The Sleeping Catastrophe: HIV/AIDS in an Already Devastated Haiti.

Haiti has been a broken country at the best of times. The devastating January 12th earthquake has thrown the drastically poor nation under the world spotlight once again, but for all the wrong reasons. At times, it would seem like the very planet itself was conspiring against this small, humble, Caribbean nation. Even, on its best of days, Haiti is crippled by endemic poverty, which is further compounded by the inexperience as well as the corrupted nature of its government. With an estimated 230,000 casualties, the social and economic consequences of the natural disaster that has just struck will incontrovertibly reverberate throughout Haitian society for generations. Moreover, with the nation’s capital, Port-au-Prince, now in ruins and the vestiges of health care infrastructure all but destroyed, little care is available to those who need it most, especially those requiring specialized assistance, this includes the 120,000 Haitian people currently living with or affected by HIV/AIDS.

The Global Pandemic
Human-Immunodeficiency Virus, or HIV, was first identified in 1981. Since then, the virus has resulted in the deaths of over 25 million people worldwide, making it the most socio-economically expensive pandemic in human history. As of 2007, according to the United Nations Program on HIV/AIDS (UNAIDS), over 33.5 million people are infected with HIV/AIDS. The virus does not discriminate. In the United States nearly 1.6 million people live with HIV, with as many as 350,000 with no knowledge of their being infected with the virus. In Washington, D.C. alone, nearly 3% of all residents are currently living with, or are affected by HIV. The Center for Disease Control (CDC) has called it a “generalized and severe epidemic,” as the rate of infection in the Washington D.C. area is greater than it is in some West African countries. Upon signing the Ryan White HIV/AIDS Act last year, President Barack Obama said; “We often speak about AIDS as if it’s going on somewhere else, and for good reason [...] but often overlooked is the fact that we face a serious HIV/AIDS epidemic of our own — right here in Washington, D.C., and right here in the United States of America.” Clearly, HIV is everyone’s problem.

Globally, HIV/AIDS is a complex and contentious issue. In both the developed and developing worlds, there still persists a widespread stigma, fear, and a sense of shame and denial concerning HIV/AIDS, especially in Asia and Sub-Saharan Africa. In order to alleviate the consequences of HIV/AIDS, organizations like UNAIDS encourage countries to provide universal access of information and treatment to high-risk groups, such as men who have sex with men, intravenous drug users, young people, children and orphans. However, many governments still enforce legislation that hinders efforts at curtailing the global pandemic. In 2007, Thabo Mbeki, former president of South Africa, one of the countries most severely affected by HIV/AIDS (more than 15% are HIV-positive), received widespread criticism among AIDS experts for advocating a position of AIDS denialism during his presidency. Such controversial policies further stigmatize those infected with HIV, reinforcing its role as ‘The Silent Killer’ as a result of people being ashamed to get tested and receive treatment.

Despite labor and cost intensive worldwide research into HIV/AIDS, no vaccine or cure has yet to be discovered. Modern anti-retroviral treatments (ART) have reduced HIV infection from a certain death sentence to a lifelong chronic illness. In developed countries where ART is easily accessible, people living with HIV (PLWHIV) are able to adhere to strict Highly Active Anti-Retroviral Treatment (HAART), which can suppress the disease progression of HIV almost indefinitely.

HIV is a pathogenic lentivirus, emanating from the retrovirus family. The virus causes disease progression within the human body by destroying the host’s immune system. The virus targets CD4+ T Lymphocyte cells – the primary defense mechanism of the human immune system. HIV inserts its own genetic code into the host cell’s DNA, forcing the infected cell to produce new HIV upon activation. Lentiviruses are generally slow acting; it can take as little as a few months or up to as many as 20 years for the virus to progress to active disease. Almost all people infected with HIV eventually develop a condition known as Acquired Immunodeficiency Syndrome, or AIDS, the final stage of HIV infection. It is important to realize that HIV and AIDS are not one and the same; a person who has developed AIDS is infected with HIV, but a person infected with HIV does not necessarily have AIDS. In most cases, once AIDS is diagnosed, the immune system has been irreparably compromised. AIDS patients typically develop one or more of 26 opportunistic infections that have been identified as AIDS defining illnesses. These range from mild bacterial infections, such as Candidiasis (thrush) to serious cancerous conditions, such as Kaposi’s sarcoma or non-Hodgkin’s Lymphoma.

