Donors single out AIDS

Despite being the only public hospital serving over 500,000 people in Haiti's South-East Department, St Michel Hospital in the coastal town of Jacmel has only one ambulance and no functioning X-ray machine; it lacks a medical director, is short of nurses and was without electricity for months before a broken generator was finally replaced.

Only one corner of the hospital - the HIV/AIDS clinic - is fully staffed and well-equipped, even boasting a computerised record-keeping system. Unlike most other services offered at the hospital, it is also completely free.

This glaring imbalance is the result of international donor funding earmarked specifically for HIV/AIDS programmes, in the context of a severely cash-strapped public health sector.

"There are other illnesses we see every day, but because they don't have HIV, we can't help them," said Margarette Vernet, the hospital administrator. "They put so much money into AIDS and they don't even look at other problems, like maternal mortality."

Haiti has the highest rates of infant and maternal mortality in the Western hemisphere, according to UNICEF. HIV/AIDS is still a major killer but so are malaria, tuberculosis, diarrhoea and respiratory infections.

A global debate has raged for the past year over whether the large sums of donor dollars dedicated to HIV/AIDS programmes has strengthened or weakened national health systems.

There are other illnesses we see every day, but because they don't have HIV, we can't help them

A report by the Washington-based Centre for Global Development, released in August, concluded that donors might actually have weakened health systems in the three countries they studied - Uganda, Zambia and Mozambique - by creating AIDS-specific systems that competed for health workers, created additional administrative burdens and strained inadequate infrastructures.

Haiti's anti-AIDS efforts have depended on international donors since the early 1980s, when the US Centres for Disease Control (CDC) funded a local research body called GHESKIO (Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections) to look into why so many Haitians were dying of Kaposi's sarcoma, a type of cancer common among people living with the HI virus.

GHESKIO later became the first organisation to offer HIV and AIDS services, and in 2000 was mandated by the Ministry of Health to replicate its prevention, treatment and care models nationally.

But it was only when the Global Fund to Fight AIDS, Tuberculosis and Malaria, and later, the US President's Emergency Plan for AIDS Relief (PEPFAR) came on board that GHESKIO-supported sites like the one at St Michel Hospital were able to start offering ARV treatment and many other HIV-related services.

Money from the Global Fund and PEPFAR now pays for antiretroviral (ARV) drugs for around 18,000 Haitians, as well as HIV-related laboratory tests, equipment and salaries.

Dr Reynold Grand Pierre, who has coordinated GHESKIO's expansion efforts, said donors like PEPFAR have tried to ensure that their funding benefited the country's broader health system, for example, by ensuring that hospitals have functioning electricity and running water.

But the manager of the HIV/AIDS clinic at St Michel Hospital, Dr Michel Bertrand, noted that he could only allocate portions of the clinic's PEPFAR-funded budget to other departments of the hospital if they provide HIV-related services.

Medical personnel working in the paediatric and maternity wards, for instance, received salary top-ups for providing services for the prevention of mother-to-child HIV transmission (PMTCT), but "we can't pay every person in the hospital" he said.

The lack of a medical director has left a leadership vacuum, and hospital staff have sometimes waited five months to get paid. "The only service working well in the hospital is this programme," Bertrand said.

Deslouches Gaston, the South-East Department's director of health, conceded that some of the hospital's services were not maintained at the same level as those provided by the HIV/AIDS clinic.

"HIV/AIDS is a priority programme; you can't prioritise all diseases. It's a choice, and in a population that's very poor and exposed, that's not a bad choice," he told IRIN/PlusNews. "But there is a need for better integration with the rest of the health system."

Ailing public health sector

Public health facilities in Haiti are under-resourced, unevenly distributed and outnumbered by privately-run services. In theory, the public and private sectors are both regulated by the Ministry of Health, but Grand Pierre said in reality there was little oversight or coordination.

People living in rural areas often have to travel long distances to health facilities. HIV/AIDS patients receive a small allowance for transport when they pick up their medication at the GHESKIO-supported clinics, but other patients often find the costs of public transport, on top of the fees charged by hospitals, are beyond their means.

"The people we serve are very poor," said Vernet. "Very often they don't have any money to pay, but we still have to try to see them and give them medication."

The legacy of Haiti's long history of political instability is a weak government with little capacity to deal with the country's seemingly insurmountable security and socio-economic problems, let alone overhaul the ailing public health sector.

The government has made no plans to wean itself off of donor assistance for its HIV/AIDS programme, a dangerous oversight in Bertrand's view. "You can't always receive funds from an external source, because the day they decide to end those funds, it puts patients at risk ... patients on ARV treatment need a guarantee."

Although Haiti's HIV prevalence has dropped from 5.9 percent among pregnant women attending antenatal clinics in 1996 to 2.2 percent of the adult population, according to the latest UNAIDS figures, Grand Pierre estimated that about 22,000 people were still in need of ARVs. Identifying them is difficult, especially in remote areas where there are few health facilities, but the country's HIV/AIDS programme also has other challenges looming.

"We don't know the level of resistance to first-line ARVs," he said, adding that viral load testing - the only accurate way to detect treatment failure resulting from drug resistance - was considered too costly to perform regularly.

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Given the number of patients who defaulted on treatment (about 15 percent over a four-year period, a recent study found), Grand Pierre suspected that many more patients were in need of the more expensive second-line drugs than the 4 percent receiving them.

"Sustainability of donor funding is a big question for people living with HIV," he commented. "There's no line for ARVs in the health budget - it's time the officials formed a plan."

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