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a848; recent comprehensive Haiti HIV/AIDS assessment andrecommendations <http://www.dec.org/pdf_docs/PNACM935.pdf> (fwd)

From: Stuart M Leiderman <leidermn@cisunix.unh.edu>

excerpts from:

USAID Support for Sexually Transmitted Infections and HIV/AIDS
Programming in Haiti: Assessment and Recommendations for Future Action

by Eliot Putnam et al, The Synergy Project, TvT Assoiates, Inc.,
1101 Vermont Avenue, N.S., Suite 900, Washington, D.C. 20005,
ph 202.842.2939, fx -7646, tvt@tvtassociates.com, www.synergyaids.com,
September 2001, 58pp.

posted on the web <http://www.dec.org/pdf_docs/PNACM935.pdf>

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The Caribbean, constituting some 36 million people in 16 sovereign states
and 18 territories, dependencies and semi-autonomous island states, has
the highest HIV prevalence in any region outside Africa. The Joint United
Nations Programme on HIV/AIDS (UNAIDS) and the Pan American Health
Organization (PAHO) estimate that 2 percent of adults in the region are
seropositive, 85 percent of whom live in Haiti and the Dominican Republic.
The epidemic is concentrated in young adults and is transmitted mainly
through sexual contact. However, perinatal transmission is rising in some
areas, particularly in Haiti. A 1998 study 1 estimated that the HIV
infection rate in Haiti is 6 percent in urban areas and 4 percent
in rural areas, making Haiti the hardest hit country in the Caribbean
region. The true extent of the epidemic, however, may be even worse since
a dependable epidemiological surveillance system that meets Haitian
and international standards does not exist.

In recent years, health sector funding by major bilateral and multilateral
international agencies has been reduced or discontinued in Haiti, despite
a growing epidemic and increasing national determination to respond to the
epidemic as effectively as possible. In Fiscal Year (FY) 2002, the
U.S. Agency for International Development (USAID) will reduce its overall
funding from $50 million to $35 million, which will affect the Mission's
population, health, and nutrition activities.

In order to program resources as efficiently as possible, a team of
consultants was asked to review and assess USAID's current HIV/AIDS
portfolio in Haiti in May 2001. The team found that while there were
significant accomplishments, such as a high level of awareness of HIV
among the population (studies show that 98 percent of the population
knows about AIDS, and more than 65 percent understand the modes of HIV
transmission) and the establishment of a national condom social marketing
program, protected sex is not widely practiced and multiple sexual
partners are common.

The assessment team was struck by what it perceived as a growing
commitment, in both public and private sectors, to confront the challenges
of ignorance and discrimination, poor health systems, lack of access to
care and support, and an absence of political will. The launch on May
7, 2001, of a new national strategic planning process by the Ministry of
Health gives rise to the hope that policy guidance and funding commitment
will follow. The national plan acknowledges the direct linkages between
sexually transmitted infections (STIs), HIV and other infectious
diseases, such as tuberculosis (TB). It will become operational by the end
of 2001.

Responding to the generalized HIV/AIDS epidemic in Haiti requires a dual
approach: to provide decentralized prevention and care services throughout
the country, while ensuring extra coverage of high-risk settings or "hot
spots" where transmission is most rapid. The team recommends, therefore,
that USAID pursue two mutually reinforcing strategies:

--A departmental approach to expanding access to counseling and services
and developing a second generation of messages on prevention, safe sex,
human rights, and care and support for the afflicted, and

p ii

--Increased focus at the national level on vulnerable or high-risk
communities most in need of services.

In the development and implementation of these strategies, related issues
of commodity security, funding, and program and donor coordination will
have to be addressed.

Major Recommendations

Departmental Strategy

The team recommends that a partnership between the public and private
sectors be established in order to control STIs and HIV in Haiti. This
partnership should entail the development of Centres de Refrence, or
Referral Centers, which would provide high-quality voluntary counseling
and testing (VCT) and other STI and HIV services. These Centers should
first be established in three departments where the more experienced
private and public health facilities are located. These three departments
are: Departement du Nord: Hpital Dpartemental Justinien in Cap Haitien,
Centre de Dveloppement Sanitaire (La Fossette), and FOSREF
Dpartement de L'Artibonite: Hpitaux Dpartementaux de Gonaives et de St.
Marc, Hopital Albert Schweitzer, and FOSREF Departement de Grande Anse:
Hpital Dpartemental St. Antoine in Jeremie and the CARE Program of Support
to Persons Living with HIV/AIDS. Additional departments can be added as
experience is gained, such as in the Departement du Nord-ouest, where
statistics show incidence of HIV to be high, especially around Port de
Paix. <snip>

p 1


This report examines the role that the U.S. Agency for International
Development (USAID) should play in Haiti during the next two to five years
to support national efforts to combat the HIV/AIDS epidemic. The team was
convened in May 2001 at the request of the USAID Mission to Haiti. The
U.S. Congress earmarked $4 million for HIV/AIDS prevention and control
assistance to Haiti in Fiscal Year (FY) 2001, along with $1 million for
prevention of tuberculosis (TB), which represented a threefold increase in
the amount of such funding in recent years for these purposes in Haiti.
Unfortunately, funding for all USAID activities in Haiti for FY 2002 will
be reduced from $50 million to $35 million, which will seriously affect
the Missions population, health, and nutrition programs. <snip>

