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Story Publication logo November 19, 2007

Haiti Fights Back Against HIV

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With HIV rates second only to those of sub-Saharan Africa, Caribbean islands that conjure visions of...

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Dr. Jean 'Bill' Pape

These are good times in this embattled capital.

Kidnappings are down and trash is picked up.

Brightly-painted trucks that serve as buses drive through bustling streets where vendors supply cheap wares and workers repair ancient machines with obsolete tools.

United Nations trucks patrol the streets, too, but after years of outside intervention, the people of this impoverished republic are running their own government.

And here, sandwiched between two of the most desperate and dangerous slums in the Americas, the clinic that was the first to investigate the Caribbean AIDS epidemic is seeing rates of infection drop, and treatment coverage rates rise faster than those of wealthier nations, including the neighboring Dominican Republic.

"The reality is that we are controlling HIV," clinic founder and director Dr. Jean "Bill" Pape said on a recent day. While the declining numbers are new, the foundation for success was laid early on, Pape said, when officials of a divided nation responded to inconvenient truths with a united front.

Pape is tall and only slightly stooped from three decades of tending to patients, and his speech is cadenced as he adds layers of support to his projections.

Pape knows the streets around the clinic enough to describe life in the ironically named Cite de Dieu and Cite de Eternite slums. It is one, he says, in which men leave their homes at dawn to avoid facing the hungry people inside, and if they have not managed to earn or steal sustenance by dusk, don't return until midnight.

The clinic he has run for more than a quarter of a century has battled the AIDS epidemic for so long that its name GHESKIO — in English, Haitian Study Group on Opportunistic Infection and Kaposi's Sarcoma — includes one of the syndrome's first symptoms.

Pape remembers "patients 1 through 42" as people who had been to the United States or had sex with Americans.
He believes AIDS came to Haiti from the U.S. through that route, a contention that is disputed by researchers citing DNA evidence.

Pape, in turn, cites autopsies and blood samples going back into the 1970s that showed no sign of the disease.
"You know, AIDS is not a disease that can be ignored," he said.

"The beauty part of Haiti"

Ignited by tourism, and fueled by hardships that led the poorest people to engage in sex work and sell their blood, the epidemic was about to take off when Pape returned to Haiti from the United States in 1979, then with the ambitious goal of improving the treatment of infantile diarrhea.

Pape often finds enough good news in the course of his sentences to end them with a smile that lights his eyes, but when he recalls his early days back in Haiti tackling what was then the leading cause of child mortality there, he looks down.

"It was horrible because over the course of a few hours you have three, four, five kids, and someone would come with a big bag and put them in," he said. "I wasn't sure I would stay in Haiti the first few days."

He found allies in nurses, then parents, then the government, he says, and soon the rehydration therapy that he had returned to introduce became universal.

Similarly, the government responded to data showing the spread of the HIV epidemic, he said.

"The beauty part of Haiti is when you get something to work, you can move rapidly to the next step."

Pape credits several factors with leading HIV infection rates to drop in recent years, from 8 percent to a projected 2 percent.

He points to a massive condom promotion campaign, screening for other sexually transmitted diseases and the Haitian Red Cross takeover of previously commercial blood banks.

But the clinic he oversees, which provides services extending beyond AIDS treatment, also offers up more of its secrets to success.

Today the clinic is funded in part by money from the United States' President's Emergency Plan For AIDS Relief, help that Pape welcomes.

Still, he smiled, he has been amused by outsiders coming in "like young Turks," prepared to show Haitians how to deal with HIV.

"In many ways the situation in Haiti has been very, very bad, so they were surprised when they came here to find well-organized teams that were capable of dealing with all aspects of HIV."

Help too late for some children

Behind a door labeled "reproductive health," doctors and counselors face one of the more gruesome aspects of years of politically stirred violence. Behind the door is a rape center that last year saw 10 to 14 girls a day, many the victims of multiple attackers.

The mislabeling of the door is purposeful, aiming to keep from identifying those who go through it as victims, says Dr. Harry Theodore who runs the center, open for a little more than a year and offering HIV testing, counseling and social services.

"We had a girl, 9 years old, who had been raped," Dr. Francine Noel, a pediatrician at the clinic, explained. "She told the same story of what had happened to her again and again. And everyone she told it to started to cry. So you knew you needed a special place for that."

In the relative calm of late, the center now sees one or two girls daily.

Down the hall, an adolescent center is an oasis from the bustle of the rest of the clinic.

Here, a corner of sofas and chairs gives teenagers living with HIV a place to meet. The center, started earlier this year, also has its own exam rooms and dental clinic.

The teenagers who come here not only receive help but also have the chance to help others, Noel said.

One such "ambassador" is a slender and flawlessly pretty teenager, who asked to be called "Amelia."

She first came to GHESKIO at 10, dying. Born with HIV and orphaned by it, too, she had been raised by an aunt and uncle, but even they were keeping their distance from her when lesions on her skin bore the marks of her illness. She wasn't allowed in school.

"I thought," she explained, "that I would never get to go to school, never travel to another country, never get to become a child psychologist so that I could help other children, never marry, because no one would ever love me."
In the U.S., antiretroviral drugs introduced in the mid 1990s turned HIV from a near-certain death sentence to a chronic but manageable disease.

They remained out of reach to most patients in impoverished countries until 2003, when money began to arrive from the Global Fund to fight AIDS, Tuberculosis and Malaria. Money from PEPFAR followed in 2004.

"They needed a few deaths to understand that it's critical," Noel said. "And a little advocacy to make them know that if they don't do anything, it will be too late. It was, in fact, for some of my children."

The medicine arrived in time for Amelia, who talks about HIV at schools and last year visited Trinidad through a UNICEF visa to talk to teenagers there. She believes she may marry some day but wants to wait until she is 30. She will go to college next year.

"Now we don't worry about health. We have health," Noel said. "Now we need college scholarships."

Winning out in the end

"I am not part of politics," Pape said." I have survived because I am outside."

But like most involved in fighting the epidemic in Haiti, he bemoans the loss of former first lady Mildred Aristide, who was forced from the country with her husband in 2004.

"She was doing the work," he said. He shrugged.

"When you're in a fight, you lose some generals, but if your vision is clear, you will win at the end."

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