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

[Bob Corbett <corbetre@webster.edu>]

From: leonie hermantin <lhermantin@hotmail.com>

Posted on Mon, Aug. 14, 2006


HAITI
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.
BY JACOB GOLDSTEIN
jgoldstein@MiamiHerald.com

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.

HUNDREDS GET DRUGS

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.

DONATIONS HELP

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.