28 January, 2003

$15,000,000 from the World Bank but no ARV access: Jamaican Bays,
Beaches Offer No Safe Harbor for People with HIV/AIDS

by Richard Stern*

Seven minutes from Sangster International Airport in Montego Bay,
Jamaica there is a somewhat run down house on a hill with a
breathtaking view of the $150/night luxury hotels on the beach
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 and a small staff of
dedicated people 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 anti- retroviral medications.

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
anti-retrovirals (ARVs), 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 buys his
medications from LASCO, a local importer of CIPLA drugs which
sells him a monthly cocktail of Duovir (AZT + 3TC) and
Nevirapine for $120 US per month, about four times what CIPLA
charges for the same cocktail if it is purchased in India.

Gladys, 28, told me how her 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
everyday. They told her to first to get a CD4 test for the
little girl and she did not have the $100 necessary for this.
The only CD4 testing in Jamaica is available at the University
of the West Indies, Viral load testing is not available. 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 also not clear why Doctors
needed a CD4 test in order to begin treatment with 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 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 anti-retroviral
medication to any of the estimated 4500 people with AIDS who
need treatment at this moment. 25,000 are estimated to be
HIV+, and three people die each day of AIDS. The population of
Jamaica is 2.8 million.

Perhaps 150 out of the 4500 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 anti- retroviral purchase. Ironically a $15,000,000 loan from
the World Bank to Jamaica for AIDS related activities may be
inadvertently delaying anti-retroviral access in Jamaica.

Dr. Yitades Gebre of the National AIDS Program told me that the
AIDS Program is 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.

But overwhelmed by its own incapacity to effectively absorb and
utilize these funds, the government of Jamaica did not even
submit an application to the second round of the Global Fund,
last year, and the World Bank will not permit its funds to be
used for anti-retroviral purchase. 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
People Living with HIV/AIDS who need medications now.

World Bank money must also be repaid at some point whereas Global
Fund money is allocated to countries without any need for
repayment, although the Global Fund does require that
sustainability of treatment be built into National AIDS
programs.

In his speech at the special United Nations Special General
Assembly on AIDS(UNGASS) on June 27th, 2001, Jamaican Health
Minister John A 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. One trained physician (Dr. Gebre
acknowledged that there are several physicians in the country
with extensive experience in utilizing anti-retrovirals,) 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. The trained physicians
could train others. In "resource poor settings" what is needed
for effective treatment are trained physicians and, ideally CD4
testing. Funds are now needed to purchase medications at the
best available prices, and there is currently no budget approved
by the government for anti-retroviral 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
anti-retrovirals at this moment it appears that there is no plan
in place.

Another argument in favor of anti-retroviral purchase is the
deteriorated state of the public hospital system in Jamaica.
Those patients who are treated, rarely receive medications for
opportunistic infections and the overall capacity of these
hospitals to meet their medical needs is minimal. With
anti-retroviral access, a high percentage of patients could
by-pass the public hospital system --- if their treatment is
successful, the need for hospitalization declines dramatically.
They also could then return to the labor force, and their
children would not be orphaned, thus avoiding an additional
burden placed on the government.

But Dr. Gebre gave no specific date as to when anyone with AIDS
in Jamaica would actually receive ARV therapy, although
indicating that the government is hoping to begin treatment for
several hundred people this year. He pointed out that a country
wide program is already in place for prevention of mother to
child prevention. He said the government plans to eventually
have four AIDS clinics in place which will provide comprehensive
services for People with AIDS.

Jamaica may at some point be able to apply for funds for a small
number of anti- retroviral medications if the regional Caribbean
proposal submitted by "CARICOM" (Caribbean Community) to the
Global Fund, is accepted, but, according to Dr. Gebre CARICOM
only has requested enough funds to purchase anti-retrovirals for
four to five thousand people, which must be divided between all
of the CARICOM member states. As many as 100,000 people
currently need anti-retrovirals in the entire region. If the
CARICOM proposal is accepted by the Global Fund Board, currently
meeting in Geneva, Jamaica must then submit a proposal to
CARICOM to receive its share of funds, but because of the
regional situation, it seems likely that available funding from
this particular source for medication purchase would only be
sufficient for perhaps 200-300 people during 2003.

