Section: Honduras
Published: September 14, 2003
In
Honduras Treatment Access Improves for People Living with HIV/AIDS
By Richard Stern*
Note: Material
for this report was accumulated from about 15 different formal and
informal interviews, as well as two workshops, that were held during
my week in Honduras, from August 18th to 24th. Although I have done
my best to verify data that is presented, it should not necessarily
be assumed that all information cited is one hundred percent accurate,
or that any given individual is responsible for any of the information
cited.
The Spanish
language version of this report was distributed ten days ago, and
I received a detailed letter from a Honduran Health Ministry official
who oversees the AIDS program there, indicating that some of my
original data presented in the first report was inaccurate. So this
later version of the report reflects these corrections.
Country
Overview
Honduras, with
a population of 6.5 million is one of Latin America’s poorest countries,
and has the second highest incidence of AIDS in the region. Approximately
80,000 people are estimated to be HIV+, creating an incidence of
1.2 percent. It is estimated that 3,500 people currently need ARV
access. Honduras is number 115 (out of 175 countries world wide)
on the most recent Human Development Index (HDI) published by UNDP.
Honduras has
received a Global Fund grant of $41,119,903 and the contract with
the Global Fund was signed February 17, 2003. ($14,000,000 of this
grant is for Tuberculosis and Malaria and $27,000,000 is for AIDS)
As of August 1st, 2003, only funds for the first six months of the
project had been disbursed. The written operating plan related to
the disbursement available for the next 18 months is scheduled to
be sent to the Global Fund in a very short time.
Global
Fund Issues Reflected in this Report
The discussion
and recommendations in this report touch on three issues that I
feel the Global Fund should make an attempt to deal with in upcoming
Board meetings.
1) How real
is the civil society "representation" in the CCM? How
can the GF increase the degree to which CCM members reflect the
real composition and needs of civil society, with respect to the
targeted Civil Society populations?
2) How we can
have more informacion and transparency with regard to the processes
and prices related to ARV purchase, when a large amount of money
is involved and a large number of individuals will benefit from
treatment?
3) The exclusion
of gay groups from being Global Fund recipients is absolutely unacceptable.
In the case of Honduras this has occurred because the government
has never been willing to grant "legal registration" to
any gay group because such Associations are viewed as "immoral."
And, of course, the CCM has set up the rule that only "legally
registered" groups can receive Global Fund money. This, in
spite of the fact that as many 25-30% of all AIDS cases in Honduras
occur in the population of Men who have sex with Men. (Official
figures may be less, but I would doubt their accuracy since most
Men who have sex with Men will not admit this to a Health Care worker.)
Report
I)
Treatment Access Panorama
It is important
to recognize the efforts of the Honduran government to “scale up”
anti-retroviral access. The National AIDS program Director, Dra.
Rosalinda Hernandez informed me during my meeting with her, that
over 900 people are now receiving anti-retroviral therapy in Honduras.
Approximately 760 are people whose medications have been purchased
by the government and an addition 140 are receiving treatment provided
by NGO’s, mostly Doctors Without Borders. With funds available from
the Global Fund and an additional allocation of funds from the Government
itself, Dra. Hernandez estimated that 1,500-2,000 people will be
receiving treatment by the end of the year. This is a significant
improvement if one considers that only a year ago, less than 200
people had ARV access.
II)
Issues Related to Choice of Therapies
Most of the
available funding is going toward first line therapy which consists
of Combivir and Efiravenz (Sustiva) The Combivir is purchased from
GlaxoSmithKline and the Efiravenz from Merck and Co. There is a
list of medications that include additional ARV’s (Ddi, D4T, Nevirapine,
Indinavir, and Abacavir) that will be purchased but it was not clear
which of the medications on this list would be purchased in which
quantities. Thus it remains unclear how many “second line” medications
are actually included in the purchase agreement which has just been
signed. During my visit I encountered a Physician who indicated
that he knows of at least two patients who need a second line medication
such as Kaletra. Although Kaletra would be extremely expensive to
purchase at existing prices it seems important to explore the purchase
of such medication, at least in small numbers to be able to treat
resistant patients.
