Government Neglect Creates Potential for Explosion of HIV/TB Epidemic and Multi-drug resistant TB in Jamaica
by Eugene Schiff*
During the last half century, Jamaican health authorities have been successful in sharply reducing the number of TB cases on the island, and nearly halting if not eliminating the spread and deaths from tuberculosis throughout its territory. However, these important gains are now threatened by the AIDS epidemic.
AIDS weakens the immune system and strongly increases an individual’s risk for developing active pulmonary and extra pulmonary TB, which are among the most common opportunistic infections affecting people with AIDS. Some statistics suggest that about one third of those with TB in the Caribbean have HIV/AIDS. Furthermore, TB is more difficult to diagnose and treat among people with HIV/AIDS, with late diagnosis and treatment of either HIV or TB being important factors increasing mortality from TB.
There are currently 23,000 Jamaicans estimated to be living with HIV/AIDS. However, with strong stigma associated with HIV/AIDS, without more widespread access to free HIV tests except for pregnant women, and without systematic reporting of tests results from the private sector, this number could actually be even higher. In the Kingston and St. Andrews region, 1.7% of pregnant women tested positive for HIV. Jamaica has a total population of 2.7 million people.
Although antiretroviral medicines have now become available in the public health sector for a little over a year, a large percentage of Jamaicans who need them still cannot access or afford ARVs. Each year many continue to acquire and die from deadly opportunistic infections caused by advanced stage untreated AIDS. Between January and March 2005, the most recent months for which data from the Ministry of Health is available, 170 Jamaicans died of HIV/AIDS, compared with 107 reported AIDS deaths during the same three months of 2004, before ARV treatment was available. During the three month period earlier this year, an average of 13 Jamaicans died from AIDS each week, many because they did not receive antiretroviral medicines and proper care in time.
Authorities report that there are between 120 and 130 cases of TB throughout Jamaica each year. Jamaica is therefore considered to be a low prevalence country for TB. A Jamaican TB specialist noted that while cases of TB among people without HIV have been declining, the overall number of cases has remained constant, as result of more people with HIV/TB co-infection.
A visit to Jamaica’s only TB referral center, the Chest Hospital, a TB sanatorium built during the British colonial era in uptown Kingston revealed several key problems that authorities hoped and indicated must urgently be addressed. The most pressing issue in mid-September 2005 was the lack of isoniazid (INH), one of the most basic and essential drugs for treating TB and also recommended as preventative prophylaxis for people with HIV. Isoniazid costs a few pennies a day, yet with the TB program so small and centralized in Jamaica, the pills are difficult to find if they are not adequately secured by the government. The pharmacy at the chest hospital needed to secure a separate generic supply directly from India, but these orders can take weeks for the drugs to get to the Caribbean. The Chest Hospital authorities insisted that these drugs must be included in the Global Fund HIV/AIDS project through the Ministry of Health, which can’t seem to spend money fast enough on expensive workshops, meetings, conferences, and travel stipends related to HIV and HIV/TB issues while ignoring the most basic needs like procuring medicines such as isionazid to those with TB. Without INH, or due to interruptions in the supply of such medicines, other combinations must be used and TB patients in Jamaica may be more likely to develop resistance to additional classes of antibiotics, which could lead to the spread of Multi-drug Resistant (MDR) TB.
Interruption of Tests which Confirm TB
Another problem the authorities at the Chest hospital pointed to came in the form of a letter from the National Laboratory, which inexplicably stated that no bacterial cultures would be performed during a period of six weeks beginning in early September, due to circumstances beyond their control. Bacterial cultures are needed to confirm suspected cases of TB, and also needed to identify potential cases of MDR TB. There is no other facility in Jamaica that would perform these cultures during this time for the Chest Hospital, so during this period of more than 10% of working year, this is another major gap in what should be the appropriate care and treatment of people living with TB and both HIV/TB.