A CARICOM official in Guyana confirmed that the Global Fund
proposal submitted by the Agency includes $4.9 million yearly for
purchase of medications for the entire 29 country region during
the next five years. At the current average cost of $1,400 per
year per person. this amount would only cover treatment for about
3500 people yearly from the region, in which there are an
estimated 500,000 people who live with HIV/AIDS, at least
100,000 of whom need treatment now.

So Jamaica's share of funding for treatment, if and when the
CARICOM proposal is approved by the Global Fund, is unlikely to
cover more than a couple of hundred people per year, as Dr. Gebre
indicated.

Jamaica has benefited from price reductions resulting from the
WHO/PAHO sponsored accelerated access negotiations. A cocktail
combining Glaxo's Combivir and Merck's Indinavir costs $1622 per
year and most other cocktails are available for between $1400-
$1800 yearly as a result of these negotiations.

Besides Merck and GlaxoSmithKline, Bristol-Myers Squibb, Roche,
Abbot and Boehringer Ingelheim participated in this process.

A private pharmaceutical company called LASCO is importing
generic products 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. Thus a cocktail of AZT + 3TC +
Nevarapine costs $1032 yearly per person, while CIPLA sells the
same cocktail to LASCO for about $360 per year. LASCO's mark-up
is roughly 300 percent. (The same cocktail is sold by LASCO for
$1420/year if purchased individually!) This author has traveled
extensively in the Latin American/Caribbean region and has
supported and encouraged the registration of CIPLA products. But
it is dismaying to see the results of CIPLA registration, as this
case illustrates.

The purpose of my visit to Jamaica was to do a series of
workshops related to advocacy and empowerment of People Living
with HIV/AIDS as well as a diagnostic assessment of the situation
related to Anti-retroviral access. One of the workshops involved
a group of women living with HIV/AIDS who are members of "JN+"
the Jamaican Network of Positive People. Several hours
of intensive interaction revealed the degree of stigma and
discrimination faced by People with AIDS in Jamaica.

One woman explained it: "we would like to get involved in
advocacy, but we are afraid. We could be kicked out of our
houses, and what about our children at school? What will happen
to them if people find out we have AIDS?" Another woman told me
that a landlord went so far as to take the roof off of a house in
order to "evict" a family of People living with AIDS that had
refused to leave. There is no National AIDS law in Jamaica, and
no law against discrimination.

Aside from the other problems with the public hospital system, it
appears that stigma and discrimination is commonplace. In
another workshop, 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
when they are still severely ill. NGO's go 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 does little to improve
attempts to combat the epidemic. Gay sex, even among consenting
adults, 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 referred to, are subject to violent attacks as well.
According to Jamaican scholar Thomas Glave, bottles of acid have
been used in attacks on gays.

Perhaps the most fundamental arguments for providing
anti-retroviral access in developing countries is that it
substantially reduces stigma and discrimination thereby enhancing
prevention efforts and reducing costs associated with the
epidemic. By providing People with AIDS with adequate medical
treatment, the government is giving a message to the entire
population that the lives of these individuals are worth
something and their rights in the society deserve to be
protected. Visibility is increased and the subject of AIDS is no
longer taboo. Countries much poorer than Jamaica are providing
ARV's with dramatically positive results.

Dr. Peter Piot, Director of UNAIDS, Dr. Gro Harlem Brundtland,
Director of WHO, and Dr. Joep Lange, President of the
International AIDS Society all issued urgent calls for massive
and rapid scaling up of anti-retroviral access in developing
countries at the Barcelona International AIDS conference last
July. Jamaica has a large contigent of AIDS experts from the
International Agencies of Cooperation, including PAHO, UNICEF,
UNDP, as well as CARICOM, working full time on the epidemic. I
spoke to several of these same experts who are well aware of what
is happening in Jamaica. Yet, concrete solutions congruent with
the goals expressed by Drs. Piot, Brundtland, and Lange seem
miles away from the pristine shores of Jamaica.

It would also appear that the situation of the CARICOM Global
Fund proposal may not have been well coordinated with other
countries, if so few of the region's 100,000 or more people
with AIDS are going to benefit by receiving treatment access.
Technical advisors could have made it clear to all of the 29
member countries that the amount of money requested is far below
was is needed to cover anti-retroviral access in the region. Or
perhaps this was made clear, and Jamaica simply did not act.

*Director
Agua Buena Human Rights Association
San José, Costa Rica
Tel/Fax 506-234-2411
rastern@...
www.aguabuena.org




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