According to
data supplied by the government official who replied to my original
report from two weeks ago, medications will be purchased for patients
who need a second line therapy because of intolerance (estimated
to be 7% of those who take ARV's) and for those who need it because
of issues related to resistance (estimated by this official to be
3%).
III)
Issues Related to Medications for Opportunistic Infections
Many People
living with HIV/AIDS told me that there are still problems in obtaining
medications for opportunistic infections, especially fluconazole
and similar medications. It is not completely clear what steps will
taken to remedy this situation although Dr. Hernandez indicated
that the AIDS program is aware of the situation and taking steps
to correct it. Some mention was made of a possible donation by Pfizer.
Pfizer’s Diflucan continues to be prohibitively expensive in Honduras,
costing over $20 per day if purchased in pharmacies in a country
where the average wage is about $150/month.
IV)
Issues Related to Prices Paid for Anti-Rertrovirales
One of the
issues that arose during my visit was related to the price paid
by the Honduran government for its anti-retrovirals. At the time
of purchase, GlaxoSmithKline appeared with a patent on Combivir,
meaning that the purchase of CIPLA’s Duovir was ruled out. (One
source told me that patenting of “combination drugs” (Combivir is
actually AZT+3TC combined into one pill) is actually not permitted
in Honduras, but this information could not be verified) The first
line cocktail of Combivir and Efiravenz accounted for most of the
spending for those who now have treatment and a significantly high
percentage of the anticipated cost for the next purchase for treatment
for approximately of 1,500- 2,000 People living with AIDS. However,
the price for the Combivir/Efiravenz cocktail is $702 per/person/per
year about $82 more per year per person than if CIPLA's Duovir were
to have been purchased.
However, there
are good quality first line cocktails that are even less expensive,
and they are composed in some cases of drugs that are not patented
in Honduras.
If a government
purchases the all-generic version of Duovir + Nevirapine, the price
would drop to $410 per year per person, according to prices achieved
in the Andean regional negotiations held several months ago in Peru.
These prices are best available prices from CIPLA and Ranbaxy of
WHO pre-qualified medications so they should also be available in
Central America at roughly similar prices. The price for D4T + 3TC
+ Nevirapine would actually be $330.00 per year per person. If and
when CIPLA’s fixed combination pill of D4t + 3TC + Nevirapine (Triomune)
is approved by WHO, this pill is listed as costing $274. per year
per person. The prices mentioned above presumably reflect prices
achieved without the intervention of an intermediary such as IDA
of the Netherlands or PAHO (Pan American Health Organization) who
are Agencies approved by the Global Fund to negotiate anti-retroviral
purchases.
V)
Issues Affecting The Gay Community
A workshop
was held on Thursday August 22nd at the facilities of the gay/lesbian
organization "Kukulcan." Approximately 39 people attended
the workshop, 33 were gay men, almost all under the age of the 30,
and six were female and/or transgendered sex workers. It is important
to note the seroprevalence in gay men between the ages of 15-29
in Honduras is over 12 % according to a studied carried out by PASCA
(Proyecto Accion SIDA Centroamerica) just over a year ago.
In the workshop
each person present was asked to present their primary concern regarding
human rights violations against sexual minorities in Honduras. The
most common issues included, among others:
a. lack of education
about AIDS and sexually transmitted diseases.
b. The government’s
constant refusal to grant legal recognition known as a “personaria
juridica” to gay groups during the past ten years.
c. Discrimination
related to employment, especially the refusal of many companies
to hire men who appear to be effeminate or women or appear to be
masculine.
d. General “social
discrimination” including name calling and physical attacks in public
places, refusal to admit people to restaurants, etc.
e. Discrimination
in educational facilities, especially constant harassment at the
high school level which forces many young gay men to abandon their
studies.
f. Discrimination
fomented by attitudes of religious leaders.
g. Fear of HIV+
gay men to reveal their AIDS status, even within the gay community,
presumably for fear of being rejected even by their peers.
