Situation Report: Sexually Transmitted Disease/Family Planning Program in Haiti

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Introduction

The population of Haiti (1995) is estimated to be approximately 7,000,000 inhabitants with a demographic growth rate of 2 percent. Seventy (70) percent of the population still live in rural areas but there is a rapid rate of urbanization, particularly in the capital. Forty (40) percent of the population are children under the age of 15.

Since the 1980s Haiti has been confronted with a deep economic crisis. The per capita gross national product is estimated to be $228 US per year. Economic problems have doubled since 1986 because of a political crisis which reached its peak with the coup d'état of September 1991, followed by the embargo and withdrawal of support by the principal donor organizations. The return of constitutional government in October 1994 brought some improvement but reconstruction remains a pressing need.

Critical Health Conditions

The magnitude of health problems affecting the population has not been well documented because of the weak information system in Haiti. Nevertheless, the following indicators are generally acknowledged:

• The birth rate in 1990 was estimated to be 13 per 1000.
• Of 1000 live births, 94 infants die before the age of one and approximately 133 before age 5. Half of these deaths are due to diarrheal and respiratory infections.
• Forty (40) percent of children over age 3 are small for their age. Six (6) percent of children in the north and 3.5 percent of children in the south suffer from acute malnutrition. The rate of low birth weight is estimated to be 15 percent.
• The maternal mortality rate is 4.6 per 1000 live births.
• The rate of anemia among women is between 35 and 40 percent.
• There is a high rate of water-borne diseases: diarrhea (7 episodes a year per child under age 5) and typhoid.
• The estimated incidence of tuberculosis is 5 per 1000. Half of all AIDS patients are tubercular.
• The seroprevalence rate of HIV is 10 percent in urban areas and 4 percent in rural areas. In urban settings the rate of seropositive reaction to the VDRL test is between 6 and 8 percent.
• Malaria is endemic in 80 percent of the country. Until now, no resistance to chloroquine has been reported.
• There are recurring epidemics: measles and typhoid in 1993, meningococcemia in 1994.
• Psychiatric conditions have increased noticeably since 1991.
• There was a great increase in cases of animal and human anthrax (charbon) in 1994. (This may be due to better reporting and supervision.)
• Prevalence of upper respiratory infections among adults in urban areas is greater than 13 percent.

Sexually Transmitted Diseases

Available epidemiological data show that Haiti is greatly afflicted with STDs and AIDS. In 1990 a national study conducted by the Haitian Childhood Institute (Institut Haïtien de l'Enfance—IHE) showed that 8 percent of men interviewed reported having had a sexually transmitted disease (genital ulcers or urethral discharge) during the year before the survey. For 1993–1994, preliminary STD data show that 35 to 50 percent of pregnant women in the metropolitan area reported having had a sexually transmitted disease.

Syphilis

Ministry of Public Health (MSPP) data show that seropositive reaction to the VDRL test was between 3 and 6 percent in the general population in 1990 and between 6 and 8 percent in metropolitan areas in 1991. Data for 1992 to 1993 reveal a seropositivity rate of between 2 and 10 percent to the VDRL/FTA-ABS test in a group of pregnant women from five sample sites (Mirebalais, Cayes, Port de Paix, Jérémie and Gonâve Island). In high-risk groups, seropositivity to the VDRL test was between 30 and 40 percent in 1990.

Table 1. Syphilis Prevalence Traits

Population Percentage with Seropositive Reaction to VDRL Test General Population 3–6% (1990) Population in Metropolitan Areas 6–8% (1991) Pregnant Women from Five Sample Sites  2–10% (1992–93)

Syphilis is the chief cause of genital ulcers in Haiti. Other causes of genital ulcers, in order of prevalence, are: chancroid, herpes, invasive genital cancer (chiefly in association with AIDS), donovanosis and venereal lymphogranuloma.

Urethral-Vaginal Discharge

Among the metropolitan population, gonococcus is the main cause of male urethritis, with 72 percent being penicillinase-producing Neisseria gonorrhoeae (PPNG).

In women, urethral or vaginal discharge is caused by trichomonas vaginalis, which is a very prevalent pathology in Haiti, Gardnerella vaginalis, candida albicans (related to AIDS) and chlamydia trachomatis. Pelvic inflammatory disease is associated with 5 percent of cases of leukorrhea (white discharge). Ectopic pregnancies due to pelvic infection were found in 7.2 cases per 1000 live births in 1989.

Hepatitis B

In 1990, 5.5 percent of blood donors demonstrated the surface antigen of the Hepatitis B virus. Control studies conducted by the Haitian Childhood Institute in 1992 and 1993 in four provincial centers and the Island of Gonâve showed the presence of the surface antigen to Hepatitis B in 2 to 8.7 percent of pregnant women. These results explain why Haiti is listed with other Caribbean countries as a country with moderately endemic HBV.

HIV and AIDS

A total of 4967 cases of AIDS, 46% among women, were reported by the Ministry of Public Health through 1992. There have been no official statistics published since that date. Table 2 illustrates surveys of HIV seroprevalence in recent years for which data are available. (Specific years are cited where known.)

