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HIV AIDS A Predator in Paradise

HIV AIDS A Predator in Paradise
Today the Caribbean has the highest prevalence of HIV/AIDS outside of sub-Saharan Africa. Some Caribbean scholars are taking steps to educate the academy and national leaders about curbing the spread of the disease.
By B. Denise Hawkins

The Caribbean is legendary for the soothing rustle of blowing palm trees, sugar white beaches and breathtaking sunsets. It also is where about 2 percent of the region’s adult population is living with HIV/AIDS, and the incidence rate is accelerating at a pace second only to sub-Saharan Africa. The Dominican Republic and Haiti together account for 85 percent of the total number of HIV/AIDS cases in the Caribbean.

In the two decades since the first AIDS case was diagnosed in the Caribbean, the disease has exploded into a global pandemic and catapulted the region to an unwanted place.

AIDS has become the leading cause of death for 15- to 44-year-olds in several English and non-English speaking island nations, and also is responsible for leaving an estimated 80,000 Caribbean children orphaned. Globally, 42 million people are living with human immunodeficiency virus (HIV) infection, epidemiologists at the United Nations and World Health Organization announced in a report released in November. Of the 38.6 million infected adults, 19.2 million are women — slightly less than 50 percent.

But while many Caribbean governments have initiated programs to slow HIV/AIDS, few have scaled up the response to the levels necessary to turn the epidemic around, scholars say.

In the past 20 years, some government and education leaders have found it easier to prepare and protect their people from ravaging hurricanes than they have from the virus that causes AIDS, says Dr. Brendan C. Bain, a professor of community health at the University of the West Indies (UWI) in Kingston, Jamaica. During the early years, on the frontline of fighting and tracking AIDS, Bain and a handful of fellow scholars, epidemiologists and clinicians also played the waiting game when it came to enlisting significant support and resources from national leaders.

UWI, the Caribbean’s leading English-speaking university system with campuses in Kingston, Jamaica, Barbados and Trinidad, long has served as consultant and adviser to government leaders on important issues. Providing a response to HIV/AIDS is one of those important matters, Bain says, but he adds that for too long, UWI was silent, in denial and afraid. But the winds of change are beginning to blow, Bain says.

“UWI administrators are beginning to summon the courage to address what others of us have been working on for years” — AIDS, says Bain who late last year was named lead coordinator of the University of the West Indies HIV/AIDS Response Program (UWI HARP), a first-ever multidisciplinary initiative created to contribute to a national and regional response to the disease.

Prompted two years ago by the need to provide and accelerate the university’s response to the growing epidemic, UWI HARP began to take shape. Today, the program has a presence on the university’s three campuses and is slowly gaining interest from many administrators, students and the wider community.

In the absence of a regional Caribbean HIV/AIDS plan, a program such as UWI HARP is needed now more than ever, says Dr. Farley R. Cleghorn, an assistant professor at the University of Maryland School of Medicine and an AIDS epidemiologist at the Institute of Human Virology, which is affiliated with the medical school as well as the University of Maryland Medical Center. Fledgling understaffed and underfunded non-governmental organizations (NGOs) and community-based programs in the Caribbean also should be cause for alarm because they have been on the frontline of providing care and treatment to people living with AIDS, Cleghorn adds.

“It costs money to have a response to AIDS,” Cleghorn says, and few government leaders in the island nations have been willing to shoulder more than “basic medical intervention.”

In August, the World Bank issued the Jamaican government a $15 million loan, which today makes up the bulk of its funding to fight HIV/AIDS, says Patricio Marquez, lead health specialist for the World Bank’s Latin and Caribbean region. With the loan, coupled with $5 million in matching funds from the Jamaican government, the country is expected to “step up its HIV/AIDS prevention and control efforts and strengthen its ability to monitor the disease, do research and surveillance,” Marquez adds. The funds are part of a $155 million multi-country loan program to benefit HIV/AIDS prevention throughout the Caribbean.

