Is AIDS in Haiti poverty?

There’s good news. The New England Journal of Medicine reports that a pilot protocol for treating HIV-infected people in Haiti has proven highly effective:

This report documents the feasibility of effective antiretroviral therapy in a large number of patients in an impoverished country. Overall, the outcomes are similar to those in the United States. These results provide evidence in support of international efforts to make antiretroviral therapy available to patients with AIDS in developing countries.

Mortality among those participating in the study was about 13% compared to more than 30% for people with AIDS in Haiti. This can’t be construed as anything other than good news.

Now I don’t have the same bee in my bonnet about AIDS as my friend and colleague Dean Esmay does. But I do tend to view medical studies with a skeptical eye and I don’t think that the study quite proves what its authors think it does. Here’s some of the efforts that the protocol included:

Extrapulmonary tuberculosis, but not pulmonary tuberculosis, was considered an AIDS-defining illness.16 HIV-infected adults and adolescents with pulmonary tuberculosis and a CD4 T-cell count of more than 200 per cubic millimeter were treated for tuberculosis, and initiation of antiretroviral therapy was deferred. In patients with tuberculosis who had a CD4 T-cell count between 50 and 200 per cubic millimeter, antiretroviral therapy was initiated after the completion of two months of tuberculosis therapy. In patients with a CD4 T-cell count of less than 50 cells per cubic millimeter, tuberculosis treatment and antiretroviral therapy were started simultaneously. The tuberculosis regimen consisted of two months of isoniazid, rifampin, ethambutol, and pyrazinamide daily, followed by four months of isoniazid and rifampin daily.20

Adherence to therapy was encouraged by home visits, provision of free telephone cards for patients to call clinic staff, peer counseling by people with AIDS, pill counts, and social support programs. If it was indicated, patients were referred for nutritional aid, and counseling was offered to pregnant women, parents of HIV-infected children, and victims of domestic violence. Directly observed antiretroviral therapy, which has been very effective in rural Haiti,21 was not feasible for our urban patients, who have limited social networks and frequently change their addresses.

Now I recognize that this finding tends to support the conclusions of the authors but I remain skeptical. Was it the drug treatment or additional food, heatlh care, and better general welfare that was the more important factor in reduced mortality? Or did selection bias influence the outcomes?

In the United States HIV/AIDS continues to be primarily a disease of homosexual men and IV drug users. In Haiti and Africa the primary means of transmission is heterosexual sex. Why? The explanations I’ve heard include differing strains of the pathogen and differences in sexual practice between African countries and the United States. I’m not convinced.

I continue to believe that more attention needs to be paid to the very poor particularly in Africa where the state of affairs continues to look bleak. We need to encourage political and economic reform in these countries, and, yes, we need to subsidize food and health care there. And, for goodness sake, let’s stop importing health care workers from places where they’re desparately needed.

We might be surprised in how far these measures might go to stem the spread of AIDS in the developing world.