8268: More than 500,000 in Caribbean mighr be infected with HIV (fwd)

[Bob Corbett <corbetre@webster.edu>]

From: Max Blanchet <maxblanchet@worldnet.att.net>

South Florida Sun-Sentinel

By Tim Collie

BAINET, Haiti -- A cool breeze is blowing as the wasted body of Jean David
Droitdieu is carried down steep, rocky trails to his mother's house.

The men cross a shallow stream at the base of a deep valley, then lumber up
a bank into a remote village of white stone homes.

There is a long, pitiful shriek as the mother sees the corpse of her eldest
son. Soon, dozens of friends and family join in a single violent wail that
seems to fill the entire valley.

The mother's small house is quickly cleared of its furnishings and swept
clean. The white-shrouded remains of the 28-year-old native son are placed
inside.

As one mother's lost son, the dead father of an orphaned child, a wise
brother and good friend, Jean David will be celebrated for a night, then
quickly buried.

As one more life claimed by AIDS, his death will be something less than a
statistic. It joins countless other deaths, officially unrecorded, but
mounting on a scale at which experts can only guess as the epidemic sweeps
through the Caribbean.

Haiti is HIV's ground zero

Now entering its third decade under the brunt of the epidemic, Haiti is the
epicenter in the Caribbean's struggle with AIDS. This desperately poor
nation has the largest number of cases in a region with one of the world's
highest infection rates.

During the past two decades, an estimated 300,000 Haitians have died of the
disease. It's by far the largest toll in the Caribbean or Latin America.

An estimated 87 percent of all AIDS cases in the Caribbean are occurring on
Hispaniola - the island home of Haiti and the Dominican Republic.

Overall, at least 390,000 adults and children in the region are now living
with the AIDS virus. The real number could be considerably higher - more
than 500,000 people - because many countries lack the resources to even
count the sick.

In spite of efforts by a host of international health agencies, the
infection rate is increasing. There are now twice as many new HIV infections
occurring as there are AIDS deaths. And that, almost inevitably, will mean a
higher death rate.

The epidemic is expanding with the help of migration, tourism, loose sexual
liaisons and a cultural resistance to sex education and programs advocating
condom use. It is taking advantage of small, transient communities, fragile
island economies and weak public - health systems ill-equipped to halt the
spread.

In Haiti, officials with the United Nations Joint Programme on HIV/AIDS
(UNAIDS) estimate that 12 percent of the urban population and 5 percent of
rural inhabitants are infected with the AIDS virus.

Crisis looms in other nations

But as large as its problem is, Haiti is not the only country seriously
threatened by the epidemic. In the Bahamas, 4.1 percent of adults are
infected with the virus. AIDS is now the major cause of death among males
ages 15 to 44 in the English-speaking Caribbean.

In some parts of the Spanish-speaking Dominican Republic, it has become the
leading cause of death among women in the same age group.

More alarming, some experts say, is the increase of infection among
expectant mothers. In Haiti and Guyana, 7 percent to 8 percent of expectant
mothers are HIV-positive, a staggering rate that suggests the scale of
contagion.

"Once it crosses 2 percent of pregnant women - that's a serious epidemic,"
says Dr. Peggy McEvoy, the recently retired Caribbean chief of UNAIDS.

All of this adds up to the early stages of "a major developmental
catastrophe" that could reverse social and economic achievements of the past
50 years in the Caribbean, according to the World Bank. That would raise
serious foreign-policy issues for the United States, the destination of
choice for refugees from the Caribbean. The region's tourist industry could
easily collapse under the weight of the epidemic, leading to political and
social disarray.

Because it can lurk for five to 10 years inside a person before any symptoms
show, AIDS strikes hardest at poor countries whose citizens lack even basic
access to health care. By the time a person is diagnosed, it is often
because the disease has progressed to tuberculosis, pneumonia or dementia.
Many are too far gone to help. Because in the Caribbean the disease spreads
primarily through heterosexual activity, young men and women are most at
risk. And they are the backbone of a developing economy.

One study by the University of the West Indies estimates an AIDS-linked
decline of about 5 percent in the gross national products of Trinidad and
Jamaica in five years. Already, an estimated five years has been shaved off
the average life span in Haiti and Guyana - to 47 for men and 51 for women
in Haiti, and to 57 for men and 62 for women in Guyana.