“The responses of Caribbean governments (to the spread of AIDS) have been slow and halting,” says Cleghorn, who works globally on the AIDS pandemic in his native Trinidad and in other regions of the Caribbean. As the principal investigator of the University of Maryland’s HIVNET project, for example, Cleghorn is working in collaboration with the Institute of Human Virology, and the Medical Research Foundation of Trinidad and Tobago, to foster joint AIDS research between clinicians and governments in the United States and in the Caribbean.

Getting to the Root of AIDS

For years, the root of the pandemic interfered with efforts to stop it. In the early phases of the disease — between 1980 and 1985 — researchers attributed the majority of new AIDS cases in the Caribbean to the spread of the disease among gay and bisexual men. In the mid-1980s, heterosexual transmissions quickly transformed AIDS rates. Cleghorn says he believes that the culture of the Caribbean, which includes an inability or unwillingness to talk openly in schools or in some healthcare settings about issues of sex and sexuality, greatly hampered efforts to educate the community and halt the early spread of the disease in the region.

Denial also saddled many communities. Officials and healthcare providers who feared acknowledging the presence of the disease amounted to an admission of complicity in the spread of AIDS.

As a result, patients and those living daily with AIDS suffered, Bain says. “Nearly everyone in the healthcare team seemed to be afraid to go near them for fear of contracting the disease,” he explains. “We have had to work hard to reverse that fear. We are still working to curb the stigma and prejudice associated with the disease. I expect that change will continue to be gradual, although I would like to see a sudden transformation in attitudes.”

Today, most universities and medical schools in the Caribbean would get “a big fat zero” for their efforts to pursue federal funds for AIDS research or include AIDS education in the curriculum, Cleghorn says. “In fact, medical students could emerge from their final exams and not see a single question on AIDS,” adds a frustrated Cleghorn.

AIDS outreach and education through UWI HARP, however, is beginning to have an impact on students, Bain says. In November, for example, the student council at the Jamaica campus organized a series of HIV/AIDS awareness programs. Also that month, UWI HARP participated in an off-campus forum hosted by the university’s school of education. UWI HARP also will be represented in April at an annual Caribbean Labor Policy Conference organized by the university’s school of business.

Last month when Bain addressed UWI’s senior management team for the first time about the new AIDS response initiative, he emerged hopeful —”my administrators are beginning to listen and respond to this call.” But what is needed to contain and provide a structure for responding adequately to this unusual pandemic is top-down and multidisciplinary support from the university and the governments, Bain says.

As a result, UWI administrators are beginning to develop a five-year strategic plan that will include a projection of staff needs and funding. “I see this as critical,” says Bain who keeps in close touch with scholars such as Dr. Michael Kelly of the University of Zambia and other clinicians working on AIDS in Southern Africa, where the disease is devastating the population. Bain credits Kelly’s presentations to UWI officials with helping to spark awareness about AIDS’ impact on the education community and jump-start a university response. Both Bain and Kelly have signed agreements with UNESCO (United Nations Educational, Scientific and Cultural Organization) to co-author a book entitled Education and AIDS in the Caribbean scheduled for publication in July.

“It is clear to me that when key leaders acknowledge publicly that HIV/AIDS is a problem that has to be tackled systematically, the community has its best chance of dealing effectively with the problem,” Bain says. But he adds that the real test of the university’s commitment to ensuring a sustainable response to what is likely to be a long-lasting and stubborn epidemic is its support of UWI HARP with dedicated staff and funding.

A $2.7 million grant from the European Union supports the work of UWI HARP on the university’s three campuses and a satellite facility. With the exception of the Mona campus in Jamaica where Bain is based, there is no paid staff. UWI HARP is still in its infancy and is taking small steps to create awareness about itself and the disease on and of the campuses. The initiative is set to launch a modest multi-media marketing campaign aimed at university students that will deliver “soft messages” such as “are you at risk for HIV/AIDS?”

