Arachu Castro

Community-based approaches to HIV treatment in resource-poor settings

Last year, HIV surpassed other pathogens to become the world’s leading infectious cause of adult death. More than 90% of deaths occur in poor countries, yet new antiretroviral therapies have only led to a drop in AIDS deaths in industrialised countries. The main objections to the use of these agents in less-developed countries have been their high cost and the lack of health infrastructure necessary to use them. We have shown that it is possible to carry out an HIV treatment programme in a poor community in rural Haiti, the poorest country in the western hemisphere. Relying on an already existing tuberculosis-control infrastructure, we have been able to provide directly observed therapy with highly-active antiretroviral therapy (HAART) to about 60 patients with advanced HIV disease. Inclusion criteria and clinical follow-up were based on basic laboratory data available in most rural clinics. Serious side-effects have been rare and readily managed by community-health workers and clinic staff. We discuss objections to the widespread use of HAART, and suggest that directly-observed therapy of chronic infectious disease with multidrug regimens can be highly effective in settings of great privation as long as there is sustained commitment to uninterrupted care that is free to the patient. Why AIDS prevention alone is insufficient The dimensions of the global HIV crisis are such that predictions termed alarmist a decade ago are now revealed as sober projections. 1

Understanding and Addressing AIDS-Related Stigma: From Anthropological Theory to Clinical Practice in Haiti

For the past several years, diverse and often confused concepts of stigma have been invoked in discussions on AIDS. Many have argued compellingly that AIDS-related stigma acts as a barrier to voluntary counseling and testing. Less compelling are observations regarding the source of stigma or its role in decreasing interest in HIV care. We reviewed these claims as well as literature from anthropology, sociology, and public health. Preliminary data from research in rural Haiti suggest that the introduction of quality HIV care can lead to a rapid reduction in stigma, with resulting increased uptake of testing. Rather than stigma, logistic and economic barriers determine who will access such services. Implications for scale-up of integrated AIDS prevention and care are explored.

Adherence to antiretroviral therapy: merging the clinical and social course of AIDS.

Compliance with HIV treatment is affected by many issues and social factors are as important as biological ones.

How Do Intellectual Property Law and International Trade Agreements Affect Access to Antiretroviral Therapy

Westerhaus and Castro argue that US-negotiated bilateral, regional, and multilateral trade agreements are hindering access to essential HIV medicines in poor countries.

Late presentation for HIV care in central Haiti : factors limiting access to care

Abstract Objective: Many patients with HIV infection present for care late in the course of their disease, a factor which is associated with poor prognosis. Our objective was to identify factors associated with late presentation for HIV care among patients in central Haiti. Methods/Design: Thirty-one HIV-positive adults, approximately 10% of the HIV-infected population followed at a central Haiti hospital, participated in this research study. A two-part research tool that included a structured questionnaire and an ethnographic life history interview was used to collect quantitative as well as qualitative data about demographic factors related to presentation for HIV care. Results: Sixty-five percent of the patients in this study presented late for HIV care, as defined by CD4 cell count below 350 cells/mm3. Factors associated with late presentation included male sex, older age, patient belief that symptoms are not caused by a medical condition, greater distance from the medical clinic, lack of prior access to effective medical care, previous requirement to pay for medical care, and prior negative experience at local hospitals. Harsh poverty was a striking theme among all patients interviewed. Conclusions: Delays in presentation for HIV care in rural Haiti are linked to demographic, socioeconomic and structural factors, many of which are rooted in poverty. These data suggest that a multifaceted approach is needed to overcome barriers to early presentation for care. This approach might include poverty alleviation strategies; provision of effective, reliable and free medical care; patient outreach through community health workers and collaboration with traditional healers.