There is no AIDS vaccine. The drugs available in industrialized countries,
anti-retrovirals that can contain symptoms, are coming down in price but
still remain out of reach in countries where annual per-capita incomes are
as low as a few hundred dollars.

Illness destroys families

AIDS is basically treated as a death sentence in poor countries such as
Haiti. Many physicians treat whatever symptoms they can, then send patients
on with anti-bacterial medicine to treat opportunistic infections. The vast
majority of the sick are on their own.

Once symptoms develop, the ill lose jobs in manufacturing, services or
agriculture. Their meager savings are quickly eroded in a desperate bid for
medical care. Households collapse. Spouses often abandon their sick mates
because of fear and stigma. Children are orphaned to the streets.

Some linger on, relying on money sent from relatives in the United States -
a key source of income for many countries - to buy expensive drugs instead
of paying for food, homes or school tuition for their children.

But the cruel calculus of the disease is unrelenting. As men die, their
wives and female companions are left fending for themselves in societies
that have few opportunities for women. Because of the sexual stigma attached
to AIDS, few women come forward until they are showing symptoms. And by
then, it's often too late.

As one parent dies, the family's income dwindles. Jobs are lost. Houses are
often sold off, along with cars, livestock and other belongings, to pay for
treatment. In poorer countries such as Haiti and the Dominican Republic,
there is no such thing as insurance to supplement government health care.
With the death of the second parent, children are sent to live with
relatives or shoved into the streets, where they become a criminal tax on
society. In Haiti, the Dominican Republic and Jamaica, roving bands of
street children are common sights. Children left parentless by AIDS are
filling orphanages and children's homes.

This process - the slow, unremitting destruction of poor families by the
disease - is occurring every day in Haiti and the rest of the Caribbean.

Spending falls far short

UNAIDS estimates it would cost $260 million annually for a comprehensive
response to AIDS in the Caribbean. That's 10 times the amount currently
being spent in the region, according to McEvoy, the former UNAIDS official.
By comparison, Broward County spends $50 million a year on AIDS programs.

In the Caribbean, that money would buy medicine, improve basic health care,
mount massive education campaigns and train doctors, nurses and counselors
to deal in a more humane way with AIDS patients. Money is not the only
issue. Experts say clinics must improve services and do more to protect
confidentiality of patients. And they say more efforts are needed to reach
those who live on the margins: sex workers, needle addicts and prisoners.
Ignoring these populations, as some countries have done, has only helped
further the spread.

The answers won't be easily found, many experts stress. The Caribbean is
home to myriad cultures and societies. Attitudes that date back hundreds of
years will have to be changed. Traditions that stress masculine culture over
women's rights must be altered, if not abandoned. That won't happen
overnight.

HIV's stigma helps it spread

It is the stigma attached to the virus - the taint of adultery, illicit sex
and drug use - that has so crippled efforts to curb its spread. Many of the
sick fear for their jobs and families if their illness is discovered, while
the young and seemingly healthy who think they are immune from HIV continue
its spread.

Stopping the disease is more than just a question of simple biology. A new
generation of medicine exists that could save lives, but it is mostly out of
reach in countries like Haiti where diarrhea and tetanus still kill children
daily.

"The biggest problem is medical care - there really isn't any public medical
care," says Jean Saurel Baujour, a leading AIDS activist in Haiti. "There is
no national reference center. Not even the most basic statistics are really
being kept.

"It's a long fight. It's a lonely fight. Many of us are going to die,"
concedes Baujour, who has HIV, the virus that causes AIDS. "We know that.
But we can help change things for the sons and daughters that follow us."

Virus kills brothers' dreams

Like many other Haitians in their teens, Jean David left for the big city at
15 to search for work. Two-thirds of Haiti's population lives in rural
areas, but life in Haiti is one of constant movement between the city and
country. In the past two decades especially, the major cities have swelled
in population as more sons and daughters have left the countryside looking
for jobs as maids, drivers and street vendors. This movement has further
fueled the spread of AIDS around the island.

Living with his younger brother, a laborer, Jean David found work as a
driver of a tap-tap, the colorful buses built onto the backs of pickup
trucks to ferry people around Haiti. He and Junior scrimped and saved, and
eventually bought a house in Cité Soleil.

