Fighting AIDS in Haiti: PEPFAR and the Global Fund

Haiti is the country most affected by HIV/AIDS in the Western Hemisphere.  That having been said, Haiti is also one of only a handfull of countries to have halted and reversed a generalized epidemic.  This is something to be proud of.  Credit mainly goes to Haitian civil society but also to national and international non-governmental organizations as well as commited government officials.  The President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for HIV/AIDS, Tuberculosis, and Malaria have, in different ways, both helped accelerate progress.

It is hard to convey the impact of HIV/AIDS in a country like Haiti. 16,000 people have died since 2005.  Each of these individuals had families, belonged to communities, and had contributions to make to their countries.  When the United States unjustly blamed Haiti for being the gateway for HIV transmission in North America, the country's tourist industry collapsed, jobs were lost, and the Haitian people stigmatized.  

If you want to fight an epidemic, you have to know the epidemic.  According to the PEPFAR Country Profile for Haiti, by the end of 2005, the national HIV prevalence among adults ages 15 to 49 was 3.8 percent.  In 2006, there were 190,000 Haitians living with HIV/AIDS, about half of whom were women.  As of 2002, there were at least 200,000 orphans as a result of AIDS. Transmission is predominantly through heterosexual contact followed by mother-to-child transmission.  Recent declines, especially in urban areas, are attributed to significant behavioral changes, including fewer partners, delayed sexual debut, and increased condom use.

The main challenges noted are continued political instability, high internal migration rates, high prevalence of sexually transmitted infections, and weakened health and social services.  Access to antiretroviral therapy is increasing but is not sufficient for rural populations, commercial sex workers, and men who have sex with men.  A comprehensive approach to HIV/AIDS requires that services be rolled out to all segments of a population - not just those whom are easiest to reach.  

So what is PEPFAR?  PEPFAR is the largest initiative ever devoted to a single disease - 15 billion over its first five years and likely to increase to 50 billion over its next five years.  Through PEPFAR, the United States supports governments, civil society, non governmental and international organizations, in 15 focus countries of special concern and other countries worldwide.  Haiti and Guyana are the only two PEPFAR focus countries in the Western Hemisphere.  The support Haiti has received through PEPFAR is significant  - more than $28 million in FY 2004, nearly $51.8 million in FY 2005, $55.6 million in FY 2006, $84.7 million in FY 2007 and approximately $100 million in FY 2008.

The first Haitian National HIV/AIDS Strategic Plan was released in 2002.  PEPFAR seeks to build the capacity of the government and civil society to implement its strategy.  Without a doubt, PEPFAR has helped a wide variety of Haitian stakeholders increase access to prevention, care, and treatment including voluntary counseling and testing.  As in most parts of the world, the majority of HIV positive individuals in Haiti do not know their status.  Without a treatment option, people will not want to be tested.  In the end, we will not be able to treat our way out of the epidemic in Haiti or other countries of the world.  Prevention needs to be a priority and can only happen when the disease is destigmatized.  These activities all support each other.

PEPFAR is not without criticism, though some of it is overblown.  Some take issue with the amount of funding that goes to promoting abstinence.  However, we can all agree that delayed sexual debut is important in preventing HIV/AIDS.  Funding for "Abstinence and Being Faithful" can be used for useful programs such as life skills training, school based awareness programs, etc.

Another criticism is that the United States Government tends to focus on initiatives as opposed to building health systems widely. There is some truth to this. Well funded initiatives tend to attract the best and brightest from NGOs, civil society, even the government.  Still, investments in HIV/AIDS can promote broader public health by building better physical and human infrastructure for dealing with health problems.  (note: this photo was taken by Evens Sanon, a Haitian photographer)

While not perfect, PEPFAR has been very succcessful in Haiti, especially in expanding treatment programs.  At the end of 2007, 12,900 Haitians were receiving anti-retroviral therapy (ART).   If you have not seen someone who need it begin ART, it seems like a miracle.  People who were dieing and a burden on their families can resume their roles as parents, care-givers, and bread-winners. By the end of FY 2008, PEPFAR aims to support treatment for 20,000.  

Who receives PEPFAR funds?  It is a long list. Partners include the American Red Cross, the Academy for Educational Development, the Educational Development Center, Food for the Hungry, Cross International, the Foundation for Reproductive and Family Health, the International Training and Education Center, John Snow Incorporated, the Haitian Ministry of Health, Management Sciences for Health, Plan International, Partnership for Supply Chain Management, Promoteurs Objectif Zerosida, Population Services International, ServeHaiti, USAID Central Contraceptive Logistics, World Concern, the World Health Organization (through the Pan American Health Organization), World Hope International, World Relief, World Vision, Catholic Relief Services, Food and Nutrition Technical Assistance (FANTA), GHESKIO, International Child Care, Partners in Health, the New York AIDS Institute, the National Association of of State and Territorial AIDS Directors, Tulane University, and RTI Capacity.

You might be interested in a documentary that PEPFAR and Warner Borthers are developing called "Saving Lives, Creating Hope."  View the trailer which includes images and stories from Haiti and elsewhere.

The United States contributes to the Global Fund for HIV/AIDS, TB, and Malaria through the Office of the Global Aids Coordinator which oversees PEPFAR.  The United States is by far its largest donor.  The Global Fund is a funding mechanism based in Geneva through which donors make their contributions and countries submit proposals.  In addition to HIV/AIDS, Haiti also receives funds for malaria and TB control.

In total, Haiti has received almost 102 million dollars in grants from the Global Fund.  These grants are overseen by a Country Coordination Team that includes reps from UNAIDS, USAID, the Haitian government and members of civil society including faith based groups. Funds have gone to the United Nations Development Program, the Sogebank Foundation, and community groups.   From the Global Fund-Haiti site, you can also find links to the UNAIDS Country Page for Haiti, a summary of USAID's role in supporting efforts to combat HIV/AIDS in Haiti, an article on increasing prevalence of HIV in Haitians living abroad in the Dominican Republic, or a report on HIV/AIDS in the Caribbean region.

Haiti has done an admirable job in fighting HIV/AIDS.  The government, civil society, and other stakeholders have, despite numerous obstacles, ramped up their prevention, treatment, and care programs for HIV/AIDS.  There is much to be done yet, PEPFAR and Global Fund will help to make continued gains possible.

Bryan