The HIV Epidemic in the Caribbean:
AIDS Christian Caribbean Empowerment Services and Solutions (ACCESS) is a based, medical, non-profit organization that is developing comprehensive health-care clinics in the Caribbean. Members of the Caribbean community face a disproportionately high number of social barriers to adequate health care, including high poverty rates, high rates of drug addiction and commercial sex, low education, and a lack of support systems. Many are without a consistent source of primary care, and those populations most vulnerable are those that have the least access to information or services. Therefore, preventable conditions and diseases, such as HIV, are at disproportionately high rates in the Caribbean.
Inspired by Christian faith, ACCESS was started to address the lack of adequate health care access because of hard-to-reach populations, financial and ethnic barriers to care, and a need for comprehensive care. The HIV virus that causes AIDS has especially ravaged local communities, further isolating and compromising those already vulnerable, impoverished, and lacking access to care. In order to address these needs, especially in the face of the rising HIV/AIDS crisis, ACCESS is developing comprehensive health care centers throughout the Caribbean. These centers will have fully equipped HIV clinics with trained physicians, outreach staff, and social-service advisors to help each patient handle the difficulties with the HIV virus.
ACCESS is now running a pilot project in San Pedro de Macoris, an industrial city in the Dominican Republic. San Pedro has one of the highest HIV rates in the Dominican Republic. Even though it is one of the largest cities, it is one of the most vulnerable because there are no comprehensive HIV care centers in the city or within a 50 kilometer radius. ACCESS has hired a family physician, Dr. Milagros de La Rosa, with strong ties to the community, to provide direct care for patients and eventually provide physicians with training and resources to administer HAART (highly active antiretroviral therapy). ACCESS seeks to create a clinical model that is centered on working with Christian physicians from the local communities; training them to provide comprehensive and Christ-inspired health care, and providing them with the necessary resources and infrastructure so that they can serve their communities. Already, with the help of Dr. de La Rosa, we have been able to see patients one year ahead of schedule. Our model of care is very similar to the one used at Esperanza, and we are planning to establish a partnership where we can bring our doctors to CCHF-affiliated clinics for training, and invite some of the CCHF physicians to our clinics in the Caribbean for cultural and language training.
Many social issues influence the health of' the Dominican community. Commercial sex is a very large public health and social rights problem, fueled largely by the relatively large financial rewards from wealthy tourists. Sixty-eight percent of prostitutes engage in commercial sex because of poverty, and 65% of their clients are found in the hotels. Sexual exploitation is especially high among the children. The Dominican Republic has the fourth highest rate of child prostitution in the world (behind Thailand, the Philippines, and Brazil). The majority of child prostitutes in the Dominican Republic enter before they are nine years old, and 77% of all child prostitutes start before they are eleven.
The health and wellbeing of Dominicans affected by these social influences are exacerbated by the barriers to health care and support services. Domestic violence is a serious problem and accounts for 10% of the deaths of women of reproductive age. (AIDS accounts for 11.5 %.) Thirty-five percent of women in a relationship suffer domestic abuse, and more than one woman is severely abused every two days.
These barriers to care and support have left many Dominicans suffering from HIV/AIDS. Between 1995 and 2005, more than 78,000 Dominicans died from AIDS. 138,000 Dominicans are known to have HIV, with estimates as high as 360,000. However, the majority are not aware of their HIV status. Seventeen percent of these HIV cases occur in youth aged 15 to 24 years. Youth are extremely susceptible because more than 50% start having sex before they turn 15. The high incidence of HIV/AIDS, coupled with the high frequency of unprotected sex and multiple sexual partners, has caused over 56,000 children to be orphaned by HIV, an increase of 70% m from 2001. Many of these children are left to fend for themselves; there is only one orphanage in the Dominican Republic specifically for those orphaned by HIV, which houses about 52 youth.
There are even greater barriers to receiving care for those with HIV, who often have to battle fierce social stigma and discrimination. Even in the medical profession, up to 34% of doctors and 25% of nurses discriminate against patients with HIV, further isolating and ostracizing from possible treatment those most in need. Only 900 people are actively receiving antiretroviral medications, and less than 5% of those infected have access to medications. Especially vulnerable are the children; of the 5,120 under 5 years of age who are carriers of AIDS, almost none have access to the needed medications. Only two laboratories in the country run the CD4 and Viral load tests needed for HIV care, and they are often too expensive for a patient to pay for in addition to all the other needs. These barriers to care and support services, especially in the face of the HIV/AIDS crisis, are preventing many from receiving aid and leaving many of the Dominicans in an extremely grave situation.
