Center for Global Development
Marie M H Deschamps,MD
Deputy Director, GHESKIO Centers
WDC,December 4,2009
Outline

Background and Context

GHESKIO Mission and impact

GHESKIO expansion of services and IMIS
Perspectives

Haiti
• Population:
•
•
•
•
Maternal mortality rate:
9,400,000
642/100,000
Majority (80%) of women deliver outside a health care
setting
Infant mortality rate:
74/1,000
HIV vertical transmission rate estimate at 30% without
intervention.
• Life expectancy at birth:
60.78 yrs
• 50% of population earns less than $2.00/day
• MD/10,000 inhabitants ratio :
2.5
Background



It is the most affected country by HIV after those in
Sub-Saharan Africa.
It is estimated that there are up to 235,000 adults and
as many as 11,800 children are living with HIV/AIDS.
Approximately 3% of the women visiting prenatal
clinics are HIV (+)
National HIV Seroprevalence studies
in Haiti (1993 – 2006)
National HIV and syphilis
Seroprevalence 1993-2003*
3
6.1%
5.6%
3.5%
6.0%
3.1%
4.5%
HIV Prevalence (%)
18.0%
16.0%
14.0%
12.0%
10.0%
8.0% 7.6%
6.0%
6.2%
4.0%
2.0%
0.0%
1993
National HIV seroprevalence: DHS
(2005-2006)**
2.5
2
1.5
1
0.5
0
1996
HIV
2000
2003
SYPHILIS
*Pregnant women at 1st prenatal visit
Urban
Rural
Women Men Both
* *5250 women and 4855 men
Total
Profile of GHESKIO Centers
 Institution Created in 1982
Recognized as “Public Utility” in 1996
Strong partnership with public sector and other
private institution (Universities, other NGO)
National Referral Center for HIV/AIDS/TB/STI/F.P
Mission: Provide services, training of medical and
paramedical personnel, and operational research
GHESKIO/MOH comprehensive model with
integrated services
STI Management
Post-HIV exposure
Counseling and
HAART
Pre-test Counseling
HIV, Syphilis, Tuberculosis
Post-Test Counseling
Reproductive
Health Services
(family planning and prenatal care)
HIV+ women
Prevention HIV MTCT with HAART
Rx = Treatment
Px = Prophylaxis
Same day
TB screening / Rx / Px
Care to HIV infected individual /
affected family
OI Rx/Px
HAART for AIDS or CD4 count 200
Nutritional support
Psychosocial support
Map of greater PORT-AU-PRINCE
GHESKIO
GHESKIO
The GHESKIO Institute of Infectious Diseases and
Reproductive Heath (GHESKIO-IMIS)
February 10, 2009