HIV/AIDS in Haiti
When the HIV/AIDS pandemic first emerged in the 1980’s, Haitians suffered widespread discrimination as the country’s rates of infection skyrocketed. The country’s name became almost synonymous with virus. Furthermore, Haiti suffered regional – almost pariah status – isolation when it was alleged that emigrating Haitians had introduced the virus to the United States. At one time, the CDC greatly offended Haiti by listing the country under the 4 H’s moniker – hemophilia, homosexuality, heroin use, and Haitian – to describe the demographic groups most at risk for an HIV/AIDS infection. During the presidency of Jean-Claude Duvalier, in an unfounded attempt to remedy Haiti’s tarnished health performance, it was illegal to mention AIDS – and later HIV – in any form whatsoever.

According to the World Bank, Haiti spends no more that $8 per capita on health care annually and has only 2.5 physicians per every 10,000 people. It is no surprise, then, that HIV/AIDS has been a leading cause of death among Haitians for more than 20 years. The introduction of effective and free treatment programs provided by organizations such as the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) has significantly improved lives. However, Haiti’s HIV/AIDS incidence rate is still one of the highest on Earth, with up to 3% of all adults, aged 15 – 49, infected with the virus. Furthermore, unlike its neighbors in the western hemisphere, the main highway of transmission in Haiti is unprotected heterosexual intercourse. Despite these troubling statistics, HIV/AIDS infection had been on a steady decline before the earthquake, but many experts now fear that this could change very quickly. The recent disaster has the potential to damage the treatment and care momentum that Haiti has been building, as the international focus on the island inexorably shifts further toward urgent humanitarian and reconstruction efforts relative to the January 12th earthquake. Among AIDS experts there is real fear being felt that the earthquake will pull resources away from coping with HIV/AIDS.

For over 27 years, GHESKIO has been providing life-saving treatment and therapy to tens of thousands of Haitians living with or affected by HIV/AIDS. This organization provides free HIV voluntary counseling and testing, AIDS care, tuberculosis treatment, reproductive health services, and management of sexually transmitted diseases. GHESKIO is one of many programs worldwide that has received sizeable funding from the President’s Emergency Plan for AIDS Relief (PEPFAR), an initiative started by the Bush administration to address the global HIV/AIDS pandemic. PEPFAR’s initial $15 billion five-year plan (2003-2008) provided ART to over 2 million PLWHIV, while at the same time preventing an estimated seven million new HIV infections. A 2009 Stanford study found that PEPFAR had reduced global death rate due to AIDS by some 10% in the countries involved, including Haiti. The success of the five year plan prompted by the State Department Office of Global AIDS Coordination to renew PEPFAR until 2013 with an extended $48 billion budget.

The Re-emergence of HIV/AIDS
The concerns expressed by HIV/AIDS experts worldwide is that by the time assistance reaches those who require specialized health care, it will be too late. HIV continues to evade modern medical science due to the virus’ highly mutagenic nature. Even the briefest “missing of doses of ART medications can cause blood levels of the virus to surge, which can lead to treatment resistance.” With up to 120,000 Haitians infected with the virus, it is imperative that treatments be delivered in a timely fashion, but given the current chaotic atmosphere presently in Haiti, especially in Port-au-Prince, where the majority of the country’s HIV sufferers reside, there is no guarantee that the affected population can continue to adhere to exact treatment regimens. The flow of ART could be interrupted at any time. Intermittent administration of ART is in some cases even more devastating then the abrupt, complete termination of treatment, as it allows the virus to become more familiar with the ART medications, and develop resistance more rapidly and comprehensively. Despite all of the other challenges faced by GHESKIO in the aftermath of the January 12th earthquake, including substantial structural damage inflicted on its 4,654m2 campus in the heart of Port-au-Prince, the organization amazingly has managed to almost immediately resume ART to approximately 80% of its patients.