Case Example: One woman, about 60 years old, had been HIV seropositive for about twelve years. Because of the possible repercussions with her family and friends, she did not tell anyone of her HIV status until about two years ago, when she started to become extremely ill. She was introduced to ACCESS by a friend of Dr. Milagros. When we first met her, she had not been eating solid foods for two months, barely had an appetite to drink juices or soups, could not walk, and was coughing severely, with lots of phlegm. She had signs of severe wasting from the virus.
We went to the city’s only HIV center in the city’s only public hospital. They provide education on HIV prevention and counseling for those who are seropositive. We went to talk with the head of the department, who was the chief counselor and also HIV positive. The counselor told us that there are only about fifty people in San Pedro enrolled in HAART out of more than thousands who are infected, and they receive the medications through personal private care physicians. With the counselor’s help, we were able to arrange a trip over to Santo Domingo, where the closest HIV center is located, to have a physical done on this patient and also five other HIV+ patients. Her visit was paid for by ACCESS funds.
From the clinic visit, it was determined that she had serious opportunistic infections of parasitic amoebas in her stomach and lungs. We wanted to enroll her in an HIV program, and the counselor of the HIV department told us that she would help. The counselor told us that through their HIV center each CD4 test would cost RD$3700 (about $120). For an impoverished population without any public aid or support, these test costs are too high and absolutely unaffordable. We decided to enroll her as the first ACCESS patient.
The total cost of the medications for the first month was RD$10,000, which amounts to about $340. (The HIV medications alone cost about RD$5090, or $175.) For a family of six living on $20 a week, this would have been an insurmountable barrier to HIV care. For the first two weeks, she had to take some 20 pills a day, mostly to help her gain her weight, improve her immune system, and increase strength. There was concern that she would not be willing to comply, so we thoroughly explained the risk of developing resistance if she is not compliant with the medications. When we visited her two weeks later, she had complied fully with all of her medications, looked a lot healthier, and was even starting to eat.
When we met with her four weeks later, she looked much healthier than when we first met her. She had gained some 1 weight, was eating solid foods and regular meals, and she was even walking. She said that she was so grateful that God had brought us into her life to help her get better. She started to cry as she explained that she knew she would have died really soon without our help.
From this case study we see a stark example of how difficult it is to receive medical or HIV care, and how many are left to perish without aid. First, there are the expenses. The tests are expensive, the retrovirals even more expensive, and the medicines to handle the side-effects and opportunistic infections for HIV+ patients can become quite overwhelming. Often there are no support structures or ways to provide these medicines and tests at cheaper rates or free of charge, and therefore many people suffer needlessly, without any aid or support. Most of the people are unaware of the effectiveness of the medicines and of their availability — or the presence of any support programs. Even in this case, had ACCESS not provided the medications for the patient, she would not have been able to pay for anything. There is a lottery in the local public hospital where of every 500 patients, one person receives free medicines and tests, but it is ridiculous to consider that as a step towards providing equality in levels of care.
Second, there are both social stigma and corruption factors that must be navigated to receive care. Many Dominicans do not reveal their HIV status to their family, friends, or sexual partners, or even seek to know their status, for fear of becoming a social outcast, thus causing many more infections. It was surprising to learn that 34% of the physicians and 25% of the nurses actively discriminate against HIV+ patients in the country, which further exacerbates their situation and isolation from care.
Finally, there is a lack of physical access to medical care. Very few physicians provide HIV care or are trained to work with HIV+ patients. The only laboratories for HIV in the country are in Santo Domingo, which therefore drive up the costs for already expensive testing.
The HIV-AIDS epidemic has ravaged the Caribbean and affected countless families and individuals. Its effects can be seen in all spheres of society, including the social, spiritual, economic, and health sectors. Therefore, we hope to expand our program to provide multisectoral approaches that will involve existing contacts With the local churches and international organizations. In our case, Dr. Eric Goosby, Executive Director of the Clinton Foundation, has made available some of the technical resources of his organization and is looking forward to continue collaborating with the project. Also, we have met with pastors in the Dominican Republic who generously offered their facilities to hold training and offered to do pastoral counselling with patients and families affected with AIDS. In order to be more effective in combating the HIV crisis internationally, we need to reconcile the notions of separate domestic and foreign missions. The resources of Christian health centers could be of incredible value to those overseas. Hopefully, in the future we will not be called foreign or domestic missionaries but simply Christ’s servants.
Ramon Gadea, M.D., is an Infectious Diseases Specialist and a Former Medical Director at Esperanza Health Center, as well as a board member of CCHF Daniel Lee is the ACCESS development intern and graduated with a B.S. in Neurobiology from Cornell University. Dr. Gadea can be contacted at accesscaribe [at] juno [dot] com. Daniel Lee can be contacted at Lee.Danj [at] gmai1 [dot] com.