Published: January 29th, 2003.
Bays, Beaches Offer No Safe Harbor for People with HIV/AIDS
By Richard Stern*
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.
so sick with wasting syndrome and other opportunistic infections
that they had to be helped up and down the stairs to see the Doctor.
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
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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
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.
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.
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
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.
Agua Buena Human Rights Association
San José, Costa Rica