AIDS, TB, and Malnutrition Are Triple Threat in Haiti

by Daniel W. Fitzgerald and Patrice Joseph

(Population Today, July 2001) Poverty is fueling a destructive synergy among HIV/AIDS, tuberculosis, and severe malnutrition in Haiti, a country whose per capita gross national income of US$460 is the lowest in the Caribbean.

Among countries in the Caribbean, Haiti has the highest HIV prevalence. More than 5 percent of persons who are 15 to 49 years old � the age range that covers people in their most sexually active years � have contracted HIV, according to the United Nations. Haiti also has the highest prevalence for malnutrition in the region (at least 30 percent of children under age 5 suffer low weight for age)¹ and the highest incidence rate of TB (at least 250 per 100,000 people).²

Even though the interactions among AIDS, malnutrition, and TB in Haiti are vicious, the following story demonstrates that interventions are possible:

Rose was a teenage girl in the rural Artibonite Valley of Haiti when her mother died, leaving her no family. Rose survived by exchanging labor for food. She met a man and moved in with him and gave birth to a daughter. The man left for the city when the child was 2. Rose did odd jobs to survive, but her daughter did not have enough to eat. Desperate, Rose moved in with another man and gave birth to another child. Soon, this child's father left. The cycle of desperation, moving in, giving birth, and abandonment repeated itself. Rose had three children by three fathers. She then became sick. She tried doing odd jobs but was too weak to work. Her eldest daughter, now age 12, begged in the streets to feed the family. Finally, wasted and bed-ridden, Rose came to medical attention and was admitted to Hospital Albert Schweitzer. She was diagnosed with AIDS, severe malnutrition, and active TB. Rose returned home and received twice-weekly home visits from hospital staff for the provision of nutritional support and for directly observed TB therapy (DOT), a program in which health workers ensure that TB patients take the full course of their treatment. Rose recovered and soon got a job with the hospital taking care of other people with TB and AIDS.

Organizations Address the Central Role of Poverty

With the support of the Haitian Ministry of Health, several organizations in this country of more than 6 million have developed interventions to reverse the effects of the destructive interactions among AIDS, malnutrition, and TB. The interventions share three characteristics:

• Recognition of the central role of poverty
• Integration of medical services for HIV, malnutrition, and TB
• Health workers who go the extra mile for their patients.

The nongovernmental organization Zanmi la Sante has addressed the central role of poverty in HIV/AIDS, malnutrition, and TB. Zanmi la Sante is a community health organization in the Peligre basin of Haiti's central plateau. In 1991, the organization conducted a study that compared TB treatment outcomes for a group of patients receiving standard TB treatment with outcomes for a second group receiving standard treatment plus financial aid.³

The group receiving financial aid had improved cure rates, lower mortality, and better ability to return to work, compared with the group receiving standard medical care. The authors concluded that if the primacy of economic causes was recognized and addressed, TB treatment outcomes could be dramatically improved. Zanmi la Sante has applied the strategy of targeted financial aid to other health interventions, including nutrition programs, provision of HIV care, and prevention of mother-to-child HIV transmission with antiretroviral therapy.

Integrating Care for AIDS, Malnutrition, and TB

Integrating medical services for HIV/AIDS, malnutrition, and TB has also proved beneficial. The Haitian Study Group on Kaposi's Sarcoma and Immunodeficiency Disorders (GHESKIO) combines patient services, research, and training to address major public health problems in Haiti.

Clients who come to GHESKIO's Port au Prince center for voluntary HIV counseling and testing are also screened for active TB; more than 1 in 20 people who come for HIV testing have active TB.⁴ People with active TB are treated, HIV positive patients are given HIV care (including TB prophylaxis), and all patients suffering from malnutrition are provided nutritional support. Integration of services has improved care for all GHESKIO patients, and GHESKIO staff now train staff from other Haitian health institutions in providing HIV/AIDS, nutrition, and TB services.

Highly motivated, compassionate caregivers are the third component of successful interventions. The Hospital Albert Schweitzer directly observed TB therapy DOT program provides a model for developing compassionate staff. Under DOT programs worldwide, community health workers visit patients to make sure they take their medicine on time and in full. Under the Schweitzer DOT strategy, the home-care workers who visit patients' homes are former TB patients. The hospital uses former TB patients because they believe that former patients are more likely to be sympathetic to those suffering from a disease that is often the source of social stigma.

These home-care workers receive extensive training. From time to time, physicians accompany them during routine home visits. These visits by the physician not only help with routine teaching and supervision of home-care workers, but also force the physician out from behind the desk, into the field, and into the home of the patient.

A recent study of treatment outcomes for DOT and non-DOT TB patients demonstrated a benefit of the Schweitzer DOT strategy.⁵ The benefit was most dramatic in HIV-positive patients. Eighty percent of the HIV-positive patients receiving DOT had successful treatment outcomes, compared with 28 percent who did not receive DOT.

Whereas most people with AIDS in Haiti die in a few months, Rose is doing well five years after her diagnosis. Also significant is that her oldest daughter, who once begged in the streets to support the family, was able to go to school after her mother's rehabilitation and can now read and write and support herself.

Daniel W. Fitzgerald is a researcher with Cornell University Medical College's Division of International Medicine and Infectious Diseases. Patrice Joseph is a member of the Haitian Study Group on Kaposi's Sarcoma and Immunodeficiency Disorders.