At the first International AIDS Society Conference since Durban, the AIDS crisis in Venezuela went without notice
By David Miller and Noreen Griffin
Editors note: This article was originally posted in August of 2017 but due to site issues was mistakenly deleted from PanAware. However, in light of AIDS 2018 which begins tomorrow (July23) we’ve decided to repost it in order to bring attention to this important issue.
At IAS 2017 in Paris last July, delivering treatment, medicines, and other HIV-related services to the most vulnerable patient populations in resource-poor, distressed, and unstable nations should have been a matter of urgency. But there were no declarations, no condemnations, and no calls for immediate action.
More than a decade ago, Venezuela was lauded for its treatment program. Now, more than a decade into its political and economic crisis, Venezuela’s oil revenues account for 95% of the country’s export earnings and the precipitous decline in oil prices has helped plunge Venezuela ever deeper into crisis. The corrupt and increasingly dictatorial regime of President Nicolás Maduro Moros, has only accelerated the country’s decline.
Venezuela’s economic crisis is a tragic example of impact of domestic instability on the testing, treatment, and care of people living with HIV and on the worsening global HIV pandemic. Venezuela’s entire healthcare system is critically short of medication, including life-saving anti-HIV drugs. Despite pleas for immediate assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria, no measurable degree of help has arrived. The World Bank continues to classify Venezuela as a high-income nation and the Global Fund “is not in a position to grant any exceptions from its rules,” according to its Executive Director Mark Dybul and Norbert Hauser.
An estimated 110,000 people in 2015 were living with HIV in Venezuela, and at least 63,000 of them had started antiretroviral (ARV) treatment, says Feliciano Reyna Ganteaume, whose Caracas-based nonprofit Acción Solidaria supplies HIV-infected people with ARVs. “[The situation] is much worse than one can describe,” he says. “When the government does take action, drug orders are placed late and not paid for on time, causing interruptions that have lasted more than months… There is not even 1 month without our receiving complaints of lack of one or more ARVs from one or more Venezuelan states,” he says. In addition, reagents for the tests needed to monitor people on treatment are in short supply.
Economic instability has greatly affected basic HIV treatment and care for people living with HIV in Venezuela. Diagnostics such as CD4 and drug resistance testing have become all but non-existent and stocks experience a lack of resupply, lasting a month or two, approximately every two to three months. Basic laboratory services and drugs such as antibiotics have become unavailable. HIV testing for mothers and ARVs to prevent mother to child transmission are in inadequate supply, resulting in late-stage diagnosis and contributing to an increased rate of mother to child transmission. Maria Eugenia Landaeta, the chief of infectious disease at the teaching hospital who oversees the HIV program for 5,600 patients, reports that a small group of AIDS physicians has been scrambling to hold it together for years. “The HIV and TB programs were the last to deteriorate,” she said. “We have tried to defend the program in all possible ways.” (https://www.theglobeandmail.com/news/world/in-venezuela-a-once-leading-aids-program-lies-inruins/article35417359/)
At IAS 2017, while the refugee crisis in Europe was a key issue of reference, with numerous posters and presentations featuring the challenges of internally displaced persons, the Venezuelan crisis went virtually unmentioned, despite the knowledge that tens of thousands were going without life-saving medications. The Venezuelan Society of Infectious Diseases (SIV) issued a statement back in November of 2016 announcing that supplies of key drugs used for the treatment of HIV were dangerously low and in danger of stock-out. These drug shortages mean that there are currently no treatment options considered first-rate under international guidelines. “The shortage of antiretroviral drugs and reagents makes it impossible to control the HIV/AIDS epidemic in the country, making it difficult to control the transmission of the virus from the mother to her children and in the general population,” Maritza Landaeta, a senior member of SIV, said. “We are seeing a collapse in the public health system. Venezuela is witnessing a miracle, a miracle of destruction.”
Vulnerabilities continue to mount for displaced persons, who are increasingly exposed to the social drivers of HIV, Hep C, and co-infections. In addition, instability in countries throughout Africa and South America also contributes to an unsteady state of universal access to HIV testing and treatment which drive the continued spread of HIV.
We have learned the hard way the consequences of complacency in the response to global pandemics. The epidemiological dimensions of Venezuela’s current descent into chaos should concern all researchers, activists, and policy makers in the Americas. HIV and its co-morbidities thrive on poverty, instability, and displacement. Several presentations at IAS 2017 focused on the impact of specific instabilities and policies on the treatment and care of its citizens, in particular, at-risk populations such as refugees, migrants and asylum seekers.
One study found a wide range of disparities negatively affecting access to testing and treatment of key at risk and populations. The disparities centered mainly on migrants, asylum seekers, and refugees. The study resulted in a website called “Barring the Way To Health” (https://www.gnpplus.net/our-solutions/barring-the-way-to-health/)
Another study at IAS 2017 analyzed a pilot program initiated by Medecins Sans Frontiere in rural areas of Yambio South, Sudan, to test the feasibility of providing HIV testing and counselling and ARV initiation in regions of chronic conflict. Five mobile teams offered testing and counselling and same day ART initiation to those who tested positive and data over a 17- month period was analyzed. Counseling sessions were provided which included instructions on what to do during times of active conflict including a constituency plan that provided access to ‘go bags’ containing a three-month supply of ARVs. During the study, there were several episodes of instability where the contingency plan was activated.
Results of this study found that levels of ARV retention (86% at 6 months and 81% at 12 months) and viral load suppression (85% below 1000 copies) were comparable to clinic settings. Throughout the study, 13,872 people were tested for HIV, of which 442 (3.2%) tested positive. Of the 442 positive individuals, 344 (77.8%) were started on ART.
A third study assessed the feasibility of providing home-based HIV testing in sub- Saharan refugee camps. Visits were made to 319 homes that reported a total of 566 individuals living in the homes, during a one- month period of time in the Nakivale Refugee Settlement. During a total of three visits per home, researchers were able to reach 507 individuals in 292 homes. Of these, 378 (75%) agreed to be home-tested and received their results. There were 7 (1.9%) individuals who tested positive for HIV. Researchers found that people were more likely to agree to be tested if there were others present. The authors concluded that home-based HIV testing is feasible in refugee camp settings.
There is robust data demonstrating that effective service delivery can be conducted for large HIV patient populations struggling in distressed economic and political circumstances. Global Fund’s ban on HIV-related assistance to ostensibly high-income countries is contributing to several regions of risk. The policy has previously led to cuts in HIV/AIDS funding to several Eastern European countries, a move heavily criticized by advocates in those countries. As international assistance for HIV/AIDS has steadily dropped over the past few years, the Global Fund has pushed harder on governments to foot their own bills. The unfolding crisis in Venezuela, and its dire implications for the diagnosis, treatment, and prevention of HIV, should shake the complacency of the Global Fund and other international aid organizations. In an ever more global community, Venezuela’s humanitarian crisis will not long stay Venezuela’s alone. We will help ease Venezuela’s pain, or we will eventually feel it ourselves.