Reducing health disparities through culturally sensitive treatment for HIV+ adults in Haiti

ABNF Journal, The, Nov-Dec, 2004 by Jessy G. Devieux, Robert M. Malow, Michele M. Jean-Gilles, Deanne M. Samuels, Marie-Marcelle Deschamps, Maxi Ascencio, Jr., Larissa Jean-Baptiste, Jean William Pape

Unlike North and Latin America, where the rates of HIV/AIDS have either been reduced or have leveled off, the Caribbean remains the only region in the Western Hemisphere with steadily increasing rates of HIV (Camara, 2002). Within the Caribbean, Haiti has been the hardest hit, with an estimated 300,000 cases, or approximately 50% of the region's total (UNAIDS, 2003). Reductions in HIV incidence suggest, however, that this figure may be closer to 180,000 (Pape, 2004). Multiple factors have led to this level of prevalence in the country including poverty, limited access to healthcare, socio-political instability, and lack of coordination among the various entities doing work in the field (Hempstone, Diop-Sidibe, Ahanda, Lauredent, & Heery, 2004). The adaptation of interventions utilized successfully in more developed countries may be one of the most important routes by which the impact of the HIV epidemic in developing countries may be ameliorated.

The effect of health disparities, driven by a combination of socioeconomic disadvantage and cultural distinctions (Page, 2004), has contributed to the increasing spread of HIV worldwide. Researchers have coined the phrase "structural violence" (Farmer, 1996) to describe an environment in which chances of acquiring a disease, along with lack of access or barriers to care are dependent on structural forces beyond the control of the individual. These forces or factors may include poverty, gender inequality, and racism or class bias. Living in a vulnerable environment, in combination with engagement in health-damaging behavior where the degree of choice of lifestyle is restricted and being exposed to unhealthy, living and working conditions, further exacerbate the vulnerabilities of disadvantaged populations (Whitehead, 1991). Researchers further suggest that the worsening social and political situation, specifically in Haiti, may be having a negative effect on health (Farmer, 2004), though there is evidence that some indicators, for example infant mortality, are improving (Pape, Deas Van Onacker, Cayemittes, Deschamps, Verdier, Severe et al., 2004).

In the early 1980s, the U.S. media widely reported that Haitians were the source of the AIDS epidemic and this led to a recommendation by the U.S. Food and Drug Administration to ban Haitians from donating blood (Dubois, 1996). This recommendation, along with the inclusion of Haitians in CDC's list of HIV risk groups, was a contributory factor in the high levels of denial surrounding HIV/AIDS issues in Haiti (St. Cyr-Delpe, 1995). The disproportionate impact of the epidemic on Haiti is starkly highlighted when actual figures are compared: there may be roughly equivalent numbers of individuals living in Haiti and the U.S. with HIV, however, the Haitian population is only approximately 3% that of the U.S. (UNAIDS, 2003; CDC, 2003). As of 1998, only 60% of the Haitian population had access to health services (UNAIDS/WHO, 2004) and estimates are that only approximately 2,800 Haitians were receiving antiretroviral therapy, though the actual need is close to 40,000 (Pape et al., 2004; UNAIDS/WHO, 2004).

Disparities affect not only access to care, but also rate of progression of AIDS. A study of a sample of 42 individuals in Haiti before the widespread availability of antiretroviral medication found that time to AIDS (5.2 years) and time to death (7.4 years) was almost twice as fast in the Haitian sample compared to progression in developed countries (Deschamps, Fitzgerald, Pape, & Johnson, 2000). The researchers hypothesize that this fast progression may be due to poor nutrition, high rates of community-acquired infections and tuberculosis.

Effective HIV/AIDS prevention efforts should address the context in which HIV is transmitted, such as interpersonal relationships, and community and cultural factors, in order to have the greatest chance for success. Researchers affirm that integrated prevention and care in resource poor settings in Haiti is feasible (Walton, Farmer, Lambert, Leandre, Koenig, & Mukherjee, 2004). Review of an accompagnateur program in rural Haiti, which involved full participation of the community in assisting HIV individuals, noted a reduction in social stigma attached to HIV due to involvement of community members in the daily lives of the participants (Behforouz, Farmer, & Mukherjee, 2004), improved weight gain and functional capacity, and found that 86% of the participants had undetectable viral loads (Koenig, Leandre, & Farmer, 2004). In another study, attention to cultural norms transformed an initially unsuccessful hospital-run effort to a successful one after encouraging a sense of ownership and initiative from community leaders and relying upon existing social structures to improve prevention efforts (Fitzgerald & Simon, 2001).

Cultural factors, such as normative multiple sex relationships, the clash between traditional vodou belief systems with biomedicine, and lack of education (Hempstone et al., 2004) interact synergistically to increase the prevalence of HIV. In a national study conducted in Haiti, even though 97% of those surveyed knew about the existence of HIV/AIDS, 24% of women and 14% of men believed that HIV could not be prevented (Cayemittes, Placide, Barrere, Mariko, & Severe, 2001). Furthermore, 35% of the women and 19% of the men surveyed knew that HIV could be prevented, but could not name any method of prevention (Cayemittes et al., 2001). Cultural and educational factors that make interventions more challenging among certain populations have been shown amenable to change. For example, a social marketing program, promoting the use of the Pante condom in Haiti, resulted in an increase in sales from 30,000/month to 600,000 in the space of approximately two years (Frank, 1995), with estimates of sales in 2002 greater than fifteen million (Pape et al., 2004).