Are We Lambs or Lions? A Perspective From HIV Advocates in Puerto Rico

At present, Puerto Rico is immersed in an economic crisis that threatens to destabilize the economy and health systems and provider networks of clinical and social services. In late June, Congress passed and the President signed the Puerto Rico Oversight, Management, and Economic Stability (PROMESA) Act, which allows Puerto Rico to restructure its debt. However, the new law does not provide direct financial assistance, allows a lower mínimum wage for some workers and establishes an unelected financial management and oversight board that will manage Puerto Rico's debt. It is concerning to us that an oversight board was imposed by the U.S. Congress to satisfy bondholders, some of whom (along with Congress itself) were complicit in creating this economic and humanitarian crisis. We are particularly concerned that beneficiaries of Medicaid, Medicare and the Ryan White Program in Puerto Rico will likely be impacted in ways that threaten patients' adherence to medications and the sustainability of these health professionals. Finally, we are worried that the imposition of the oversight board will leave us in limbo and could endanger the lives of 20,243 Puerto Ricans with HIV (who are also U.S. Citizens of course).

Compounding the situation is the exodus of doctors and specialists leaving Puerto Rico (as a result of the lack of financial remuneration), and insurance companies' failure to meet clinical needs or during hospitalizations and their failure to comply with national quality strategies to avoid health complications (especially those associated with HIV) and hospital readmissions. Although reimbursements to providers have continued as usual, beginning in December 2015 the present administration has instructed the Treasury Department to stop releasing funds except for federal checks targeted for HIV prevention and care.

Together, we ask, "How do we maintain success and eradicate HIV in Puerto Rico given this current economic situation?" "How can we successfully meet the targets of the National HIV/AIDS Strategy by 2020 without the necessary funds?" We know that the oversight board will remove our financial autonomy, but how will this impact HIV, STD, viral hepatitis, and tuberculosis funding? As community leaders and legislators it is our responsibility to discuss how we will respond to this humanitarian crisis created by the mismanagement funds by public figures in the past either through ignorance or incompetence. Sadly we cannot rule out direct corruption as a possible reason for the crisis as well as it is never far from consideration in these scenarios.

Community efforts around HIV/AIDS have been vital in stabilizing and strengthening the care for people with HIV living in Puerto Rico. The relentless advocacy efforts of the past nine years serve as evidence that active community participation is the key to success. However, you should never let your guard down. Great achievements have been made in:

  • eliminating drug rationing through the San Juan Planning HIV/AIDS Planning Council and reducing the waiting list for access to medicines and appropriate therapies;
  • managing the supplies inventory and establishing copayments for people with private and reimbursement plans within a reasonable time; and
  • ensuring that the Ryan White Eligible Metropolitan Areas of San Juan comply with the biannual eligibility requirements in order to guarantee patients' access to complete antiretroviral treatments and program quality improvements.

However, we have a long way to go to eliminate disparities in services for people living with HIV.

Although much more is needed to be done to implement and harmonize locally, we also know that the expectations and regulations will guide us to where we should be. We especially ask that the HIV community and HIV service organizations in the mainland U.S. continue to work with us to pressure Congress to make sure that people living with HIV are not left behind by the oversight board or others as we work to solve this financial crisis. We must stand up as lions on behalf of social justice and against corruption for people living with HIV and not surrender meekly as lambs.