The timing of the assessment coincided with two significant public events
that took place in Haiti in May 2001, the first just as the team was
beginning its work, and the second near its conclusion. First, on May 7,
2001, the government of Haiti launched a formal six-month process
to develop a national strategic plan to combat HIV and AIDS. Second, on
May 20, 2001, churches, youth groups, community organizations, and
institutions throughout Haiti celebrated the International AIDS Memorial
with formal events and informal gatherings, candlelight vigils,
and personal testimonies. The scope and fervor of participation in the
Memorial provided compelling evidence of the extent to which HIV/AIDS
affects all aspects of Haitian life, and spoke to the growing willingness
of people to spread messages of prevention, care, and personal support.

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3.1 Status of the Epidemic

Sentinel HIV surveillance has been conducted in Haiti since the early
1990s. A 1998 study estimated an infection rate in the adult population
of 6 percent in urban areas and 4 percent in rural areas. Even though
infection rates are no longer rising and may be declining in some areas,
these statistics make Haiti by far the hardest hit country in the
Caribbean region. For example:

--Between 260,000 and 300,000 Haitians are HIV-positive, with 35,000 to
45,000 new cases occurring each year (POLICY Project projection, as
presented by MSPP to the United Nations General Assembly Special Session
on HIV/AIDS, June 2001).

--Of 8,000 patients tested in 2000 at the Groupe Haitien dEtude du Sarcome
de Kaposi et des Infections Opportunistes (GHESKIO) Centers, 22 percent
were sero-positive for HIV.

--On average, 110 people die from AIDS in Haiti each day. The cumulative
number of deaths from AIDS in Haiti could reach one million by 2010.

--In 2000, 9,124 cases of TB were reported to the World Health

--According to GHESKIO Centers, 50 percent of patients with TB in
hospital have AIDS, and 30 percent of patients AIDS who do not receive
treatment develop TB.

--A 1994 study 3 of 1,000 pregnant women in a poor section of
Port-au-Prince showed that 47 percent had at least one STI. Nationwide,
across all population groups, 40 percent of pregnant women when tested
were diagnosed with at least one

--Studies by E. Gaillard and S. Hunter suggest that 133,000-190,000
children under age 15 had lost one or both parents to AIDS by 1998, and
that the number could reach as high as 400,000 by 2010.

--Dependable VCT services are available at only four sites in Haiti, all
in the private sector. Although as many as 10 public hospitals have HIV
testing kits, because of faulty equipment, lack of training, or other
reasons, none provide acceptable VCT services.

--A dependable epidemiological surveillance system that meets Haitian and
international standards does not exist.

Controlling the epidemic in Haiti and limiting its negative consequences
are difficult for multiple reasons that have behavioral, social, and
political factors. They include: <snip>

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--Protected sex is not widely practiced, despite a nationwide condom
social marketing program (in 1995, condom use among women and men was 12
percent and 32 percent respectively, according to the Acquired Immune
Deficiency Syndrome Control and Prevention Program (AIDSCAP));

--The common behavior of having multiple sexual partners, and lack of
empowerment by women to negotiate sexual relationships (37 percent of
women interviewed in a recent study reported having been forced to have
sexual relations without their consent);

--High levels of denial by families and communities, and the acute stigma
attached to persons with HIV and their families, especially in rural

--Country-wide lack of access to competent screening for STIs and
voluntary counseling services;

--Intermittent government leadership, which has rarely extended beyond
support for the planning process, and governments that have not been able
to provide resources to ensure adoption of norms and delivery of services
in the public sector;

--Government involvement with the HIV epidemic is confined to the health
sector, and relies almost entirely on a dedicated but underfunded National
AIDS Coordinator within MSPP;

--Most services, in both public and private sectors, are located in urban
areas, whereas 65 percent of Haitians live in rural areas;

--A feeling that Haiti has been isolated from international participation
in AIDS forums and dialogue, especially since the close of the AIDSCAP
office in 1996.

AIDS has been an additional burden to a country that has chronic poverty
and deficiencies in good governance. Some Haitians still refer to HIV as
"Kat Aches", Creole for "four H's", as though they were unaware of the
regrettable legacy of blame and shame that the term represents. <snip> In
the late 1980s, official U.S. government publications referred to the
principal risk populations (or vectors) for HIV as hemophiliacs, heroin
addicts, homosexuals, and Haitians. A compelling history of cultural and
political legacies at play can be found in Farmer's book, "Haiti and the
Geography of Blame".


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Stuart Leiderman
Environmental Response