In the Dominican Republic only about 200 of an estimated 20,000 People Living with AIDS who need anti-retroviral medications actually have treatment access. Dr. Maria Isabel Tavarez, General Director of DIGECTISS, (which functions as the National program for control of Sexually Transmitted Diseases), confirmed that 210 people are now receiving treatment as a result of medications donated by the Clinton Foundation last year. DIGECTISS is responsible for the implementation of anti-retroviral access in the Dominican Republic.

Medications sufficient to treat 500 people were donated to the Dominican Republic by the Clinton Foundation and entered the country last October, but delays in putting people on treatment have been due to the need to build infrastructure in various centers of attention according to Dr. Tavarez. AIDS activists have called the delays "unacceptable." It was not possible to contact the Clinton Foundation representative for this program. Dr. Tavarez has indicated that the Clinton Foundation would be willing to donate medications to treat up to 2,000 additional PLWA in the Dominican Republic by the end of the year.

While in the Dominican Republic last week at a Caribbean regional AIDS conference, entitled "A Multicultural Caribbean United Against HIV/AIDS," this writer spoke to several physicians and activists who complained about the delays in distributing medications from the Clinton Foundation. Many pointed out that there have been long delays in obtaining CD4 tests for patients, and that that CD4 testing was a requirement to initiate treatment.

However, when Dr. Tavarez was asked if her program would follow WHO guidelines for "resource poor" countries indicating that it is appropriate to provide treatment for patients who are clinically ill with opportunistic infections and were HIV+, with or without initial CD4 testing, she replied that treatment is available for such patients, but that physicians in the various Clinics need to make specific requests so that her program can forward the medications to them. None of the physicians I spoke to while in the Dominican Republic were aware that DIGECTISS would provide treatment according to WHO guidelines without initial CD4 testing, but Dr. Tavarez has now cleared up this issue.

An additional source of funding for scaling up treatment access in the Dominican Republic is the Global Fund for AIDS, Tuberculosis and Malaria, (GFATM). The Dominican Republic's $48,000,000 proposal was approved in January of 2003 but numerous delays have occurred and the proposal has yet to be signed. Civil society actors tend to blame delays on the Principal Recipient which is the Presidential Commission on AIDS (COPRESIDA), but COPRESIDA spokesperson Jaime De La Rosa denies this and told this writer that the current delay is due to the decision to the change in the local Funding Agent from Price Waterhouse to accounting firm Deloitte and Touche. A significant delay has also occurred as a result of objections by local USAID leadership to COPRESIDA serving as the Principal Recipient.

(Actually the debate about who is at fault for the failure of the Global Fund program to be implemented in the Dominican Republic seems to be an endless one. Only one thing is sure: The trained and experienced professionals who make up the CCM have been unable to resolve their differences in a form that would be congruent with the treatment and prevention needs of 9 million people, most of them poor, in this country, and the money is still sitting in a bank in Geneva.)

In the 14 months since the Global Fund proposal was approved, approximately 4,500 Dominicans have died of AIDS.

Unfortunately, what is occurring in other countries in the region, is that even after the Global Fund contract is signed, it may take as much as a year for actual program implementation to begin due to the complicated requirements of the Global Fund, as well as the lack of efficiency by the Principal Recipients in fulfilling the Fund's requirements for disbursement of funds and for procurement of medications.

The delays in Global Fund implementation seem in sharp contrast to the appearance of Dominican First Lady Rosa Gomez de Mejia at last week's regional AIDS Conference, held in three five star hotels along the beach in Santo Domingo, the country's capital. In the Conference's closing ceremony, Mrs. Mejia called for commitment throughout the region to confront the challenges of the AIDS epidemic, but did not mention that only about 4% of Dominicans who need treatment actually receive it, even though $48,000,000 in external support has been available for well over a year, and is still delayed. The World Bank also provided a $25,000,000 loan to the Dominican Republic three years ago, but many key actors in civil society complain that there have been extensive delays and anomalies in disbursing these funds as well.