Table 2. HIV Prevalence Traits

Age Group Percentage 14-19 years 6% (1992) 20–24 years 7% (1992) Socioeconomic Factors Percentage Urban 10% (1992) Rural 2% (1986); 4% (1992) Low Income 10.3% (1989) Higher Income 3% (1991) Commercial Sex Workers 61% (1987); 72 % (1990) STD Clients—Males 28% STD Clients—Female 14% TB Clients—Adults 24% (1991) TB Clients (Outpatient)—Children 13% (1992) TB Clients (Inpatient)—Children  1.5% (1992) Blood Donors 2.2% (1992) Pregnant Women 2–10% (1992–93)

In Haiti, the STD/AIDS program is integrated with the primary health care system but it is not linked to family planning services. It is almost impossible, therefore, to provide statistics concerning the incidence of STDs among family planning clients. The only research on this subject was carried out in 1992 at the Centre pour le Developpement de la Santé (CDS) family planning clinic in Cité Soleil. In this study, out of 100 women referred, 4 percent had gonorrhea and 20 percent had chlamydia trachomatis.

The sociopolitical instability which followed the events of September 1991 greatly influenced the course of these pathologies because it resulted in large-scale migration from the cities to rural areas. This semi-urban population with a high rate of HIV seroprevalence came into contact with the rural population, which probably contributed to the spread of HIV infection.

Existing Programs for Management of STDs and AIDS

Although AIDS was identified in Haiti in the early 1980s, little has been done to establish systems for the management of STDs and AIDS during the last 10 years. During the last 3 years, there has been increased talk about a common effort to manage STDs and AIDS in family planning clinics but in practice, little has been done.

The Association for the Promotion of the Haitian Family (PROFAMIL) is perhaps the only organization developing an integrated STD/AIDS/FP program. Their “double protection” approach offers integrated reproductive health care to populations at risk for unwanted pregnancy as well as those at risk for STDs.

Although there has been a delay in addressing the problem of STDs/AIDS and family planning in Haiti, the Cornell Gheskio Group has initiated a training program for physicians, nurses, paramedical personnel and pharmacists in the use of three algorithms which were developed in Haiti with the assistance of WHO. Thus, between 1992 and 1994, 583 health workers from the nine departments (states) of the country were trained in the use of these algorithms, under a program financed by WHO.

The Ministry of Health has developed a program which it hopes to implement with the help of international funding sources. The general objective of the program is to:

• reduce morbidity and mortality from infectious and communicable diseases in 20 Unites Communales de Santé (Health Commune Units, i.e., administrative areas) during the next 12 months

Specific objectives are to reduce the:

• transmission of STDs and AIDS among the sexually active population, particularly among adolescents
• socioeconomic impact of AIDS on individuals and communities

Planned activities include training; information, education and communication (IEC) initiatives; epidemiological surveillance; provision of supplies; operations research; and supervision. Ideally, integrated STD/AIDS/FP programs should improve STD/AIDS control, treat cases of infertility associated with STDs and offer family planning methods appropriate to clients’ risk status. Ultimately, increased knowledge about STDs and AIDS should improve their management and lead to a decline in these diseases.

Problems in Implementing the Programs

Problems which explain the delay of these programs include:

• sociopolitical problems which have lessened the motivation of health personnel and decision-makers
• lack of training for health personnel
• shortage of health personnel (physicians, trained biologists, social workers) in distant parts of the country
• logistic difficulties (e.g., supplies and equipment necessary for laboratory diagnosis are lacking)
• ignorance of the population
• high cost of laboratory tests
• high cost of drugs bought in private pharmacies

Recommendations

In view of the situation in Haiti, it is clear that only a public health approach will succeed in limiting the spread of STDs/HIV/AIDS.

Routine screening for STDs is controversial and expensive. Nevertheless, every department (state) should have an HIV referral and testing center for the at-risk population. This, of course, requires expanding counseling services. It is unrealistic to think that it would be possible to screen routinely for all other STDs, as the cost would be prohibitive and not within reach of most developing countries.

Departmental referral laboratories should be made more accessible and the cost of examinations should be within the reach of patients.

The most sensible approach to treatment would seem to be the use of algorithms that make it possible to treat all patients who are symptomatic. Followup of these patients should be strengthened and, as far as possible, their partners should also be treated. Cases of recurrence would have to be investigated in greater depth.

There remains the problem of available drugs for treatment. If medications are not available at a reasonable cost, the problem will remain unsolved. In Haiti at the present time, through PROMESS, a central pharmacy managed by the Ministry of Public Health and WHO, 12 generic medications for the treatment of STDs are available. They are sold at health centers at up to 35 percent lower cost and made available to the population at reasonable prices.

The greatest challenge and the most promising path is that of information, education and communication campaigns to bring about behavior change among people at risk. Double protection, i.e., offering integrated services to populations at risk for both unwanted pregnancy and STDs, would seem to be a solution which should be promoted to the greatest extent possible.

References

Dantica E (Institut Haïtien de Santé Communautaire). Personal communication.

Kamara B (OPS/WHO). Personal communication.

Liautaud B and R Melon (Cornell Gheskio). Personal communication.

Lubin R and J Désormeaux (Centre pour le Developpement de la Santé). Personal communication.

OPS/WHO. 1994. Analyse de la Situation Sanitaire, Haïti (Analysis of Health Conditions in Haiti). December.

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