Haitian Program May Serve As Model for Drug Therapy in Developing World

A "radical" program in Haiti that delivers and monitors the use of antiretroviral drugs is being "closely watched" as a model for providing "complex" HIV/AIDS treatments in the developing world, the South Florida Sun-Sentinel reports. Run by Dr. Paul Farmer, an associate professor of medicine at Harvard Medical School, and the Boston-based charity Partners in Health, the initiative not only supplies some HIV/AIDS patients in the rural Central Plateau region with drugs, but also teaches local residents to monitor patients' drug adherence. Operated out of Clinique Bon Sauveur, a "fortress-like" hospital, the program is part of a "comprehensive community health care program" that offers services ranging from prenatal care to dentistry. "As far as I know, we're the only ones providing this therapy in Haiti, and that's a scandal," Farmer, who has intermittently worked in the country since the early 1980s, said. Although drug companies recently have "slashed" prices on anti-AIDS medications, critics say complex drug therapies may be futile in developing nations where health infrastructure is lacking and treatment adherence may be low. However, if a program can work in Haiti, where the public health system has "collapsed" and "nothing resembling social welfare" exists, it may be prove feasible in other developing nations, the Sun-Sentinel reports.

The HIV Equity Initiative
In 1995, Partners in Health launched the HIV Equity Initiative, supplying HIV-positive pregnant women with AZT in order to reduce vertical transmission. In 1997, the program expanded to offer prophylactic triple-drug therapy to rape victims. And in 1998, the initiative began offering antiretroviral drugs to a "small" group of patients who failed to respond to treatment for opportunistic infections, such as pneumonia and tuberculosis. Today, 44 patients receive the antiretroviral drugs and all HIV patients are "carefully monitored" and treated for opportunistic infections before being placed on the more expensive AIDS drugs. Through a series of practices, the clinic has reduced costs and found "cheaper" diagnostic and treatment "alternatives." Initiative workers have trained locals to participate as monitors in directly observed treatment, a "well-known medical strategy" whereby health care workers observe patients taking their medicines to ensure compliance with the treatment regimen. Such adherence is especially important with antiretroviral drugs because noncompliance can lead to drug-resistant strains of HIV. While critics argue that drug regimens become more difficult to follow in nations where basic resources like food and water are scarce, Farmer pointed out that studies have shown patients in developing countries to be "no less diligent" in taking their medications than those in some U.S. cities and added that using the "drug resistance argument" to deny treatment now that drugs prices have decreased is "simply immoral."

Exercising Caution
Others, such as Dr. Tom Coates, executive director of the AIDS Research Institute at the University of California-San Francisco, remain cautious for a number of reasons. "I don't want to deny life-saving drugs to people in developing countries, but this certainly isn't an area that we want to go into blindly to just hand out drugs to poor people. In San Francisco, we've found that these drugs have paradoxically raised the infection rate. People felt they were chemically protected and they didn't change their behavior ... There's a real danger that not only do you hurt the patient, but you end up with a serious problem with drug-resistant strains," he said. The World Bank also "warned" last year that antiretroviral therapy may "undermine prevention efforts by encouraging the mistaken impression that scientists have found a 'cure' for AIDS" and stressed the notion that treatment "should not obscure prevention -- still the most effective approach against the virus." But Farmer's program is offering hope to those in the community and to those searching for a model for AIDS treatment in the developing world. "What Paul Farmer is doing in Haiti is absolutely phenomenal ... If you had 25 Paul Farmers in Haiti and the Dominican Republic, then you would be well on your way to stopping the epidemic. The problem is that you don't have 25 Paul Farmers in the world, much less in Haiti," Dr. Peggy McEvoy, the recently retired Caribbean chief for UNAIDS, said (Collie, South Florida Sun-Sentinel, 6/17).

Battling Stigma Through Education
In a related article, the Sun-Sentinel today reports on the Association for National Solidarity (ASON), Haiti's first AIDS advocacy group. A grassroots organization, ASON was formed by political dissident Saurel Baujour, who learned of his HIV-positive status when attempting to gain political asylum in the United States in 1993. At the time, AIDS was classified as a public health threat and Baujour was denied entry. Returning to Haiti and witnessing the "social stigma that was crippling efforts" to combat HIV/AIDS, Baujour and others formed ASON to assist HIV-positive individuals and their families. "This is really no different than any other fight for democracy. In fact, it's more of a struggle. When you look at the enormity of the discrimination against people with the disease here, the poverty and the efforts to get treatment, you realize it's a greater fight than the one we went through [politically] in the early 1990s," he said. The group has focused on HIV/AIDS education and prevention; however, traditional religious beliefs have made it difficult to engage in an open dialogue about HIV/AIDS, and "fears" of catching the disease through water or casual contact persist. Such fears were magnified by the "international stigma" Haitians faced in the early 1990s when the CDC included them in the "4-H" risk group -- homosexuals, heterosexual IV drug users, hemophiliacs and Haitians.

Bringing HIV/AIDS to the Fore
ASON and others are playing an "important role in reducing the stigma" attached to the disease in Haiti, Jan Voordouw, an official at the Panos Institute, an international aid agency, said. ASON members organize public speaking events and performances, "brav[ing] threats to go public" with the disease, and plan to increase efforts to collect antibacterials and other medications for HIV/AIDS patients, who "[l]acking anything resembling social insurance," must pay for their own medications, the Sun-Sentinel reports. "There is still a great deal of stigma attached to the disease, but that is changing among the younger generation ... [who] have grown up with it, have seen it and know many who are infected. They are much more open about discussing and dealing with it," Voordouw added. ASON continues to focus on "combat[ing]" the stigma, especially as it relates to women. "Here to have AIDS is often to be treated like you're guilty of a crime, but the women are the ones who suffer the most ... In ASON, we're trying to respect women, as well as protect our wives who don't have the disease," Baujour said, adding that his wife has "kept [him] alive" (Collie, South Florida Sun-Sentinel, 6/19).