Heterosexual Transmission of HIV infection in 475
Discordant Couples
7.6
6.82
6.8
4.8
2.89
2.58
1
al
e
M
al
e
Fe
m
No
Condoms Clinical Disease
in Index
G
en
.U
lce
rs
Se
r.
Sy
ph
ili
G
s
en
.D
isc
ha
rg
e
Sexual Activity
Ye
s
0
No
Ye
s
8
7
6 5.4
5
4
3
2
1
0
STI in HIV Spouse
Deschamps MM, Pape JW, Hafner A and Johnson WD Jr. Heterosexual Transmission of HIV in Haiti. Ann Intern Med;125:324-330, 1996.
Background and Context | Haiti and HIV
AIDS in Haiti characterized by rapid progression
0
1
2
Seroconversion
0 years
3
4
5
6
7
CD4<200
6.8 years
Clinical
AIDS
5.2 years
8
Death
7.4
years
Source: Deschamps, M. et al. HIV infection in Haiti: Natural History and Disease
Progression. AIDS 2000, 14:2515-2521 .
New individuals tested for HIV at
GHESKIO (VCT Center)
35000
30000
26921
24691
23313 24116
25000
Individuals
28780
20000
21279
15000
16087
8757
10000
13245
10310
5000 7987
0
1998
1999
2000
2001
2002
2003
Years
2004
2005
2006
2007
2008
HIV prevalence among new individuals tested for HIV
at GHESKIO (VCT Center)
100%
90%
80%
33%
29%
26%
23%
19%
19%
17%
17%
17%
16%
15%
83%
83%
83%
85%
13%
12%
87%
88%
34%
Percentage
70%
60%
50%
40%
30%
67%
66%
71%
74%
77%
81%
83%
81%
20%
10%
0%
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Negative
Positive
Years
New individuals tested for HIV at GHESKIO
(VCT Center) by sex
20000
18284
18000
15574
16000
18421
15832 16312
14110
Individuals
14000
10726
12000
8809
10000
8000
6000
4859
4436
8282
8379
8637
8671
5355
3625
4000
2000
7167
6684
5468
7734
3108
3288
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Female
Male
New youth people* tested for HIV at GHESKIO
(VCT Center)
10000
9000
Individuals
8000
7000
6000
5000
4000
3000
2000
1000
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Years
*Individuals from 10 to 24 years old
Population
Women
Men
HIV Prevalence among new youth people* tested for HIV at
GHESKIO (VCT Center)
100%
10%
Percentents
95%
11%
10%
9%
9%
8%
6%
6%
94%
94%
5%
14%
90%
85%
90%
80%
89%
90%
91%
91%
93%
95%
86%
75%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2007
Negative
Positive
*Individuals from 10 to 24 years old
Years
HIV Prevalence among people tested at
GHESKIO (VCT Center)
35%
30%
Percentage
25%
20%
15%
10%
5%
0%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Years
Males
Females
Syphilis prevalence among Adolescents and young
adults* tested at GHESKIO (VCT Center)
14.0%
12.0%
Percentage
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Males
*From 10 to 24 years old
Years
Females
Population
Prevalence of HIV among street children
examined at GHESKIO, per age group
Age Group
(Year)
15 - 19
20 - 24
Total
Women
%
19
Men
%
5.5
Total
%
10.4
24.2
22
24
15
5.6
9.2
Knowledge and Behavior of the Youth visiting
the GHESKIO Centers
n=4,113
85 % were self referred
67% of the boys and 56% of the girls are in
secondary school
85% of them are informed of HIV/AIDS through
radio and TV broadcasts
48% of the boys and 74 % of the girls had their first
sexual experience when they were 15-19 years old.
Only 19 % of the girls and 21% of the boys used a
condom during their first sexual experience.
Knowledge and Behavior of the youth visiting the
GHESKIO Centers ( cont.)
90% of both boys and girls know that condoms
protect.
Only
9 % of the girls and 25% of the boys regularly use
condoms
38% of the boys and 5 % of the girls had more than
one sexual partner during the last 6 months
24% of the boys and 33 % of the girls had a previous
STI
Only 14% of the boys and 9% of the girls think they are
at risk for HIV.
Behavioral Changes
among Young Adults in Haiti
Excellent
Knowledge of
AIDS
Sex with
occasional
Partner
Condom use at
last Contact
15 – 19 Y/O
15 – 19 Y/O
20 - 24 Y/O
20 - 24 Y/O
Males
Females
Males
Females
1999
2003
1999
2003
1999
2003
1999
2003
24
54
26
45
29
60
33
54
50
12
31
2
60
20
52
2
50
52
37
25
48
63
36
88
Survival and Response to ART
12 month
survival
Viral load
<50
Adults
(910)
87%
Children Adolescents
(191)
(146)
81%
87%
76%
56%
49%
Severe et al. N Eng J Med 2005; 353:2325-34. George et al. J Infect Dis 2007; 185:1411-8.
Charles et al. 2007; Submitted.
Pregnant woman tested for HIV at GHESKIO
(VCT Center)
3500
2915
3000
Individuals
2521
2500
2079
2000
1909
1658
1970
1500
964
1000
977
480
500
95
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Years
Pregnant women
HIV prevalence among Pregnant woman
tested at GHESKIO’s VCT center
18.0%
16.4%
16.4%
16.0%
15.2%
14%
Individuals
14.0%
12.1%
12.0%
10.9%
11%
10.4%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2001
2002
2003
2004
2005
2006
Years
Prevalence (% )
2007
2008
Syphilis prevalence among Pregnant woman
tested at GHESKIO’s VCT center
14.0%
Individuals
12.0%
12.2%
10.6%
10.1%
10.0%
9.1%
8.3%
8.0%
7.4%
7%
6.0%
5%
4.0%
2.0%
0.0%
2001
2002
2003
2004
2005
2006
Years
Prevalence (% )
2007
2007
PROGRESSION ANNUELLE DE LA PRISE EN CHARGE DES
VICTIMES DE VIOLENCE SEXUELLE DANS LES CENTRES
GHESKIO
De 2001 à juin 2009
600
503
2001
481
500
2002
2003
400
372
337
2005
272
300
2004
2006
200
100
164
42
58
67
0
20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10
N.B.: 2298 victimes de 2001 à Juin 2009 soit 22 mâles et 2276 femelles
2007
2008
2009
Women’s empowerment

