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28892: Hermantin(News)Amid unrest, Haiti gains in fight on AIDS (fwd)

From: leonie hermantin <lhermantin@hotmail.com>

Posted on Mon, Aug. 14, 2006

Amid unrest, Haiti gains in fight on AIDS
The outlook for people with AIDS in Haiti is improving, even as the fate of many Haitians sick with other diseases remains bleak.

PORT-AU-PRINCE - Even as an unstable government, warring gangs and frequent kidnappings have brought despair to many in Haiti, the fate of AIDS patients has begun to improve.

Haiti has long had the highest AIDS rate outside of Africa, and for years the impoverished country lacked the money to buy AIDS drugs, leaving thousands to die. But since 2003, when a massive influx of foreign support for treatment began, the number of people receiving AIDS drugs has climbed from a few hundred to nearly 8,000.

Testing for HIV, the virus that causes AIDS, and care for patients who have HIV but do not yet need drugs are also increasing across the country, with funding to bring care to nearly all who need it by 2008.

''The prospects for controlling the AIDS epidemic in Haiti look very good,'' said Dr. Jean William Pape, one of several Haitian AIDS doctors discussing Haiti's progress at this year's International AIDS Conference, which opened Sunday in Toronto.

Progress has been so dramatic that a story now making the rounds in Haiti describes patients who become distraught when they learn they don't have AIDS -- because they know that AIDS patients receive free medicine, treatment and sometimes food, all of which are often unavailable to those with other illnesses.

The implication: The infusion of more than $100 million in foreign aid has in many parts of the country boosted the level of support for AIDS patients far above the care given people with other illnesses in the fragmentary national healthcare system.

''We are putting a diamond into mud,'' said Dr. Georges Dubuche, of Management Sciences for Health, a nonprofit group that runs several healthcare projects in Haiti.

Doctors are not suggesting that there is too much money for AIDS care in Haiti. The funding -- most of it targeted directly to a handful of nonprofit healthcare groups, largely bypassing government agencies -- has begun to address the acute inequality that emerged in the 1990s, when expensive new drug cocktails transformed AIDS into a manageable disease in rich countries, while patients in poor nations continued to die because they couldn't afford the drugs.

''I felt dead. My mother had to carry me in,'' said a 37-year-old woman who came to Gheskio, Pape's clinic, three years ago. The clinic, a bustling research center set behind concertina wire and across the street from a crumbling slum where U.N. soldiers clash with armed gangs, now sees thousands of patients.

''Since I came here, everything changed,'' the woman said. ``I couldn't walk; I walk now. I couldn't eat; I eat now. No more vomiting. No more diarrhea. It's like I'm back to the world.''

But as the acute inequality of access to AIDS drugs has eased, broader, chronic inequalities have returned to the fore. Life expectancy in Haiti is 53 years for men, 56 for women. One child in eight dies before age 5 -- and only 20 percent of those children have HIV, reports one recent study.

Nationwide, 2 percent to 3 percent of Haitians are infected with HIV -- down from 6 percent a decade ago.

''There are 97 percent of people with other diseases and other issues,'' said Dubuche, who cites care for pregnant mothers as an example. ``We are putting prevention of mother-to-child transmission [of HIV] into maternity wards that are not proper. Many things are not there -- drugs, IVs. There is no operating room. Most of them can't do blood transfusions.''

The disparity between AIDS patients and others is apparent at the Immaculate Conception Hospital in Les Cayes, one of several provincial public hospitals with new AIDS treatment teams.

Gheskio oversees the project in conjunction with the Ministry of Health. International funding pays for drugs, laboratory equipment, local staff members and mobile teams -- comprising a doctor, nurse, social worker, pharmacist and lab technician -- that make regular training and monitoring visits to each site.


About 200 patients now receive AIDS drugs at the hospital. The staff is treating hundreds more who are HIV-positive but don't yet need drugs, and dozens of new patients are tested for HIV every day.

