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.

Several were so sick with wasting syndrome and other opportunistic infections that they had to be helped up and down the stairs to see the Doctor.

Jamaica's response 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 in India.

Gladys, 28, 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.

The Jamaican 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. Perhaps 150 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.

Government officials 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.

Dr. Yitades 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.

But overwhelmed 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 medications now.

World 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.

This 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.

Another 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.

But 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.

Jamaica may 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 now.

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.

Jamaica 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.

Besides Merck 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 in Jamaica.

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.

Richard Sternh
Director
Agua Buena Human Rights Association
San José, Costa Rica
Tel/Fax 506-234-2411
rastern@racsa.co.cr
www.aguabuena.org