Issue "b"
above, related to the inability of gay groups to receive legal registration
(“personaria Juridica”) is especially worrisome at this particular
moment given the fact that the funding available for NGO’s from
the Global Fund requires a personaria juridica in order to be eligible
to receive funds, according to the guidelines set by the Country
Coordinating Mechanism. Thus groups, even those which are extremely
well organized such as Kukulcan, Comunidad Gay San Pedrana, and
Collectivo Violeta, cannot currently receive funding from the Global
Fund. This seems highly contradictory, given the fact that prevention
in the gay community should be a priority for the Global Fund, given
the high incidence of HIV among young, sexually active gay men.
Time during
the workshop was also dedicated to discussing the situation of two
policemen who are in jail in San Pedro Sula, Honduras largest city,
for the murder of a transvestite there. The only witness, a transvestite
who was present during the killing, continues to receive threats
on her life and has “protection” from the local Human Rights Commission,
but group members expressed concern that this protection was not
sufficient to guarantee this witness’s well being. This incident
has received ample coverage in the press in Honduras, and the fact
that two policemen are actually in jail seems to be significant
in the sense that in other Central American countries policemen
are suspected of having murdered transvestites but none have been
arrested.
VI)
The Role of the Churches in Honduras:
During one of
the lunches I attended, I sat next to a representative of one of
the Evangelical church groups who are now devoting significant resources
to fighting the epidemic in San Pedro Sula and other cities. The
person made references to the Bible and emphasized abstinence as
the only real solution to the dilemma of prevention. When I raised
the issue of homosexuality, I was first told that (Evangelical)
Church “believes that everyone has the capacity to change their
(presumably sinful) behavior…” and that the Bible is clear about
this issue. After 15 minutes of debate, we at least arrived at a
point where this person was willing to admit that no church member
should be judgmental of others whose lifestyles are different. This,
after I described to her the cruel and inhuman situations often
facing youth from fundamentalist families who struggle with sexual
identity issues.
The issue of
the Church’s participation in efforts to fight the epidemic in developing
countries to me is paradoxical and contradictory. Wonderful humanitarian
efforts such as hospices and comprehensive youth programs are juxtaposed
with discourses that seem to place the Biblical realities of 2000
years ago above the realities of an epidemic that the Apostles could
not have foreseen, and therefore could not have addressed in their
teachings. If they were as good of men as they are reputed to be,
surely they would have made some revisions in the face of the devastation
that AIDS has wrought.
VII)
Children and Orphans Made Vulnerable by HIV/AIDS in Honduras
I also attended
only the first day of a two day seminar entitled “Children and Orphans
made Vulnerable by AIDS Honduras” (“La Ninez Huerfana y Vulnerable
por el VIH/SIDA en Honduras”) sponsored by UNICEF. According to
UNICEF, there are from fourteen to seventeen thousand AIDS orphans
in Honduras. Six to seven thousand children in Honduras have lost
both parents to AIDS and an additional eight to ten thousand have
lost at least one parent. (It is important to note that an “orphan”
according to UNICEF is a child who has lost at least one parent
to AIDS.) A study that was presented at the conference authored
by Pamela Santos Cáceres of UNICEF indicated that AIDS orphans
living in institutions receive much better care and medical attention
than those who live with surviving family members. Orphans placed
with relatives may be considered by these family members to be an
economic burden and perhaps suffer from other forms of discrimination
and lack of attention, whereas those in the private institutions
are generally well treated and receive adequate medical attention.