‘The Disease Will Come to
the Caribbean’

In the early 1980s, Bain was not unlike many physicians and clinicians that were as intrigued as they were frightened by the modern-day plague that was emerging in the United States. Before long, Bain was preparing for a predator in paradise — AIDS — that he and other clinicians knew very little about.

It was June 1981, Bain recalls, when he and some of his colleagues, including the chief of the small epidemiology unit at the Ministry of Health, reviewed the first AIDS report issued from the Centers for the Disease Control and Prevention and concluded — “the disease will come to Jamaica and we must begin to plan for it.” A year later in November 1982, AIDS did come to Jamaica as predicted. A Florida hospital diagnosed the first case of the disease seen in a Jamaican national, who later returned home to the island nation.

In the early years of AIDS, the work of many researchers and clinicians working on AIDS was considered “low tech.” They could describe the early cases of the disease and track its reckless path through the island nations, gaining an understanding of who was most at risk for contracting HIV infection and why. They also were the only ones who saw the face of AIDS.

Strict confidentiality policies governing healthcare kept AIDS patients concealed from the general public. “For the most part, the public was only told the cumulative count of cases,” Bain says. “Because they weren’t allowed to see persons with the disease, there was a tendency to deny that the disease existed.”

A strong stigma around AIDS also prevented those living with the disease from telling their families or community. In fact, Bain says, “several patients told friends and sometimes family members alternative diagnoses in an effort to hide the reality that they had AIDS.”

The Caribbean got a late start on its response to AIDS. And now, just as some critical new programs and approaches are being introduced in Jamaica and across the island nations — counseling and screening of pregnant women for HIV/AIDS; administering anti-retroviral drugs to expectant mothers with HIV/AIDS to reduce mother-to-child transmission of the disease — educators and clinicians already are pondering a long-term fight against AIDS that could span the next 50 years.

But some say it is now or never for an AIDS response in the Caribbean. The Caribbean has no choice but to plan and act immediately to curb the further spread of the disease, says Prime Minister Owen Arthur of Barbados.

“The Caribbean has never lost a generation of its most talented young people because of war or natural disaster. It is in danger of doing so because of the pandemic of AIDS,” said Arthur in a recent interview with Perspectives in Health magazine. “With it goes the hope, promise and idealism of the best educated and most creative minds in the history of the Caribbean people.”

Because of their distinctive culture, Haiti and the Dominican Republic are not typically a part of AIDS response plans developed by English-speaking Caribbean countries. Haiti has been the hardest hit of any of the Caribbean regions with 13 percent of pregnant women testing HIV-positive, and 8 percent of adults in urban areas and 4 percent in rural areas infected. In the Spanish-speaking Dominican Republic, an estimated 2.8 percent of the population has HIV/AIDS. Some researchers say that the best data on HIV infection in the Caribbean was developed in the Dominican Republic, which in 1991, started tracking the rates of infection among pregnant women, patients with sexually transmitted infections and sex workers.

But there is hope on the horizon for the Caribbean’s battle with AIDS, suggests Cleghorn pointing to islands such as Bermuda, Barbados and the Bahamas. Bermuda’s AIDS fight has benefited from its wealth, its proximity to the United States, the presence of American physicians and the spread of the disease largely through intravenous drug users, compared to sexual transmission, which is more difficult to contain. Barbados turned to an infusion of World Bank funds to undergird its response to AIDS and today has “a less than 1 percent infection rate,” says Cleghorn of the island that also has successfully monitored and treated its disease cases. And the islands of the Bahamas are beginning to see a reduction in its AIDS rate as well, which over time spiked when an influx of Haitian and other immigrants sought refuge on its shores. The Bahamas, Cleghorn says, also benefits from a healthy economy.

The successes these island nations have realized, however, didn’t happen overnight, Cleghorn cautions. A country’s real response to the AIDS epidemic, he says, has the potential to reduce the spread of the disease, lower the disease rate and ultimately mitigate its impact. But a sufficient response to AIDS, Cleghorn says, “costs money and requires a real investment.”

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