$15 Million for Infrastructure but No AIDS Drugs for Jamaica
Seven minutes from Sangster International Airport in Montego Bay, Jamaica, there is a somewhat run-down house perched on a hill with a breathtaking view of the luxury beachfront hotels below and of the cruise ships docked across the bay.
I spent Wednesday, January 22nd, 2003 in that house talking with people who are living with HIV/AIDS (PLWHA) and with the small, dedicated staff from a local NGO who support them. These people are dying. Of about 25 who showed up on that Wednesday to see a volunteer doctor who comes every two weeks, only one had access to antiretroviral medications (ARVs). Several were so sick with wasting syndrome and other opportunistic infections that they had to be helped up and down the stairs to see the doctor.
Jamaica's response to its AIDS epidemic seems to have been too little and quite late.
Max, a 44 year old, the only member of the group who could afford antiretroviral medications, told me that when he was seen at the local hospital a nurse refused to take his blood pressure after she opened his medical file and saw his diagnosis. Max obtains his medications from LASCO, a local importer of generic ARVs made by CIPLA in India, and buys a cocktail of Duovir (AZT + 3TC) and nevirapine for $120 per month, about four times what CIPLA charges for the same cocktail if it is purchased in India.
Gladys, 28, told me how she had begged local hospital officials and then private doctors to get medications for her five year old daughter Emily who was becoming more and more ill every day. They told her to first to get a CD4 test for the little girl, but she did not have the necessary $100 for this test. CD4 testing in Jamaica is only available at the University of the West Indies and viral load testing remains unavailable. Emily died November 17th. It is not clear why CD4 tests in Jamaica costs $100 when in many countries in the region the cost of this test is under $30 per person. It is also not clear why the doctors needed a CD4 test before starting treatment for an obviously critically ill child. Presumably it is because they had no pills to treat her with.
Joel, 26, who could not have weighed more than 90 pounds, is a former taxi driver who alternately cried and slept while waiting to see the doctor. He said he is lucky because his father cares for him, while many others have been thrown out of their houses.
The Jamaican government does not provide antiretroviral medication to any of the estimated 4,500 people with AIDS who need treatment at this moment. Twenty-five thousand people in Jamaica are estimated to be HIV-positive, and three people die each day of AIDS. Perhaps 150 out of the 4,500 who need treatment have access to ARVs because they buy them privately or because they receive donated medications or have contacts with relatives in the U.S.
Government officials told me the Health Ministry has no budget for antiretroviral purchase. Ironically a $15 million loan from the World Bank to Jamaica for AIDS-related activities might be inadvertently delaying antiretroviral access in Jamaica. Dr. Yitades Gebre of the Jamaican National AIDS Program told me that they are currently focusing on how to utilize the World Bank money for prevention programs as well as for capacity building and implementation of infrastructure related to treatment access. The World Bank will not permit its money to be used to purchase antiretrovirals.
But overwhelmed by its own incapacity to effectively absorb and utilize these funds, the government of Jamaica did not even submit an application last year for the second round of grants from the UN's Global Fund for AIDS, TB and Malaria. So the government of Jamaica is stuck with an excess of potential infrastructure, but no funds for actual purchase of medications. The victims of this unusual "embarrassment of riches" appear at this point to be the people with HIV/AIDS who need medications now.
In a speech at the UN in 2001, Jamaican Health Minister John Junior stated that, "We welcome the proposed establishment of a global health and HIV/AIDS fund and hope that the allocation of resources from the Fund will not be subject to bureaucratic impediments which would limit timely and adequate disbursements to those worst affected." We tried to reach Minister Junior to find out why Jamaica is one of the very few developing countries which has not even submitted a proposal to the now established Global Fund, but he was unavailable for comment.
