Tue July 3, 2012
Treating HIV: From Impossible To Halfway There
Originally published on Fri July 6, 2012 1:20 pm
This story begins 11 years ago. It was a time when many, if not most, experts said it was unthinkable to treat people with AIDS in developing countries using the triple-drug regimens that were routinely saving the lives of patients in wealthier countries.
"Many people in Africa have never seen a clock or a watch their entire lives," said Andrew Natsios, then head of the U.S. Agency for International Development, the nation's foreign aid agency, explaining to a congressional committee why patients in the countries hardest hit by AIDS couldn't be trusted to take their medication on time. "And if you say '1 o'clock in the afternoon,' they do not know what you are talking about."
The patient who most sticks in my memory is Francois St. Ker, a 44-year-old, 6-foot-tall man who barely weighed 100 pounds back in the spring of 2001. He was on the brink of death from AIDS when the American doctor Paul Farmer started treating him with new HIV drugs purloined somehow (don't ask) from the pharmacy of a Boston teaching hospital.
St. Ker was working as a welder in Port-au-Prince when he started wasting away from HIV infection. He came back to his home village of Cange, in Haiti's central highlands, to be buried there.
When I met him, St. Ker was still frail but on the road back to health — a change in fortune that seemed to astonish him. He wanted to show me something in a dark shack behind his aunt's house. Inside he pulled back a cardboard covering to reveal a brightly painted beige-and-orange coffin.
"There are two coffins here," St. Ker said. "The one on top is for me. The one on the bottom is for my aunt." But neither would be needing it anytime soon.
I caught up with St. Ker recently. He's healthy and vigorous — a changed man.
"By the grace of God I am very well," he beams, and takes me on a tour of his well-kept, prosperous-looking farm, with its sugar cane and mango trees and dovecote.
"I do agriculture, I raise cattle. I have plantain. I have those chickens over there," he says. Clearly he has a lot of energy. "Yes, it requires a lot of work."
And over 11 years he's been totally faithful about taking his HIV medicine. "Every day! Every day! I manage myself," he says. "I need to see the future of my children. I am a miracle! I compare myself to a second Lazarus."
And that shiny coffin? "We sold the coffin, somebody else use it, not me."
In part because of stories like St. Ker's, word filtered back to policymakers that maybe treating AIDS in places like Haiti was not impossible. At one point, a small group of AIDS doctors from developing countries gathered in the Oval Office at the behest of President George W. Bush.
"The president wanted to hear firsthand from people on the ground that we could make it work," recalls Dr. Bill Pape, a Haitian doctor who was in the group. "And we were unanimous to say — and coming from different backgrounds, in different countries — it could work. And we guaranteed that it would work."
In his 2003 State of the Union message, President Bush announced a $15 billion emergency program to treat and prevent AIDS in poor countries. It's called PEPFAR, the President's Emergency Program for AIDS Relief.
"There are whole countries in Africa where one-third of the adult population carries the [HIV] infection," the president told the assembled senators and House members. "Yet across that continent, only 50,000 AIDS victims — only 50,000 — are receiving the medicine they need."
PEPFAR changed everything. Around 7 million people around the world now take antiviral drugs that suppress HIV to undetectable blood levels. That's about half of those who need it, based on the state of their declining immune systems.
Today in Haiti there are thousands and thousands of modern-day Lazaruses. And fewer these days are getting to the final stages of AIDS that St. Ker reached before they're rescued by treatment.
In Port-au-Prince, Dr. Vanessa Rouzier shows me around the country's biggest AIDS clinic. "One reason it's so busy is that being infected with HIV has lost a lot of the terrifying social stigma the disease had when it was always fatal," she says.
She stops to greet a round-faced little boy named Faustin, who stares up with big eyes from his mother's lap. "This is one of my challenging patients who was very sick," Rouzier says. "He was at death's door."
Faustin got drug-resistant TB from his father, who's under treatment for HIV. The two diseases often go together. The little boy has had a rocky course.
"He wasn't walking, he wasn't talking when I started treating him two years ago," Rouzier says. "And now he's going to school."
Rouzier says that contrary to predictions, the outcomes of HIV treatment in Haiti are just as good as in the United States.
