Progress in AIDS Program in Haiti

BARCELONA, July 11 -- It is possible to successfully treat AIDS patients at a squatter's settlement where there is no reliable electricity, virtually no laboratory testing and little more than the right drugs, eager patients and the will to bring the two together.

That was the message brought from Haiti today and presented to the 14th International AIDS Conference.

Paul Farmer, an American physician who has worked in that Caribbean nation for two decades, said he and his colleagues have been treating about 200 people with three-drug antiretroviral therapy, some for several years. Scrounged from myriad sources, the medicines are dispensed through "directly observed therapy" (DOT), the strategy used with great success to treat tuberculosis.

Farmer's rural health center occasionally sends blood samples to a Harvard Medical School lab to see whether the medicines have suppressed growth of the AIDS virus.

"Yes, the patients are suppressed. It's not as if poor people are a different species. These drugs work for everyone," Farmer told the conference delegates, to applause and cheers.

His work in Cange, a settlement of 3,000 people in central Haiti, is the most dramatic example of simplifying treatment and bringing it to the poor that has been presented here this week. Simplification of treatment and scaling it up massively in the developing world are major themes of this gathering of 15,000 researchers, practitioners, activists and patients.

"There is a lot of talk here about 'forecasting demand' for antiretrovirals in poor countries," Farmer said. "We should not forecast demand. The demand has always been there. We should forecast our own ability to stop ignoring demand."

Zanmi Lasante ("Partners in Health" in Creole) is sharing a $67 million award to Haiti made in May by the Global Fund to Fight AIDS, Tuberculosis and Malaria. The fund is an independent organization created last year to disburse donated money to organizations and nations who present cogent, feasible plans for treating or preventing the three named diseases.

This is the first large grant the program has received. Farmer, who is on Harvard's faculty, first sought funding for an antiretroviral program in 1996, the year life-sustaining three-drug combinations were first used widely in the United States, cutting mortality tenfold in some groups of infected people. He said large donors consistently refused to contribute, saying such projects were neither cost-effective nor feasible in a setting of such profound poverty. "Some have even argued . . . that it is 'irresponsible' to provide antiretrovirals to the poor," Farmer said.

The Cange health center draws patients for its program from about 60 villages, some more than five hours away by foot. There are few passable roads in the province, which does not have electricity.

Over the next year, Zanmi Lasante will provide antiretroviral treatment at four more sites in Haiti. One of the new health centers will be in Las Cahobas, near Haiti's border with the Dominican Republic, where HIV/AIDS testing is not available. Today, some people travel from the town of 50,000 to the squatter settlement to be tested and, if possible, treated.

About 2,000 of Zanmi Lasante's patients are infected with human immunodeficiency virus (HIV). In addition to the 204 now taking three-drug combinations of antiretroviral drugs, about 250 with advanced AIDS are in critical need of the medicines, Farmer said. He expects the HIV caseload to double in the next year as people come forward to be tested, knowing that treatment is a possibility.

Antiretroviral treatment is only used in patients at the symptomatic stage of the disease, and not all of them can get it. (About half of those have active tuberculosis, and many of the rest have some other opportunistic infections, which are treated first.) Three measurements are required to start or continue antiretroviral treatment: an AIDS test, a white blood cell count and the patient's weight.

"Weight is a great way to follow [the course of treatment in] our HIV patients," said Farmer, 42, who has a doctorate in medical anthropology in addition to his medical degree.

In his lecture, he showed side-by-side photographs of a man. In one, the man sits in a chair, bare-chested, with bulging ribs and collarbone. In the other, after gaining nearly 30 pounds in two months, he is barely recognizable as he examines a bottle of pills.

"This is Samuel," he said. "He asked me to tell you, 'Now my children are not afraid to be seen with me on the street.' "

The patients on antiretrovirals take pills twice a day. A community health worker visits once a day and watches the person take the medicines. Often, this person observes the second dose as well, although that is not required. In a sample of patients who have had blood samples sent to the United States, 80 percent have undetectable HIV in their blood -- a fraction better than many U.S. clinics, he noted.

Using directly observed therapy occurred to him in 1996, after his application for a grant to start an HIV treatment program was rejected. He realized he could "overlay" one on the tuberculosis DOT program already in place.

"It was an 'aha!' moment," he said. Farmer hastened to add he doesn't think DOT is the only way antiretrovirals can be provided in severely poor settings or that clinics without DOT programs shouldn't consider treating HIV patients. "We don't think this should be yet another excuse to delay long-overdue interventions," he said.