This reporter discussed with Dr. Gebre other issues related to the situation of people living with HIV/AIDS in Jamaica who need ARV treatment now. A single trained physician (Dr. Gebre acknowledged that there are several physicians in the country with extensive experience in utilizing antiretrovirals) can easily treat up to 100 people per month or possibly more, especially if CD4 testing is available. The government will be using some of the World Bank money to purchase a CD4 machine, thereby lowering the cost of the test. Funds are now needed to purchase medications, but there is currently no budget approved by the government for antiretroviral purchase, except for prevention of mother-to-child transmission. The World Bank loan will undoubtedly enable Jamaica to eventually implement many excellent programs, but for those who need antiretrovirals now it appears that there is no plan in place.
Antiretroviral access could also relieve the burden on the public hospital system in Jamaica. AIDS patients who are treated rarely receive medications for opportunistic infections and the overall capacity of these hospitals to meet the need is minimal. When antiretroviral access arrives, a high percentage of patients could likely by-pass the public hospital system, since, if their treatment is successful, the need for hospitalization should decline dramatically. People on treatment could also return to the labor force, and their children would not be orphaned, thus avoiding additional burdens on the government.
But Dr. Gebre gave no specific date as to when anyone with AIDS in Jamaica would actually receive ARV therapy, although he indicated that the government is hoping to begin treatment for several hundred people this year. He said the government plans to eventually have four AIDS clinics in place which will provide comprehensive services for PLWHAs.
Jamaica may be able to apply for funds for a limited supply of antiretroviral medications if the regional Caribbean proposal submitted by "CARICOM" (Caribbean Community) to the Global Fund is accepted. But, according to Dr. Gebre, CARICOM has only requested enough funds to purchase ARVs for 4 to 5 thousand people, and that must be divided between all of the CARICOM member states. As many as 100,000 people currently need antiretrovirals in the entire region. If the CARICOM proposal is accepted, Jamaica must then submit a proposal to CARICOM to receive its share of funds, but because of the regional need, it seems likely that this would only be enough to buy medications for 200 to 300 Jamaicans during 2003.
A private pharmaceutical company called LASCO is importing generic ARVs sold by CIPLA. This reporter obtained a copy of the price list for LASCO products if purchased "wholesale." The combination of Duovir (AZT +3TC) sells for $600 yearly and nevirapine sells for $432, pricing a triple cocktail of AZT + 3TC + nevirapine at $1,032 yearly per person. Yet CIPLA sells the same cocktail to LASCO for about $360 per year.
Aside from the other problems with the public hospital system, it also appears that stigma and discrimination are commonplace. I was told that at Kingston General Hospital people with AIDS are segregated into a back corner and routinely ignored by nursing staff. If they have no family to visit them, they will live in appalling conditions and are often discharged while still severely ill. Local NGO's are summoned to the hospital on an emergency basis to try to find space in hospices for those who are being asked to leave.
The stigma suffered by gays and lesbians also hurts efforts to combat the epidemic. Gay sex is still illegal under "buggery" laws enacted when Jamaica was a British Crown Colony. Prosecution may occur for public as well as private acts and, when arrests are made, names and addresses are routinely published in newspapers. This situation reduces the opportunity to do prevention work in the gay community, which remains largely underground. "Batty Boys," as gay men are called, are subject to violent attacks as well.
One of the fundamental arguments for providing antiretroviral access is that it substantially reduces stigma and discrimination thereby enhancing prevention efforts. By providing people with AIDS with adequate medical treatment, the government would be giving a message to the entire population that the lives of these individuals are valuable and that their rights in society deserve to be protected. Their visibility would increase and the subject of AIDS would no longer be taboo.
Countries much poorer than Jamaica are providing ARVs with dramatically positive results, but it appears that the best opportunity to make ARV access a reality here soon has been mishandled. CARICOM's Global Fund proposal may not have been well coordinated with other countries. Technical advisors could have made it clear to all of the 29 member countries that the amount of money requested is far below what is needed to cover antiretroviral access in the region. Or perhaps this was made clear, and Jamaica simply did not act.
Richard Stern is Director of Agua Buena Human Rights Association, San José, Costa Rica; www.aguabuena.org.
This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.