In the same closing ceremony, Dominican PLWA Ramon Acevedo called for treatment access for Dominicans living with AIDS, and the Dominican Network of People Living with HIV/AIDS (REDOVIH) held a short demonstration following Acevado's speech.

UNAIDS representative Michel Sidibe who has worked in Africa gave a stirring presentation calling for Access to treatment in the region, and indicated that 90 percent of people in the Caribbean region still do not have ARV access. "How will our future generations look at us, if they know that we don't make treatments available while we have them?," he said. The Caribbean has the world's second highest rate of HIV infection after Sub-Saharan Africa. An estimated 500,000 people in the region, or 2.4% of the population, are HIV+.

However, Sidibe was seemingly unaware that his counterparts at UN Agencies as well as the key regional Agencies, PANCAP (The Pan Caribbean Partnership Against HIV/AIDS) and PAHO (The Pan American Health Organization) have accepted the status quo regarding ARV's in the Caribbean for years in the Dominican Republic, Jamaica, St. Lucia, Grenada, Antigua, Suriname and many other countries, which are completely lacking in government sponsored treatment access. It is not clear to this writer what specific plans these Agencies have for scaling up treatment access in the Caribbean region. The rhetoric may be there, but words must be followed by concrete plans.

PAHO was represented in the closing session by its Assistant Director, Dr. Carissa Etienne, who discussed the WHO "3 by 5" concept, again delivering the latest rhetoric out of Washington, while making no specific mention of PAHO's plans to intervene in the tragedy occurring right there in the Dominican Republic.

Ironically, countries in regions much poorer than the Caribbean, including many countries in Latin America, and many in Africa are now providing ARV access. Why the delays the Caribbean?

As the crowd exited the closing ceremony one very high ranking PANCAP official was overheard by this writer saying "Couldn't they have put the Person with AIDS somewhere else in the program? Why did it have to be right before the first lady spoke?," as if to say that it was more important to avoid 'embarrassment' to the first lady, than to uncover the realities of the epidemic in the region. During the Conference, which was attended by 1,800 people, there were excellent presentations focusing on scientific issues as well as on research in prevention and a few presentations related to scaling up issues. But still, the overall tone of the Conference was mostly "self-congratulatory." No Person Living with AIDS was present in the inaugural ceremony, and it was only because of the protests of several activists that Acevedo was allowed 10 minutes during the closing ceremony.

Perhaps a PLWA from Jamaica put it best in an e-mail I recently received, stating that "I attended the eleventh conference of the Global Network of People with HIV/AIDS in Trinidad in 2001, and within 24 months after the conference, 7 of the 11 delegates from Jamaica were dead. Did the information received at the conference increase their hopelessness? Were they invited to make up numbers to increase conference attendance or was their care and treatment put foremost?"

The Agua Buena Human Rights Association, which I direct, together with REDOVIH, filed a petition with the Interamerican Human Rights Commission in Washington, asking for access to ARV treatment in August of 2002. The Commission granted "medidas cautelares" (temporary protective measures) ordering the Dominican Government to provide immediate treatment for 124 People with AIDS who signed petitions forwarded to Washington, but the government, which is led by Rosa Gomez's husband, President Hipólito Mejia, has delayed compliance as long as possible and sent dozens of letters of protest to the Commission. In the meantime an estimated 30 of the 124 individuals who received the medidas cautelares have died.

Related articles by the Agua Buena Human Rights Association available on the web:

$15 Million for Infrastructure but No AIDS Drugs for Jamaica http://www.aegis.com/pubs/gmhc/2003/GM170304.html

Caribbean AIDS Outreach Efforts Hampered by Homophobia: http://www.sodomylaws.org/world/stlucia/slnews02.htm

COMMENTARY: The Global Fund and Treatment Access in Latin America - A Critical View http://www.aidspan.org/gfo/archives/newsletter/Issue16.pdf

Global Fund Bureaucracy Results in More Needless Deaths in Guatemala http://www.eatg.org/modules.php?op=modload&name=News&file=article&sid=142

AIDS and Human Rights in Cuba: A Personal Memoir http://www.thegully.com/essays/cuba/030502_cuba_AIDS_stern.html

Agua Buena Human Rights Association