Although the AIDS epidemic in the broader Latin America and Caribbean region is not as pervasive as in Africa, over 1.8 million people were estimated to be living with HIV in the region in 2007, including 230,000 in the Caribbean and 1.6 million in Latin America. Moreover, the adult prevalence rate in several countries in the Caribbean and Central America are among the highest outside of sub-Saharan Africa. In terms of sheer numbers, Brazil accounts for about one-third of those living with HIV in Latin America, but its prevalence rate of 0.5% (2005) is low compared to many countries in Central America and the Caribbean. Furthermore, Brazil's active prevention efforts have lowered prevalence among the high risk groups—intravenous drug users and homosexuals—and the government's extensive antiretroviral (ARV) treatment program has lowered death rates. In contrast, the mode of transmission in several Caribbean and Central American countries has been primarily through unprotected heterosexual contact, which has made it more difficult to contain the epidemic because it affects the general population. The estimated adult infection rate in the Caribbean was 1.0% in 2007, with the epidemic claiming an estimated 11,000 lives during the year and 19,000 lives in 2006. An estimated 17,000 adults and children in the region became infected in 2007. AIDS remains one of the leading cause of death among adults in the Caribbean aged 15-44 years. The Caribbean countries with the highest prevalence or infection rates in 2006 were Haiti, the Bahamas, Belize, Guyana, and Trinidad and Tobago, with rates between 2% and 4%; and Barbados, the Dominican Republic, Jamaica, and Suriname, with rates between 1% and 2%. Haiti and the Dominican Republic account for three-quarters of the region's infected population. The U.S. Agency for International Development (USAID) notes that Haiti's poverty, conflict, and unstable governance have contributed to the rapid spread of AIDS over the years. In both countries, however, there are indications that the epidemic could be reaching a turning point because of prevention efforts. Nevertheless, trends in both countries suggest the need to protect against a resurgence of the epidemic. In Haiti, there are been declining infection levels in Port-au-Prince and other cites, and the declines appear to be associated with some protective behavioral changes (an increase in condom use and a drop in the number of sexual partners) although AIDS mortality has also been a factor. In the Dominican Republic, where there has been a large increase in the use of condoms by commercial sex workers, the epidemic appears to have stabilized. However, workers on sugar cane plantations (bateyes) continue to have high prevalence rates, with rates up to 12% found among males aged 40-44. In Central America, Honduras has the highest prevalence rate of 1.5% (with AIDS related diseases the second leading cause of death in the country), while El Salvador, Guatemala, and Panama have rates just under 1%. The epidemic in Central America is concentrated in large urban areas, although some rural areas have been hard hit. In Honduras, the Garifuna community (descendants of freed black slaves and indigenous Caribs from the Caribbean island of St. Vincent) concentrated in northern coastal communities has been especially hard hit by the epidemic, with over 8% and 14% of the population infected. Although unprotected heterosexual sex has been the main mode of HIV transmission in most countries in Central America and the Caribbean, sex between men is a factor in epidemics in both regions. In Belize, Costa Rica, El Salvador, Guatemala, Nicaragua, and Panama, high HIV infection rates are found among men who have sex with men. In many cases, men who have sex with men also report having female sexual partners. In Central America, bisexuality has been a significant bridge for HIV transmission into the wider population in Central America. High prevalence rates have also been found among female sex workers in El Salvador, Honduras, and Guatemala. In Honduras, however, recent studies have shown that increased condom use by sex workers and men who have sex with men has reduced prevalence rates in the major cities of Tegucigalpa and San Pedro Sula. In the Caribbean, stigma and widespread homophobia (which drives people away from HIV services), have been significant factors in the spread of HIV. Although the share of HIV infections in the Caribbean attributed to sex between men is about 12%, homophobia and stigma could hide a higher percentage. In recent years, human rights organizations have criticized Jamaica for pervasive homophobia and targeted violence against gay men that has also carried over to violence against people living with HIV and organizations providing HIV/AIDS education and services. In June 2004, Jamaica's leading gay rights activist, Brian Williamson, was murdered, while in November 2005, Steve Harvey, a noted Jamaican AIDS activist, was murdered in what some news reports have characterized as a hate crime. UNAIDS condemned