Small Steps in Preventing and Treating HIV/AIDS in Latin America and the Caribbean

Small Steps in Preventing and Treating HIV/AIDS in Latin America and the Caribbean

By Eliza Barclay

At a small medical clinic in the Cinco Casas bateye, an isolated rural community in the central part of the Dominican Republic, 43 AIDS patients are receiving anti-retroviral therapy. In some ways, this is a major achievement; these patients are part of a highly stigmatized population of descendents of Haitian sugar-cane workers who were formerly receiving little to no medical attention at all. But they are incredibly fortunate relative to thousands of others like them. While the Dominican Republic (DR) has managed to keep its AIDS rates from rising in the last decade, it still has been slow to reach those with and affected by the virus. And the DR is many steps behind where it should be, according to health experts in the region.

Eighty percent of the residents of the Cinco Casas bateye live in extreme poverty. The Bateye Relief Alliance Dominicana (BRA Dominicana) is a nongovernmental organization that provides free medical services in the bateyes—communities adjacent to the now mostly fallow sugar cane fields—and runs the clinic in Cinco Casas. According to Maria Virtudes Berroa, executive director of BRA Dominicana, bateye residents have been systematically excluded from the public health care system because of racial, economic, and social discrimination. But while the bateyes have mostly been forgotten or ignored for centuries, they are starting to receive some scrutiny because of an alarming figure: between 5 percent and 12 percent of Dominican bateye residents are HIV-positive.

Even though the national HIV prevalence rate in the DR is relatively low – 1.1 percent, according to the Health Ministry – the lack of an effective national strategy for confronting the disease is emblematic of the challenge the disease poses for middle-income countries in Latin America and the Caribbean (LAC). Few countries in the region have had to face an epidemic of the staggering proportions as sub-Saharan Africa’s – yet progress in this region has been very slow, save for a few anomalies like Cuba and Haiti.

“Sometimes it’s easier to work in a country that has almost no health infrastructure, like Haiti or parts of sub-Saharan Africa, than a country that has some, like Peru or the Dominican Republic,” said Keith Joseph with Partners in Health, a social justice and health NGO that works in Haiti, Peru, Mexico, and several other countries. Health ministries and other public entities in middle-income countries are often slow to acknowledge the seriousness of the HIV epidemic and then resist offers of assistance, he added.

It is difficult to generalize about the epidemic’s regional profile because prevalence, prevention efforts, and access to treatment vary so widely country to country and within the LAC region. By the end of 2006, the number of people with the virus is estimated to reach 1.95 million, 210,000 more than in 2004, according to the 2006 AIDS Epidemic Update, an annual report produced by the Joint United Nations Program on HIV/AIDS (UNAIDS) and the World Health Organization (WHO). But by 2015, LAC is expected to have nearly 3.5 million people living with HIV.

At the end of 2005, the Caribbean's HIV/AIDS prevalence rate of 1.2 percent was the second highest in the world, after sub-Saharan Africa, according to UNAIDS/WHO. The island of Hispaniola, which includes Haiti and the DR, accounts for about 75 percent of those cases. But the Bahamas, Guyana, Belize, and Trinidad and Tobago also face serious epidemics, but have so far received little attention. Each has a prevalence rate of over 2 percent.

According to Disease Control Priorities in Developing Countries, 2nd ed. (DCP2), a comprehensive public health guide launched in April 2006, successful HIV/AIDS programs require high-level political leadership, active engagement of civil society and religious leaders, population-based programs designed to alter social norms, condom promotion, surveillance and control of sexually transmitted infections (STIs), programs to combat stigma and discrimination, and interventions targeting key “bridge” populations.

“The biggest barriers to AIDS work in the region are stigma, discrimination, the link to homophobia, and a fear of being tested,” said Sir George Alleyne, the former head of the Pan-American Health Organization (PAHO) and a DCP2 editor. “The reactions to the epidemic have been more vigorous; they’re connected to history and religion, a perception of sin and morality, moral deviance beliefs, as well as laws that make homosexuality a crime.”

Brazil, Cuba, and Mexico have each developed strong national policies that have prioritized the AIDS epidemic by implementing effective national disease control programs, according to DCP2, but much of the rest of the region lacks such focus and leadership.

In LAC, the epidemic is concentrated in key populations, according to the UNAIDS. The most affected groups differ from country to country: sex workers in the Caribbean, drug injectors in Puerto Rico, men having sex with men in Mexico and Central America.

LAC, like every other region of the world, also continues to be challenged by the lack of good evidence needed to help tailor prevention and care interventions for particular manifestations of the disease.

Treatment for HIV/AIDS is a bright spot in the fight against the epidemic in the region. Anti-retroviral drugs (ARVs) have become more widely available because of increased political will, a reduction in drug costs, influential NGOs, and contributions from international donors. By the end of 2006, an estimated 345,000 people in LAC were receiving ARVs, according to WHO. The number is more than 50 percent greater than the number of people receiving treatment in 2003, and accounts for 75 percent of the total population in need of the drugs. Worldwide, only about 20 percent of those needing ARVs receive them.

Another major factor shaping policy, prevention, and treatment programs in the region is the increasing participation of international multilateral and bilateral funders, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Clinton Global Initiative, and the U.S. Agency for International Development (USAID). But according to interviews with HIV and health experts in the region, there is some sense that the epidemic’s scale in Africa sometimes overshadows the smaller problem in LAC. Some fear that international funders will seek to reach more people and will be drawn to projects in Africa and other regions where more people are affected by the virus.