Then, almost two years ago, Jean David came down with something resembling
the flu. He rapidly lost weight, vomiting and spitting blood for days at a
time, his relatives say. After visiting a series of doctors, he wound up in
a public hospital, where patients can stay only as long as they can afford
their medicine.

"I sold off the house one room at a time to pay all of this," Junior says.
"I rented the rear room to a family to get some money, then I sold them a
room. Then I sold another room. I was living in the third room, but finally
I sold that, too." The entire house eventually netted him about $700 -
almost twice the annual salary for the average Haitian.

Doctors, who in poor areas charge about $1 for office visits, are
ill-equipped to deal with sickness as debilitating as AIDS. Though many
doctors advertise the availability of AIDS tests, they usually don't give
them until a patient is showing symptoms of full-blown AIDS, health workers
say. When they do test, the doctors often don't even tell their patients
they have tested positive.

Compassionate lies

"What we find out is when we tell the patient, they tend to die sooner,"
says Dr. Michel Thomas, a doctor who has a small practice in Cité Soleil.
"They just lose hope. The stigma is so great here against AIDS, you just
tell them they have TB or another opportunistic infection."

In a narrow, cramped examining room littered with hypodermic needles, Thomas
says he averages at least one patient a day who tests positive for the
virus. Last year he diagnosed 350 people with the disease. During the first
two months of this year, he saw more than 70 new patients who are
HIV-positive.

On this day he is examining a local schoolteacher. The man, gaunt and
exhausted, sits hunched on a rusting examination table in an unlit
6-by-6-foot room. He tested positive in October after becoming so weak from
weight loss and frequent diarrhea that he no longer could stand in front of
his elementary-school class.

But instead of telling his patient that he had the AIDS virus, Thomas called
the man's minister. The minister informed the patient's wife. All agreed
that telling the teacher would probably end up killing him sooner.

"This is like a special case - he is a church member," Thomas explains. "It
was a decision we made in part because it would have created a scandal at
the church. They would have hounded him out of the community."

'Directly observed therapy'

There are signs of hope. Despite the dreaded march of numbers marking each
new death, important efforts are being mounted.

>From the Clinique Bon Sauveur in the remote Haitian village of Cange, a
Harvard *University* professor and physician named Paul Farmer has developed
an effective and affordable method to give treatment to the poorest of the
poor.

Using drugs purchased with donations, Farmer has adopted directly observed
therapy, a method commonly used with tuberculosis medicines.

Designated health-care workers venture into the countryside every day, often
hiking for several hours, to homes of AIDS patients. There, sometimes
several times a day, they observe the patients taking their medicine with
food and water. If the drugs are not taken daily, they can further damage
the patient's health as well as create more powerful strains of the AIDS
virus.

The method answers critics who argue that the AIDS drugs are too expensive
and the regimen too complex for poor people in developing nations.

Early in the epidemic, Farmer and a priest held town meetings with leaders
to educate people about the disease. As a result, they have succeeded in
overcoming many of the taboos so often cited by AIDS officials as barriers
to fighting the epidemic.

His philosophy is simple: Haiti's sick deserve the same treatment afforded
to AIDS victims in wealthy nations such as the United States. While
prevention is important, there is no lack of preventive information among
Haitians, Farmer says. Most know that HIV is spread through sex, although
some still believe that sorcery can also cause it.

Less-costly options can help

As the number of patients receiving the therapy has grown, the clinic has
developed techniques to save money while increasing its reach. It has
developed cheaper alternatives for diagnosis, treatment and the care of AIDS
patients that Farmer believes could easily be copied elsewhere.

To date, 21.8 million people have died of AIDS throughout the world. By
2004, AIDS is forecast to eclipse both the Black Death, which wiped out at
least 40 percent of Europe's population in the 14th century, and the 1918
Spanish flu epidemic, which killed 30 million to 40 million people.

AIDS would then be the deadliest epidemic in human history, according to
UNAIDS.

"As far as I know, we're the only ones providing this therapy in Haiti, and
that's a scandal," Farmer says. "Here you have the greatest plague since the
Black Death running rampant, and nobody else seems to be doing this. It's
unbelievable."