the murder and called on the Jamaican government to address homophobia and other causes of stigma and discrimination that are fueling the spread of HIV. In September 2006, the Jamaican government launched an anti-stigma media campaign to combat discrimination associated with those infected with HIV. The AIDS epidemic in the Caribbean and Central America has begun to have negative consequences for economic and social development in the region. In 2001, the Pan American Health Organization (PAHO) maintained that the AIDS epidemic threatened to undo many of the health gains made in Latin America and the Caribbean. In the Caribbean, which is the second most affected region in the world, AIDS is one of the leading causes of death among adults aged 15-44 years. Life expectancy and infant mortality have already been affected in some countries. UNAIDS reported in 2004 that in Haiti, life expectancy was 10 years lower than it would be without the epidemic. In 2006, it reported that life expectancy in the Dominican Republic was estimated to be three years lower than without the AIDS epidemic and that AIDS mortality in Trinidad and Tobago would reduce the country's overall population by 2010. As the epidemic has continued, already-strained health systems in the region have been further burdened with new cases of AIDS. As a result of the epidemic, there are reportedly some 250,000 AIDS orphans in the Caribbean (with 200,000 of those in Haiti) and some 73,000 AIDS orphans in Central America. According to the World Bank, continued increases in HIV prevalence in the Caribbean will negatively affect economic growth. The epidemic, according to the Bank, will have a negative impact on such economic sectors as agriculture, tourism, lumber production, finance, and trade because of lost productivity of economically active adults with the disease. In particular, the labor market in the region will be dealt a shock because of deaths from AIDS. The Prime Minister of St. Kitts and Nevis, Denzil Douglas, maintains that the epidemic threatens to cripple the labor force just as the region needs to become more competitive in world markets amid the momentum toward hemispheric free trade. Looking ahead, the World Bank warned in 2001 that "what happened in Africa in less than two decades could now happen in the Caribbean if action is not taken while the epidemic is in the early stages." A 2004 report by the Pan Caribbean Partnership Against HIV/AIDS maintained that the epidemic is taking its greatest toll on younger people who traditionally have been the most productive human resources. The U.S. government has viewed the HIV/AIDS epidemic not only as a humanitarian crisis, but also as a national security issue because of its negative impact on economic development and political stability abroad. Under Secretary of State for Global Affairs Paula Dobriansky warned in 2002 that the disease was spreading in regions close to home, particularly Central America and the Caribbean. Scott Evertz, former Director of the White House Office of AIDS Policy, warned in 2002 that AIDS problems abroad could jeopardize the health of Americans, and described the Caribbean as "our third border." USAID Assistant Administrator for Latin America and the Caribbean Adolfo Franco testified in 2005 that migration from the region can contribute to the risk of HIV in the United States, citing statistics that Caribbean immigrants account for 46% of all immigrants testing HIV positive in New York City. The response to the HIV/AIDS epidemic in the Caribbean and Central America has involved a mix of support by governments in the region, bilateral donors (such as the United States, Canada, and European nations), regional and multilateral organizations, and nongovernmental organizations (NGOs). Many countries in the region have national AIDS programs that are supported through these bilateral, regional, and multilateral programs. The World Bank has provided significant support to combat HIV/AIDS in Latin America and the Caribbean, with Brazil becoming the first country in the region to receive such assistance. In June 2001, the Bank approved a $155 million lending program for the Caribbean to help countries finance their national HIV/AIDS prevention and control projects. Under this program, the Bank has approved loans to Barbados (2001), the Dominican Republic (2001), Jamaica (2002), Grenada (2002), St. Kitts & Nevis (2003), Trinidad & Tobago (2003), the Caribbean Community's (CARICOM) Pan Caribbean Partnership Against HIV/AIDS (PANCAP) (2004), Guyana (2004), St. Lucia (2004), and St. Vincent (2004). In March 2005, the World Bank approved an $8 million Central America regional project to manage and control the epidemic. The Inter-American Development Bank has supported HIV/AIDS activities in such countries as the Bahamas, Belize, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, Suriname, and a regional program through CARICOM. Moreover, its assistance to support health infrastructure in the region has been important for HIV/AIDS treatment and care programs.