HIV/AIDS: Haiti Pre-decision Brief for Public Health Action
- Immediate assistance for persons living with HIV/AIDS
- Ensure integration of HIV interventions in the humanitarian and primary care response (primary and mobile clinics and outreach) to rapidly reach displaced populations.
- Re-establish treatment and support services for people living with HIV/AIDS (PLWA) in re-established / new communities.
- Diagnostic capacity and surveillance
- Monitor access to condoms and other prevention services and commodities among displaced and other vulnerable populations.
- Monitor use of HIV/AIDS services at healthcare facilities in affected areas, including use by internally displaced persons (IDPs).
- Evaluate the current laboratory capacity, improve laboratory output, and provide necessary diagnostic and monitoring services for HIV/AIDS patients.
- Consider studies of antiretroviral (ARV) drug resistance in populations with substantial interruption of ARV treatment
- Critical treatment and supplies
- Ensure access to ARVs to patients already under treatment and those newly identified.
- Ensure access to HIV-preventive services, including condoms and post-exposure prophylaxis.
- Ensure adequate supply of blood safety consumables, including for testing, in order to assure a safe and adequate blood supply.1
- Ensure adequate injection safety supplies and practices in the context of infection control, specifically appropriate healthcare waste management (HCWM).1
- Support the Ministère de la Santé Publique et de la Population (MSPP) in re-establishing the national blood service; conduct mobile campaigns in the departments to collect blood from low-risk donors.
- Ensure accessibility of critical prevention services to newly displaced populations, including condoms, counseling and HIV testing, prevention of mother-to-child transmission (PMTCT), post-exposure prophylaxis, STD treatment, and HIV/STD prevention messaging.
- Maintain security in all affected areas to minimize violence (including sexual violence and exploitation).
1. What was the situation in Haiti prior to the earthquake?
- Prevalence: Haiti has the highest HIV prevalence rate in the hemisphere (2.2%)2 ; more than 120,000 persons are estimated to be living with HIV/AIDS (UNAIDS) in Haiti.2 Approximately 31,132 were receiving antiretroviral treatment at the end of September, 2009.3 (there were a total of 48 treatment sites providing ARV treatment in the country; 36 PEFPAR sites and 17 Global Fund Sites (GFS). HIV sentinel surveillance carried out in pregnant women in 2006/7 at 17 sites found a median prevalence of 4.4% (range 0.8-11.8%; urban 5.9%, rural 2.7%).4 A reported four (4) HIV-infected infants are born each day, among the 8,000 HIV- infected women who become pregnant each year. Rates of infection are higher in commercial sex workers (CSW) and men who have sex with other men (MSM) (~5%). HIV is highly stigmatized in Haiti.
- Surveillance and Diagnostic Capacity: An active electronic HIV/AIDS reporting system, in place before the earthquake, is currently the backbone of public health surveillance in Haiti. The National Public Health Laboratory (LNSP) supported HIV diagnosis and early infant diagnosis in the country. HIV diagnostic capacity was generally available at all 131 President’s Emergency Plan for AIDS Relief (PEPFAR) services sites, but may be limited due to constraints posed by an increased number of patients needing post-earthquake care. Existing testing algorithms for HIV diagnosis can be used without modification; all 131 PEPFAR service sites have continued operating and offering services, despite the earthquake. CD4 testing is available at most 36 PEPFAR treatment sites.
- Blood Supply and Injection Safety: The Programme National de Securité Transfusionnelle (PNST) was responsible for collection, processing, and distributing blood with PEPFAR support. In FY09, 21,233 units were collected of which 18,943 were ultimately distributed; 62.8% of the donations were from volunteers and 37.15% family replacement. The Transfusion Transmissible Infection (TTI) rates among donors who had been initially screened by self deferral questionnaire were: HIV 1.33%, HBV 4.16%, HCV 0.47%, syphilis 3.67%, and HTLV 0.78%, for a combined rate of 9.08%. Injection safety efforts were limited in terms of amount and distribution of injection safety equipment and supplies and HCWM.
- Antiretroviral (ARV) Distribution: Before the earthquake and since, ARV procurement and distribution through Supply Chain Management Services (SCMS) has been working effectively in Haiti. The PEPFAR program has been distributing ARVs to both PEPFAR and GF.5 All current PEPFAR partners are reporting they are functioning and providing services to greater than 90% of their clients, although they are doing so in strained circumstances (e.g., tents, mobile teams).