The Dominican Republic

The example of the DR shows how HIV/AIDS programs in LAC can be slow to get off the ground, but that interventions with “bridge” populations, like sex workers, can help stem the spread of the disease.

According to Joseph, who worked extensively in the DR and Haiti with Partners in Health and the Columbia University School of Public Health, HIV work in the DR has been hampered by corruption in the health ministry and “irresponsible behavior” by international funding entities.

“[One funder] wanted the scale up [in ARVs] to happen quickly to get the numbers up,” Joseph said. “But you need basic health services in place before you can do that so it became a big mess, and the government got useless advice from [another program].”

Indeed, according to DCP2, poorly coordinated scale-up of ARVs in some developing countries runs the risk of jeopardizing the duration of clinical benefit for the first group of patients who receive low-quality care and depress future response rates if drug resistance increases.

The DR also still lacks free, rapid testing for HIV. Joseph says he’s surprised the DR’s HIV rates have remained so low given the mishandling of the epidemic, but he also noted that the last national health survey was done in 2002 and current prevalence figures are likely underestimates.

Other NGOs like BRA Dominicana have also not been impressed with the government’s effort to prevent and treat the disease.

“The government’s response has been unsatisfactory, they should really intervene more,” said Berroa of BRA Dominicana Inc. “They have more than 40 units dispensing ARVs, but many of them don’t function well, and patients face the stigma from hospital workers when they go for their treatment.”

But there have been some successes, particularly in prevention among the nation’s nearly 100,000 sex workers. According to DCP2, studies show that peer-based programs promoting condom use can be an effective intervention. Unprotected intercourse is less common, communication about condoms with partners is more common, and HIV incidence is significantly lower when peer-based programs with groups like sex workers are in place.

The HIV prevalence rate among the DR’s sex workers ranges from 2.5 percent to 12.4 percent, according to the Center for Orientation and Integral Research (COIN), an NGO that works to educate and empower Dominican sex workers. Outreach work to sex workers using fellow sex workers, known as messengers, to communicate health issues has helped stabilize the epidemic within that group, according to Luis Moreno of COIN. COIN has also begun prevention and education efforts on other Caribbean islands with large sex tourism industries to reach Dominicans working there and to support other countries’ efforts to engage sex workers in the HIV/AIDS discourse.

Haiti

The failure to reach HIV/AIDS patients in the DR is more striking when compared to the success in its significantly poorer neighbor, Haiti. In the late 1990s, Haiti had a prevalence rate of 6 percent, but it has dropped to about 2 percent (3.2 percent in urban areas). It is the only country in LAC that has seen a notable drop in the HIV prevalence rate, due mostly to the long-term involvement of strong NGOs like Partners in Health and Groupe Haitien d'Étude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO).

International funders are also optimistic about Haiti. “Haiti has a very good chance to achieve results and make an impact in fighting HIV/AIDS,” said Bertha Ormeno, Haiti fund portfolio manager for the Global Fund, during the launch of Round V funding in Port-au-Prince in October 2006.

The country is now distributing ARVs to 7,000 people (while the DR is only reaching 3,500) with an aim to reach 40,000 by 2010.

The country has also been able to test well over 70,000 people by launching a rapid-testing program through the help of four key NGOs working in the country: GHESKIO, Partners in Health (PIH), Management Sciences for Health (MSH), and Catholic Relief Services. Some of these groups are partnering with USAID, CGI, and the Global Fund.

“The way that Haiti is approaching AIDS could be a model for the whole Caribbean,” said Georges Dubuche, with MSH. “Haiti is showing that the poor can be trained to work as community health workers to provide care.”

PIH’s full-service medical center, Zanmi Lasante, in the central plateau of Haiti, has developed a unique AIDS treatment model. As of September 2006, the center was monitoring more than 8,930 HIV-positive patients and dispatching community health workers to provide directly observed antiretroviral therapy to 2,377 patients with advanced AIDS. The center’s AIDS program also offers extensive prevention and education efforts in Haiti.

According to DCP2, first-line ARV therapy has a cost effectiveness of $350 per disability-adjusted life year. Cost effectiveness has steadily improved as the prices for ARVs have come down dramatically.

But according to Jean-Robert Brutus, the Haiti country director for Family Health International (FHI), a group that receives USAID funding for AIDS work in Haiti, the country may struggle to find as many as 40,000 patients because the selection criteria is strict. So far, only one of every six in need of ARVs has been identified. “But we have to be strict with who we put on ARVs because we want people to maintain treatment and avoid developing resistance to the drugs.”

While Haiti and the DR today have had little cross-border collaboration on the AIDS issues, public health experts are beginning to worry because 1 million Haitians cross into the DR every year to work. Others, like FHI’s Brutus, are concerned that Haiti’s success at bringing the prevalence rates down may mean that the country is denied funding in the future, particularly from the Global Fund. “We might not get the Round VI money for being successful,” said Brutus. “It would be a crime to step back from Haiti.”

Indeed, LAC countries, like the rest of the developing world, still have a long way to go in the fight against HIV/AIDS. As stated by UNAIDS executive director Dr. Peter Piot in November, “We need to greatly intensify life-saving prevention efforts while we expand HIV treatment programmes.” 

Eliza Barclay is a freelance journalist based in Mexico City. She can be reached at elizabarclay@gmail.com.