Epidemiology Center (CAREC) for HIV/AIDS surveillance purposes. As a group they have worrisomely high infection rates, second only to Africa's.
Even excluding high-risk islands like Haiti, with an HIV/AIDS infection rate of at least 6 percent, or Guyana, where the infection rate has risen to 3.5 percent, the remaining islands of CAREC are suffering 1 percent to 2.5 percent infection rates. This may not seem overly severe. But the telling point is that the HIV/AIDS infection rates inch relentlessly and seemingly inexorably upward.
To HIV/AIDS authorities, these countries now appear to be at a ''tipping point." Typically, an infection rate seems ''to sit and sit, and then it reaches the level we are now seeing when it develops a strong potential to take off and spread widely and quickly," notes Dr. William Rodriguez, who directs international HIV/AIDS programs at Harvard Medical School.
For nearly three years he has been an adviser on AIDS in the Caribbean for the Clinton Foundation HIV/AIDS Initiative. ''Aggressive prevention and effective treatment are essential right away or the consequences could be severe," he warns.
In fact, it is the impending economic impact of HIV/AIDS on the islands that largely led the Clinton Foundation to join in on their HIV/AIDS fight.
''Because he sees global poverty as the defining issue of our generation," said Ira Magaziner, head of the Clinton Foundation HIV/AIDS Initiative, ''President Clinton met in St. Kitts with the leaders of Caribbean countries to see what they felt was the best way to help them combat poverty." Possibly, for example, through social betterment programs. Instead, they told him, if we can't solve our AIDS problem, it will sabotage all other development programs." Since then, added medical expertise and awards of more than $10 million, obtained through the Clinton HIV/AIDS Initiative and the Global Fund to fight AIDS, tuberculosis, and malaria, have stepped up programs.
The overriding problem for these economically fragile island chains called the Leeward and Windward Isles, is not risk of contagion for visitors. They are more likely to bring HIV with them than take it home. But officials worry that talk about the problem may discourage visits.
While the prosperity of all the Caribbean islands depends on tourism, especially from the winter-weary from the United States, Canada, and Northern Europe, the islands also must staff their extensive farms, schools, hospitals, banks, commerce endeavors, and construct housing and additional infrastructure. To maintain an adequately large and skilled workforce, they cannot afford to lose a substantial number of workers to HIV/AIDS.
Yet those closest to the epidemic know money and medicines are not the only factors in preventing and treating this disease. Local customs and practices are key to control. And especially so in islands like St. Kitts and Nevis, with only 35,000 residents.
''To find out what's happening you go to the hairdressers." says Dr. Kathleen Allen-Ferdinand, the foremost HIV/AIDS specialist here and a dynamic advocate of prevention. The islands may seem time-locked, but she is as up-to-date as any American physician on HIV. And there is nothing easygoing about her campaign to thwart HIV/AIDS. She knows how much effort it will take to protect the people in St. Kitts/Nevis and how difficult it will be.
She knows the most pernicious problem is the stigma still associated with HIV/AIDS here. Though modern anti-AIDS drugs, free if need be, are available to patients, Dr. Allen-Ferdinand and other island physicians often collect the medicine at local pharmacies so a patient is not seen as needing it.
Driving the epidemic are sociologic, more than physiologic, factors. Sexual activity begins at an early age, typically by age 14. Nearly all high schoolers are sexually active. The teenage birth rate is 20 percent.
St. Kitts/Nevis has a very low marriage rate. Some 51 percent of newborns ''are not the result of a stable sex relationship," she notes, ''not even a common-law marriage arrangement." A situation and response study ordered by the government found that the average man in St. Kitts has, at any given time, four women sex partners.
Cultural and religious taboos also interfere with prevention: Catholics and Rastafarians are not sanctioned to use condoms. And male-dominated sex is prevalent among the locals and deprives many women of protection against HIV infection.
HIV/AIDS is basically a heterosexually transmitted disease here. Needle-injected narcotics are rare. Alcohol and ''ganja" are the abused substances that lead to unprotected sex. Where one Kittitian was infected with HIV in 1984, today more than 350 are believed to be, one-third of them not knowing they are.
At its crux, it is the scale of the Caribbean outbreak that is so striking. Brazil, for example, has a much larger number of people with HIV/AIDS. Yet for every person infected in Brazil, in proportion to population, five are infected in the Caribbean. To his credit, Kittitian Prime Minister Denzel Douglas, strongly supports public AIDS education campaigns.
'If the current infection rate continues to climb," says Dr. Allen-Ferdinand, ''by 2010, the UNAIDS estimates foresee that we in the CAREC nations will lose 5-to-10 years in life expectancy. HIV/AIDS already is the greatest killer of our young adults."
Loretta McLaughlin is a former Boston Globe editorial page editor and a senior fellow at the Harvard AIDS Institute.