- Condom Supply and Distribution: PEPFAR condom procurement and distribution is executed through the United States Agency for International Development (USAID). In 2009, 21.4 million condoms were ordered, with an additional 8 million ordered through USAID social marketing programs (of those, 338,000 were female condoms). In 2010, 24 million condoms have been ordered, with an additional 4.9 million ordered through USAID social marketing programs (186,000 of those are female condoms). Condoms are being distributed for the population through mobile clinics.6
- PMTCT: About half of all pregnant women are tested for HIV through PEPFAR (approximately 4,000 women annually). Of all HIV-infected pregnant women, about 40-50% receives a complete course of ARV for PMTCT. PCR testing of infants just began in 2009 and, of approximately 800 infants tested, 8.5% were positive. Since the earthquake there have been many missed opportunities for PMTCT but, in the past few weeks, things are beginning to return to pre-quake levels.
2. What is the likelihood of cases/outbreaks of this disease developing in the near future?
- With the interruption of HIV treatment for patients in the affected area due to loss of medications and/or lack of access to care and treatment services, there may be a greater likelihood for HIV transmission due to higher viral loads in patients and displacement of populations. Patients are migrating to other urban and rural areas, putting a strain on the HIV/AIDS services there. A major increase in prevalence, however, is unlikely.
3. Should an outbreak occur, how would this be detected?
- No active surveillance for HIV/AIDS is needed during this post-earthquake period, but screening of blood and blood products and continued screening of pregnant women to determine eligibility for PMTCT treatment should continue; Voluntary Counseling and Testing (VCT) should be offered wherever IDP are located. Continued sentinel surveys for HIV in pregnant women and other most at risk populations should be done, when feasible.
4. What options for public health action should be considered to prevent transmission of HIV?
- Rapid restoration of HIV/AIDS prevention and care and treatment services (provision of condoms, voluntary HIV testing and counseling for individuals and couples, injection safety including HCWM, adequate and safe blood supply, post-exposure prophylaxis (PEP), PMTCT services, early infant diagnosis, and the continuous provision of medications for care and treatment) should be implemented, including in areas to which HIV/AIDS patient may have migrated.7 Condoms should be widely distributed at various locations – clinics and health centers, and bars, brothels, community centers, and other settings where people may meet sex partners. Special attention should be paid to mobile populations and displaced persons in urban, rural, and border areas, where increases to the pre-quake population may be straining community resources and security.
- Maintain security in all affected areas to minimize violence (including sexual violence and exploitation) the incidence of rape is reported to have increased in IDP camps according to media reports. Currently, PEPFAR provides PEP to victims of sexual assault at all ARV treatment sites across the country. In addition to ARVs, the PEP kit also contains morning-after contraception. Treatment for sexually transmitted infections and psychosocial support should also be made available.
- Support re-building of the HIV response as medium-to-long term plans for the country are developed. The availability of HIV/AIDS prevention and treatment services has been substantially impacted by the earthquake. Public health capacity for HIV/AIDS prevention and treatment should be restored and further developed in conjunction with other public health priorities to improve the public health system. Increased partnership and collaboration within the UN and with key financial partners (e.g., PEPFAR, Global Fund) is essential.
5. What options for public health action should be considered to support persons currently infected with HIV?
- Health care and sanitation services should be provided to the affected population as soon as possible. During periods of acute or chronic stress, such as rapid onset natural disasters, a person’s ability to withstand shocks, stress, and trauma decreases. Since HIV-infected individuals are at increased risk for other infections (e.g., TB, community-acquired pneumonia, diarrheal disease), health care and sanitation services are essential.8 All current PEPFAR partners are reporting they are functioning and providing services to greater than 90% of their clients, although they are doing so in strained circumstances (e.g., tents, mobile teams). Many are also being asked to provide general medical care to displaced persons living in/near their facilities.
- Address potential for ARV drug resistance. Previous to the earthquake, little was known about the level of resistance among the PLWA placed on treatment. Currently, there is essentially no resistance testing in Haiti. Only 3% of PLWA have been switched to second-line regimens based on clinical failure. Because of the interruption in the continuity of ART in affected patients and the potential for the development of ARV drug resistance, consideration should be given to surveying the prevalence of resistance in those with prolonged interruption in therapy.
1 Guidelines for addressing HIV in humanitarian settings www.aidsandemergencies.org
4 Ministère de la Santé Publique et de la Population, Institut Haïtien de l’Enfance, Centres GHESKIO, Centers for Disease Control and Prevention, Etude de séro surveillance par méthode sentinelle de la prévalence du VIH, de la syphilis, de l’hépatite B et de l’hépatite C et chez les femmes enceintes en Haïti 2006/2007.
7 Spiegel PB, Bennedsen AR, Claass J, Bruns L, Patterson N, Yiweza D, Schilperoord M. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet. 2007 Jun 30;369 (9580):2187-95. http://www.unhcr.org/469dd53e2.pdf
- Page last updated MArch 19, 2010
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