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Section: Honduras
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.)


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.


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


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
Agua Buena Human Rights Association
San José, Costa Rica
Tel/Fax 506-2280-3548



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