Some of the money flowing in to the AIDS project has benefited the hospital as a whole. For the first time in years, for example, the hospital can consistently pay its water and electricity bills every month, although power outages are still frequent, said Dr. Reynold Grand'Pierre, the Gheskio physician who manages the national expansion program.

But because people with ailments other than AIDS must pay for care, the hospital's main wards -- large, concrete rooms with open windows and rows of metal beds -- remain half-empty.

''Some patients don't come because they don't have enough money,'' said Dr. Roland Charles, an internist at the hospital. ``People stay home and die sometimes.''

Some of those people are dying of AIDS but either don't know that free AIDS care is available or don't know that they have the disease. Grand'Pierre hopes to address this by pushing HIV testing out to clinics nationwide.

On Haiti's rural Central Plateau, the nonprofit group Partners in Health/Zanmi Lasante is addressing the same problem by making a complete package of basic healthcare available free to indigent patients, whether or not they have HIV.

Since 2003, the group -- which has its Haitian base in Cange, on the Central Plateau, and also has offices in Boston, where its founder, Paul Farmer, is on the Harvard faculty -- has expanded outward from a single site into formerly dysfunctional public-health clinics throughout the Central Plateau.


The group used AIDS dollars to launch the expansion but added additional funding from foundations and individual donors to offer care to all patients. Within months, traffic at the expanded clinics skyrocketed. The holistic approach has been essential to finding HIV patients, said Dr. Joia Mukherjee, the group's medical director.

''There was this concept that if you had centers for [HIV] testing, people would come find out their status,'' she said. 'But in rural areas, at least, that doesn't happen, because people don't say, `Hey, I wonder if I have HIV today.' They come into clinics because they're ill.''

One of the clinics, in the tiny town of Boucan Carre, sits down a muddy track and across a river from the main dirt road that runs through the plateau. The building that formerly housed the clinic is now a staff eating area and is barely big enough to hold a stove, table and sink. Behind that building, a new two-story structure houses a small inpatient hospital, maternity ward, X-ray facilities and several consultation rooms.

The clinic, which saw about 10 patients a day before the expansion, now sees more than 200. Doctors at the clinic are following 350 HIV patients, including 150 on AIDS drugs.

And working in the remote villages that surround the clinic are 65 accompagnateurs, villagers trained by Partners in Health and paid $40 a month to make daily visits to a half-dozen or so patients to monitor their health and make sure they take their medicine.

The program has been cited as a model for developing AIDS programs in poor, rural settings worldwide. Yet even here, the outlook is grim for many patients who lack jobs, and whose makeshift huts don't keep the rain out.

''They get soaking wet every night. They have no income,'' said Dr. Louise Ivers, a Partners in Health doctor who works on the Central Plateau. ``Those are things that are fundamentally associated with disease -- with tuberculosis, with diarrhea. Without a road, patients can't get to the clinic.''

Throughout Haiti, poverty has remained in many ways a more intractable problem than HIV.

Gheskio and Partners in Health have paired with other organizations to provide food to patients -- but the patients often end up sharing the food with hungry family members. Many are too poor to afford even basic transportation.

One recent morning in Les Cayes, a field worker from the treatment center in Les Cayes travels to the countryside to find an 11-year-old boy who urgently needs treatment but missed his appointment because his father lacked $3 for bus fare. (See accompanying story.)

Later that day, a woman brings in her pill bottle so the doctor can check on whether she has taken all of her AIDS medication. Strict adherence is essential, because when patients miss doses, the virus can mutate to become resistant to the medication.

Last year, Pape and his colleagues published a paper in the prestigious New England Journal of Medicine, showing that, even through waves of widespread violence and civil unrest, Gheskio's patients took their drugs as faithfully as patients at U.S. clinics.

But today, there are two pills too many left in the bottle; the patient has missed a dose, she explains, because she ran out of food and did not want to take her pills on an empty stomach.

It's very important that you take your pills every day, the doctor says, even if you have no food.