HIV-1 care in resource-poor settings: a view from Haiti

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Originally published in The Lancet, Vol 362, 20 Sep 2003. Reprinted with permission from the author.

When asked, "Have you no morals?" Alfred Doolittle, in George Bernard Shaw's Pygmalion, answered: "Can't afford them, governor. Neither could you if you was as poor as me."1 The modern concept of human rights underpins a moral society and holds governments responsible for fulfilling these rights. From informed consent to the right to privacy, civil and political rights have dominated the human rights focus of the HIV-1 epidemic. Yet, the economic and social rights of people with HIV-1 infection, in particular the rights to health care and to share in scientific advances, are glaringly disparate between rich and poor countries. This disparity has become the focus of debate in transnational HIV-1 vaccine research.

  
Clinique San Michel, January and July 2003

Haiti, whose yearly health budget is $US15 million, less than $2 per person per year, is one of the sites for the HIV Vaccine Trials Network. Health care and HIV-1 treatment will be guaranteed to trial participants. Yet, Haiti's public-health infrastructure cannot provide even basic medical care for the rest of the population. How can governments as poor as Haiti's fulfil the right to health care without external help?

The Global Fund to Fight AIDS, Tuberculosis and Malaria is the first international fund with which antiretrovirals can be purchased. With help from the Haitian Ministry of Public Health, money from the fund has been used to provide HIV-1 prevention and treatment through-out Haiti: in Port au Prince at GHESKIO centres, and in central Haiti by Partners In Health's HIV Equity Initiative (HEI).

Providing a comprehensive HIV-1 treatment programme has necessitated revitalising the public-health infra-structure, and improving the delivery of essentials such as vaccination, sani-tation, and clean water. For example, the Clinique San Michel in Boucan Carre serves a rural population of 40 000. Because of the financial crisis in Haiti, the clinic was in disrepair, poorly stocked, and inadequately staffed (figure 1). During the past 10 years, fewer than ten patients per day were seen and no testing or treatment for HIV-1 or tuberculosis offered. Early in 2003, HEI stocked the clinic with essential medicines, hired and trained health workers to do active case finding, and increased wages to prevent the drain of staff from this rural area to Port au Prince. After 6 months, the clinic sees more than 150 patients for general medical care daily (figure 2), does more than 100 HIV-1 tests per month, and treats about 100 patients for tuberculosis. Thus, improving basic health care has been a building block in expanding HIV-1 prevention and treatment.

Certainly, the search for a vaccine is of urgent importance. Yet the achievements of the first two decades of HIV-1 research, in particular HAART, have not been shared with resource-poor countries. Not only are poor governments unable to provide HAART, but also the public-health community has opposed provision because of cost and perceived competition with resources for HIV-1 prevention.2

In 1998, in rural Haiti, we began providing HAART to a few patients with advanced AIDS. This effort was met with scepticism because of cost and the perceived lack of evidence that such therapy would be feasible, sustainable, or effective in resource-poor settings.3,4 Access to HAART has now been scaled up, and should cover all central Haiti and Port au Prince in the next 5 years. A patient in rural Haiti comments: "I was a walking skeleton before I began therapy. I was afraid to go out of my house and no one would buy things from my shop. But now I am fine again. My wife has returned to me and my children are not ashamed to be seen with me. I can work again", (figures 3 and 4).

  
Before initiation of HAART and after 1 year of HAART

Governments are the guarantors of human rights, but it is only with international assistance that the government of Haiti has been able to begin to address the right to health. The Global Fund is the first step towards a worldwide responsibility to fulfil this right. However, the fund lacks support from donors and will not meet its financial needs for the third round of proposals.5 If the medical community is to use data generated in high-burden and vulnerable populations to develop an HIV-1 vaccine, we must ensure that the global community will help governments fulfil the right to health and share the fruits of research with the world's poorest communities.

Joia S Mukherjee, Partners In Health, Harvard Medical School

1. Shaw B. Pygmalion. New York: Brentano, 1916.
2. Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART in sub-Saharan Africa. Lancet 2002; 359: 1851-56. [Text]
3. Farmer P, Léandre F, Mukherjee JS. Bull World Health Organ 2001; 79: 1145-51. [PubMed]
4. Gilks C, AbouZahr C, Türmen T. HAART in Haiti--evidence needed. Bull World Health Organ 2001; 79: 1154-55. [PubMed]
5. Fund the Fund. The current funding crisis. http://www.fundthefund.org/crisis.html