Micro credit was introduced in 2005 to women visiting
GHESKIO’s reproductive health unit in collaboration with
the MIF institution (ACME), support of UNFPA and
Merieux Foundation.
 The objective is to empower women and develop income
generating activities.
 A fixed interest rate of 2%/month was granted.
 688 (42%) of the 1638 beneficiaries were HIV+, and 269
(39%) of the HIV Positive beneficiaries had AIDS and
receiving HAART.
 The majority 1474 (90%) of the women had no other
income. The capacity to repay the loan was used to evaluate
the impact.
Loan portfolio as of July 2009
2879 loans to 1638 individuals
Loan Cycle
First
Number
of Loans
HIV
Positive
HIV
Negative
Loan Amount
in HTGS
Loan Amount
in US Dollars
1638
688
950
10,194,500
254,862.50
Second
717
316
401
6,422,000
160,550.00
Third
296
166
130
3,282,500
82,062.50
Fourth
104
76
28
1,309,000
32,725.00
Fifth
60
46
14
931,500
23,287.50
Sixth
40
31
9
850,000
21,250.00
Seventh
19
12
7
553,500
13,837.5
5
4
1
290,000
7,250
23,833,000
595,825.00
Eight
Total
2676
---------
---------
One US Dollar is equal to 40 HT Gourdes: 1638 individuals received 2879 loans
Reimbursement rate of the portfolio
by clinical status - March 2005 – July 2009
Total
Non AIDS
AIDS
First Loan
93%
89%
97%
Second Loan
88%
83%
93%
Third Load
97%
97%
97%
Fourth Loan
98%
99%
97%
Fifth Loan
88%
89%
87%
Sixth Loan
86%
90%
82%
Seventh Loan
84%
90%
78%
91%
91%
91%
Average
*Among 688HIV(+) 264 (38%) had AIDS and are receiving HAART
GHESKIO National Expansion services for Prevention and Care
of HIV/AIDS/TB/Malaria (MOH/GHESKIO network)
43 HIV sites supervised by GHESKIO
- PEPFAR
- FM
11 Malaria sites
GHESKIO Centers
Multidisciplinary mobile teams essential for supervision, monitoring
and continued on the job training
Interventions
(as of 12/2008)
NATIONAL
GHESKIO
Tested and counseled for HIV 1,692,614
and syphilis
517,395
Tested for HIV
1,272,688
447,622
HIV-infected
99,143
44,425
Tested for syphilis
880,590
379,685
Serology + for syphilis
52,991
23,817
Pregnant women tested for
HIV and syphilis
781,329
178,986
HIV-infected pregnant women 14,802
5,396
Patients treated for STIs
n/a
48,579
HAART
18,558
9,054
ART Network
MOH and Gheskio Sept , 2009
All HAITI
MOH/Gheskio Network
(www.mesi.ht)
%
# Patients
placed on
ART
30, 886
15,576
50%
# Active
Patients
24, 655
12,490
51%
CSW and HIV prevalence
Haiti
N=352
Prevalence
HIV+ 16 / 352 (5%)
RPR+ 22/352 (6%)
GRA+ 34/352(9.6%)
Cost per sex exchange
Haiti
site Payment per sexual contact
Haiti site recruitment
areas:
n=5
(Range :US)
Port au Prince
$0.50 - $2.40
Delmas
$2.40 - $6.00
Carrefour
$0.50 - $2.40
Croix Bouquets
$ 0.50-$2.40
Pétion -Ville
$2.40 - $6.00
Distribution of Sex Workers
according to their worked areas
N = 293
Non défini
N = 11
Croix-des-Bouquets
(Plaine)
(3.8%)
N = 10
*** 2 HIV+
(3.4%)
Delmas
N = 28
Carrefour
N = 127
(43.3%)
*** 2 HIV+
Port-au-Prince
(9.6%)
N = 104
*** 1 HIV+
(35.5%)
*** 10 HIV+
Pétion-Ville
N = 13
(4.4%)
Summary/Perspectives
 Women, Adolescents, CSW, particularly young girls
are the most vulnerable : Lack of education-Poverty.
 There is the need for national scale up services for FP
services, ARV, antenatal care to decrease MM and
prevention of HIV , syphilis, unwanted pregnancy,
cervical, breast cancer..
 GHESKIO women’s health clinic will be created to
focus those needs with the MOH in collaboration with
partners .