VIII)
Civil Society Representation on the CCM
This issue is
very difficult to summarize. The "Fundacion Lucha Contra el
SIDA" is a legally chartered Foundation serving the purpose
of the Country Coordinating Mechanism (CCM) in Honduras. Representing
the very large population of People Living with HIV/AIDS in Honduras
on the CCM is the President of "ASONAPSIDA," the Honduran
Network of People Living with HIV/AIDS. The question has been raised
extensively in both of my visits this year by innumerable People
Living with HIV/AIDS as to what extent the President of ASONAPSIDA
can or cannot adequately represent their needs. One of the inherent
problems that comes with the acceptance of a Global Fund grant is
the fact that groups composed of People Living with HIV/AIDS will
be receiving substantial funding through the CCM which is controlled
in varying degrees by the government's representation, (depending,
of course, on whose opinion you listen to.) This may have the unintended
effect of curtailing the criticism of a government's lack of response
to the epidemic by Civil Society actors, including People Living
with HIV/AIDS.
On the one hand,
the Global Fund will provide more funding to resolve problems. On
the other hand if there are gaps related to treatment access or
human rights violations they may or may not be as fully addressed
by leading NGO's who may fear the loss of potential revenue. It
is important to remember that in Latin America, prior to the Global
Fund, only very minimal amounts of financial support have been available
through National AIDS Programs for civil society. Most NGO funding
in the poorest of Latin American countries has always come from
outside donor sources, thus NGO's may have felt freer to openly
and actively denounce violations occurring against the AIDS affected
community, without jeapardizing their financial support. The Global
Fund, appearing on the scene represents a "Windfall" of
resources, and the dynamics related to advocacy may change considerably.
The other issue
of great concern is that in Honduras, the only way for an NGO to
get funding through the Global Fund is to belong to ASONAPSIDA.
Independent organizations of People Living with HIV/AIDS would be
excluded under the current guidelines.
But many People
with HIV/AIDS I encountered have significant idealogical differences
with ASONAPSIDA and consider that it has taken a somewhat conservative
stance with respect to those "gaps" in human rights and
treatment access which exist. Yet these same individuals are well
aware that their only chance for funding is to "belong"
to ASONAPSIDA, so they are placed in a very difficult position.
It is important
to mention that there are undoubtedly a large number of People Living
with HIV/AIDS who are satisfied that their needs are adequately
represented by ASONAPSIDA, although in my own contact with a number
of long term Honduran activists, they expressed varying degrees
of dissatisfaction with this process.
The ideal way
to have perhaps minimized the impact of this problem would have
been for the Global Fund to assign its own, salaried "neutral"
staff member to participate in those CCM's which have grants that
are accepted in order to be sure that CCM is not overly controlled
by governments, and that the Civil Society representatives would
not be indirectly intimidated by those who have more control in
the CCM. However, until now, the Global Fund has made it clear that
it will not take such an active role in the on-going process of
project implementation, and instead assigns "Portfolio Managers"
to oversee the process.
Unfortunately,
there are other situations in the Latin American region regarding
manipulations and bullying by governments in CCM's which, in my
opinion, are very distressing (and I am NOT talking about Honduras)
but presenting these publicly is also a double edged sword, because
the concern would exist that "unmasking" political mismanagement
in CCM's could cause the Global Fund to hold up or even deny funds,
thus also penalizing the innocent as well as the guilty.
In general I
feel I should also mention that there is a relatively empowered
Civil Society in Honduras and that the government is making an effort
to listen to all sides of the situation, in spite of the complexities
and nuances that I have described above.
Since my visit
last month concluded I have received information from a reliable
source to the effect that a series of workshops had been scheduled
in order for Civil Society, particularly People Living with HIV/AIDS
to discuss their priorities for the next Global Fund "operating
plan" which is to be sent this month to the Fund, and covers
the next 18 months of the project in Honduras. After the workshops,
their recommendations and concerns were to be transmitted to the
CCM. This latest process which I have not personally observed, certainly
provides a potential avenue for Civil Society to be able to have
meaningful input into CCM processes.