Measuring Coverage in MNCH: Validating Women’s Self-Report of Emergency Cesarean Sections in Ghana and the Dominican Republic

Background Cesarean section is the only surgery for which we have nearly global population-based data. However, few surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR). Methods and Findings This study compares hospital-based data, considered the reference standard, against women’s self-report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a survey, given the observed prevalence, sensitivity, and specificity from this study. Hospital data were matched with exit interviews for 659 women delivered via cesarean section for Ghana and 1,531 for the Dominican Republic. In Ghana and the Dominican Republic, sensitivity and specificity for emergency cesarean section defined by decision time were 79% and 82%, and 50% and 80%, respectively. The validity of emergency cesarean defined by operation time showed less favorable results than decision time in Ghana and slightly more favorable results in the Dominican Republic. Conclusions Questions used in this study to identify emergency cesarean section are promising but insufficient to promote for inclusion in international survey questionnaires. Additional studies which confirm the accuracy of key facility-based indicators in advance of data collection and which use a longer recall period are warranted.

Infectious disease in Haiti

More than 50 years after the introduction of chemotherapy for the treatment of tuberculosis (TB), the disease is far from being under control. Among curable infectious diseases, TB remains the number‐one killer—each year, 2 million people still die of the disease and 8.4 million more fall ill (World Health Organization (WHO), 2002a). And future projections are grim. Fewer than half of all TB cases are diagnosed, and of those that are, fewer than 30% have access to the care recommended by the WHO (WHO, 2002a). The increase in TB worldwide is due, in part, to the expansion of the HIV/AIDS pandemic (WHO, 2001): at least one‐third of people with HIV die of TB (WHO, 2002a). HIV/AIDS now causes more than 3 million deaths per year (UNAIDS, 2002). More than 90% of HIV/AIDS deaths and new infections occur in poor countries where less than 5% of those who need antiretroviral treatment have access to these therapies (WHO, 2002b). If we consider that, on average, 10% of people with HIV need antiretroviral treatment, the 5% figure comes down to less than 1% in sub‐Saharan Africa, the region most affected by the pandemic. > The social contexts in which our patients became infected are an integral part of their stories Large‐scale social forces, such as racism, sexism, political violence, poverty and other social inequalities, are rooted in historical and economic processes and sculpt the distribution and outcome of HIV/AIDS and TB. We refer to these social forces as ‘structural violence’ (Castro & Farmer, 2002, 2003a,b; Farmer, 2003), which predisposes the human body to pathogenic vulnerability by shaping the risk of infection and subsequent disease reactivation. After infection, structural violence also determines who has access to diagnostics and effective therapy. Drugs that could stop or slow down these epidemics, such as …

In and out: user fees and other unfortunate events during hospital admission and discharge

In various countries it has been reported that patients who receive hospital care, for example assisted birth, are detained inside the health facility until they pay their bills. The practice of hospital detention, whose magnitude is unknown, has been criticized as anti-humanitarian by UNICEF and human rights organizations. However, according to the author, leaving the hospital with a confirmed diagnosis and the recommended treatment can prove more difficult than simply being detained, particularly when health budgets are allocated with disregard for the social conditions in which people live, as in Latin America and elsewhere.

Quality of life of people with HIV/AIDS receiving antiretroviral therapy in Cuba: a cross-sectional study of the national population.

OBJECTIVES We studied the effect of antiretroviral therapy (ART) on the quality of life (QOL) of Cubans with HIV/AIDS. METHODS We conducted a cross-sectional study including administration of the Medical Outcomes Study-HIV Health Survey Questionnaire to a representative sample of the 1592 Cubans receiving ART in 2004. For univariate analyses, we compared mean HIV scale scores. We used logistic regression models to estimate the association between role function and year of diagnosis, between pain and sex, and between health transition and region of diagnosis, with adjustment for demographics, ART regimen, and clinical status. RESULTS There were 354 participants (73 women, 281 men). Scores for all functional activities showed means higher than 80 out of 100. Pain interfered more in women than in men (73.2 vs 81.9; P = .01). When HIV diagnosis occurred after 2001, the probability of experiencing difficulties performing work (odds ratio [OR] = 4.42; 95% CI = 1.83, 10.73) and pain (OR = 1.70; 95% CI = 1.01, 2.88) increased compared with earlier diagnosis. People treated with indinavir showed a greater perception of general health (58.9 vs 52.4; P = .045) and greater health improvement (78.6 vs 67.8; P = .002). CONCLUSIONS Although Cubans receiving ART are maintaining a high QOL, we observed significant differences by sex and time of diagnosis. QOL assessment can serve as a health outcome and may allow identification of QOL reductions potentially related to ART side effects.