Despite once calling together of a Committee of experts in the area of TB/HIV co-infection, neither the Jamaican Health Ministry, the National HIV/AIDS Program, nor the Global Fund Project managed by the same governmental authorities have provided sufficient follow up to improve the care and treatment of people living with both diseases. While rapid HIV tests are now routinely available for all pregnant women, getting results for an HIV test for those with TB still can take more than a month. Negative test results take about 2 weeks, while a positive result requires confirmation and will take a month or longer. This makes it more difficult for doctors to know how to provide the best care for these individuals, besides guessing after three and a half weeks that since the test result is taking so long the individual must be HIV positive. Since as many as one third of those with TB also have HIV or AIDS, ensuring that necessary steps are implemented to provide easy to use rapid test kits in the Chest Hospital in Kingston should have been a priority for the National HIV/AIDS Program years ago, but apparently it still is not.
Lack of Preparation for Physicians
Not only have the central health authorities failed to ensure that basic tests and medicines for treating people with HIV/TB co-infection are available, but physicians and medical students in Jamaica are now no longer sent to perform rotations at the Chest Hospital, and most therefore graduate without any real practice or training in the basic care of TB. Most are therefore unprepared to diagnosis and treat patients with TB and HIV/TB co-infection as they enter private practice, provide primary care or work in hospitals and clinics throughout the island.
Essentially, although the official overall rates of TB in Jamaica remain very low, the HIV/AIDS epidemic threatens to erode all the advances made in Jamaica to control TB thus far. Should an epidemic occur, anyone who lives in, works at, or cares to visit the hot and crowded shantytowns in downtown Kingston (and elsewhere), the overcrowded and under-funded public hospitals in Jamaica, or has taken the absolutely jam-packed buses and shared taxis blasting the latest reggae and dancehall hits that provide transport within the cities and all corners of the island can recognize the potential risk, primarily to many poor Jamaicans and health workers (but also to their employers and tourists), for acquiring HIV and TB. It should be an outrage, but is unfortunately no surprise that poor people’s rights and health care needs are not really valued much at all in Jamaica by those with the power and resources to make a difference.
The health risk for TB that is so strongly associated with marginality in Jamaica and elsewhere is now compounded for those with HIV and AIDS of all social classes, but especially the poor and those without ARV medicines. If it is true that 5-10% of people with HIV are at risk for developing TB each year, according to these estimates, as many as 2000 individuals with HIV could potentially develop active TB in Jamaica, which is fifteen times more than the current official number of reported TB cases including HIV/TB co-infection and those with TB alone. Furthermore, many more of the 23,000 people living with AIDS are also at high risk for TB. Yet even today with robust funding for HIV/AIDS from the Global Fund, this issue has largely been ignored. Very few are aware of the special challenges facing individuals with both diseases and the need for stronger advocacy to improve and better integrate care for both HIV and TB in Jamaica, the region, and worldwide.
Worldwide campaigns to raise awareness about TB sometimes stress that every breath counts. In Jamaica where growing levels of poverty and inequality are literally sickening, this is not the case. Hundreds dying from HIV/AIDS are left on the street or in public hospital wards, unemployed and unemployable, homeless or expelled from their homes, sick and coughing from TB and a range of other opportunistic infections. Many sleep in and roam the dirty and dangerous downtown streets just blocks from the Ministry of Health’s towering headquarters. It is ironic that it is still the Catholic missionaries, many from India, the Philippines, and Haiti, countries with much more severe problems of poverty, homelessness, and HIV/TB epidemics of their own, that provide care, shelter, spiritual messages and food to destitute Jamaicans dying of AIDS in Kinston’s concrete jungle. Of course, it is primarily the Jamaican government, the privileged bureaucrats at the ineffective international health and development agencies, and sheltered Jamaican elite, who should be doing much more in responding to these needs, since they affect everyone and intrinsically are a matter of marginality, human rights and access to treatment.
This report was made possible by a TB/HIV Advocacy Grant from the Open Society Institute
*Agua Buena Human Rights Association
San Jose, Costa Rica
Tel/Fax: 506-430-5970, 506-835-3768