Recommendations:
1) The Fundacion
Lucha Contra el SIDA, which functions as the Country Coordinating
Mechanism (CCM) in Honduras, must make an urgent "pro-active"
effort to assure that gay and lesbian NGO’s can receive funds during
the very next period of disbursement. A pro-active effort should
be made by the government to grant gay (gay/lesbian/bi/trans) groups
(especially those with a proven track record of success) their legal
registration immediately, as an indication of “good will” after
so many years of discrimination. Otherwise, they will be excluded
from receiving Global Fund money for at least the next 18 months.
2) With respect
to AIDS orphans as defined by UNICEF in point number VII above,
it is clear that the Government has not assigned resources to care
for these children. In my opinion the government should not attempt
to create a whole new infrastructure to deal with these children,
but rather should be assigning resources for their care to existing
private institutions that have a demonstrated track record of success
in caring for orphans, including AIDS orphans. One such institution
is “Los Pequenos Hermanos” (near Tegucigalpa) which cares for over
500 children, including nearly 20 who are themselves living with
HIV/AIDS and undetermined number who are orphans as a result of
AIDS. Another institution which I have also visited is "Hogar
Montana de La Luz," near the city of Danli, which cares exclusively
for very young children (under 7 years old) who have AIDS. I have
personally visited each of these institutions and my impression
that their level of skills in providing appropriate care and attention
for AIDS orphans and children who Live with HIV/AIDS is excellent.
There is no reason for the government to try to build a whole new
infrastructure to care for these children. It should provide adequate
“per diem” reimbursement, as well as medical care, to existing institutions
that already know how to take care of these children.
3) The issues
regarding prices of anti-retroviral medications in Honduras need
to be addressed and clarified. There is no evidence, as such, to
suggest that government is not buying ARV’s at the best legally
available prices. But the government needs to make this process
transparent, and also explore every available option currently available
under the TRIPS (ADPIC) agreement in order to be open to the possibility
of purchasing generic medications that have been approved by the
World Health Organization. To the best of our knowledge, aside from
Combivir, there are no other ARV's patented in Honduras, however,
as the example of Combivir illustrates, it is only when large scale
purchases are on the table, that one begins to hear about patents.
IDA, as the principal intervening Agent/Organization with respect
to medication purchase, should also make clear that manner in which
this process was handled.
5) With respect
to the above issue, the Global Fund should make some effort to make
public the information regarding which medications are being purchased
at which prices where Global Fund monies are involved. This way,
each country doesn't have to "reinvent the wheel" when
purchases are being made.
6) The various
Churches in Honduras need to reexamine their positions with respect
to prevention, sex education, and attitudes toward sexual minorities.
7) The Global
Fund should consider assigning a well trained salaried "neutral"
professional to be in country and participate in CCM activities
as well as the on-going evaluation of the projects themselves. Even
at a cost of $150,000 per year in terms of total expenses for such
a person, this would be money extremely well invested. For example
an outlay of $150,000 annually during five years in Honduras would
only be approximately 2% of the total grant amount which has been
awarded. The Portfolio Managers, while dedicated and competent,
cannot possible understand all of the complexities and nuances related
to the implementation of the project, given the fact that they probable
spend less than a month each year in the target countries
Conclusions:
When the highest
officials of the government of President Ricardo Maduro took office
just under two years ago, they probably never realized the degree
of opportunities as well as challenges they would face with respect
to the AIDS epidemic in their country.
The presence
of the Global Fund and the technical assistance and support provided
other International Agencies of Cooperation now working in Honduras,
as well as the courageous efforts of People Living with HIV/AIDS,
have forced those at the very highest level of government to examine
issues related to their own capacity to confront the epidemic from
many different points of view. Many Latin American and Caribbean
governments have not risen to this challenge, and AIDS remains a
peripheral issue, but in Honduras, civil society as well as government,
are making an intelligent and generally comprehensive effort to
confront the overwhelming challenges of the epidemic.
*Richard
Stern
Director
Agua Buena Human Rights Association
San José, Costa Rica
Tel/Fax 506-2280-3548
www.aguabuena.org