GHESKIO is not alone in devoting itself to helping HIV sufferers in Haiti; the New York based Aid for AIDS and the Red Cross are also active in assisting PLWHIV since the January 12th earthquake. According to Paul Garwood of the World Health Organization (WHO), “There is a need to quickly resume these basic health services to ensure people with already existing conditions receive the treatment they require.” Despite this encouraging comment, however, the WHO remains surprisingly inactive when it comes to the coping with the problem, issuing a health risk assessment report that only briefly mentions “the continuity of care for chronic diseases such as HIV and Tuberculosis,” with no actual detailed plan of action up its sleeves.

The need for international organizations to regain an intensified focus on approaching HIV/AIDS is an urgent one. Haitians practicing risky behavior are at higher risk than ever before for potential infection. Without an intensified international focus on universal access of treatment and care, it is highly likely that HIV/AIDS infections will once again wreak havoc on the small Caribbean country. “HIV was a crisis in Haiti before the earthquake,” says Luis Ubinas of the Ford Foundation, which recently donated $250,000 to Clinton’s HIV/AIDS Initiative (CHAI). The international community, according to Ubinas, has a “responsibility, to help build a strong and effective system of prevention and treatment that endures for the future.” Already, over 7,500 Haitians die from AIDS-related complications each year. To even temporarily delay paying attention to the issue is risking further long-term disaster.

Haiti’s ‘Shaky’ Socio-Economic Future
The crisis in Haiti is going to get worse before it will get better. The devastation caused by the January 12th earthquake is likely to produce repercussions for generations. Haiti has been essentially immune to the recent economic crisis, ironically due to its all but non-existent formal economy and perpetual rock-bottom poverty. However, the country has continually endured economic failure, to which HIV/AIDS has been enormously attributed. Haiti’s economy depended heavily on tourism, with 54% of its GDP coming from the services sector before the earthquake. At the beginning of the HIV/AIDS pandemic Haitian society was decimated by the complete collapse of its tourist industry in the wake of international hysteria and paranoia as the virus spread. Little else is available to Haitians to make a living besides accommodating foreign visitors. Due to the minimal opportunities within Haiti, the fact that large levels of foreign aid compensate its largely failed economy is not surprising. Poor nations like Haiti depend on human capital to encourage further economic expansion and the level of development required to lift millions of its citizens out of abject poverty. Continued high HIV/AIDS infection in Haiti will continue to hinder social and economic development efforts in the long term. Furthermore, high rates of infection combined with the decimation felt in the earthquake are likely to deal Haiti’s already broken economy an even greater blow. The vicious cycle of poverty is further compounded as international focus moves away from traditionally coping HIV/AIDS to more urgent humanitarian efforts. It is likely that universal access to HIV/AIDS information and treatment will suffer, further placing thousands of Haitians at greater risk to infection.

Haiti has been unjustly synonymous with HIV/AIDS for a much of the past two decades. The issue was a crisis long before the earthquake, and although infection rates were finally on the decline, recent events have ensured that the virus will continue to plague the small island nation further into the future. The efforts of organizations such as GHESKIO provide invaluable care to Haitian HIV/AIDS sufferers. Universal access to care and information is pivotal in attacking the Haitian pandemic at its source: unprotected heterosexual intercourse. HIV/AIDS treatment has taken a backseat within the international community to the January 12th earthquake. However, to delay re-addressing the issue with the traditional emphasis will ensure that chronic and new problems stemming from HIV/AIDS will carry this recent disaster far into the future. To delay coping with HIV/AIDS any further means that 27 years of hard work may have only been a temporary solution. Humanitarian efforts in Haiti are of crucial importance to save as many lives as possible but this should not be at the cost of damaging the efficiency of HIV/AIDS care. Both humanitarian disasters require sustained attention and devotion.