And now Haiti is planning to do another once-unimaginable thing: start treating HIV patients early, before the virus has damaged their immune systems. That will not only preserve the long-term health of HIV-infected patients, but studies are showing that it can also cause new HIV infections to dwindle, because drug treatment prevents people from infecting others.
So treatment may also be prevention. Pape, who helped persuade Bush to fund global HIV treatment, says, "I think we would need to treat at least half of all the HIV-infected patients" in order to see Haiti's epidemic start to recede.
Haiti's not there yet. But Pape thinks it's within reach. Right now about 38,000 Haitians are getting HIV treatment. U.S. health officials based in Haiti think that can be doubled within the next two years.
And that would be just over half of all the Haitians now infected with HIV.
MELISSA BLOCK, HOST:
This is ALL THINGS CONSIDERED. From NPR News, I'm Melissa Block.
ROBERT SIEGEL, HOST:
And I'm Robert Siegel.
Later this month, the U.S. will host the first International AIDS Conference to be held in this country in 22 years. The conference, in Washington, D.C., comes at a time of major shift in AIDS treatment. For the first time, the end of the pandemic is in sight.
BLOCK: Recent studies show that people with HIV who are treated with drugs are far less likely to infect others, and that is beginning to slow the spread of the disease in some hard-hit countries. Currently, about seven million people around the world take drugs against HIV every day. That's about half of those who need them.
All this month, we'll be reporting on HIV and AIDS from around the country and around the globe. Today, we begin in Haiti, where, only a decade ago, there was little hope that the disease could be treated. NPR's Richard Knox traces the story of a remarkable turnaround.
RICHARD KNOX, BYLINE: The turning point came almost 10 years ago. New drug cocktails that came out of the mid-1990s had transformed AIDS from an inevitable killer to a manageable chronic disease, but only in wealthy countries. In the developing world, almost nobody could get the life-saving drugs.
PRESIDENT GEORGE W. BUSH: There are whole countries in Africa where more than one-third of the adult population carries the infection. Yet across that continent, only 50,000 AIDS victims - only 50,000 - are receiving the medicine they need.
KNOX: That's President George W. Bush in his 2003 State of the Union speech when he announced a $15 billion emergency program to treat and prevent AIDS in poor countries. It changed everything. Bush had wanted to do something bold to close the gap in AIDS treatment between rich and poor, but he needed convincing. At one point, a small group of AIDS doctors from developing countries gathered in the Oval Office. Among them was AIDS researcher Dr. Bill Pape.
DR. BILL PAPE: The president wanted to hear firsthand from people on the ground that we could make it work. And we were unanimous to say - and coming from different backgrounds, in different countries - it could work, and we guaranteed that it would work.
KNOX: Not only could it work, but it was working. Using drugs scrounged from the pharmacies of U.S. teaching hospitals, Pape and another participant in that meeting, the American doctor Paul Farmer, were treating AIDS patients in this hemisphere's poorest country, Haiti.
PAPE: Bonjour. Bonjour. How are you?
FRANCOIS ST. KER: (Speaking foreign language)
KNOX: Francois St. Ker was one of the very first patients treated in Haiti. Good to see you.
KER: (Speaking foreign language)
KNOX: I first met him in 2001, a 6-foot-tall man who barely weighed 100 pounds and looked much older than his 44 years. He was on the brink of death when Dr. Paul Farmer started treating him with the new HIV drugs.
St. Ker had come back to central Haiti to be buried in his home village. Back then, he showed me the brightly painted orange-and-brown coffin he brought with him, along with his burial clothes.
KER: (Through Translator) There are two coffins here. The one on top is for me. The one on the bottom is for my aunt.
KNOX: But when I caught up with him recently - 11 years later - with our translator Jean Magloire, St. Ker was transformed.
KER: (Through Translator) By the grace of God, I am very well.
KNOX: He looks healthy and strong and eager to show off his well-kept farmstead, with its sugarcane and mango trees and pigeon house.
KER: (Through Translator) I do agriculture. I raise cattle. I have plantain. I have those chickens over there.
KNOX: Must take a lot of work to keep all this in good shape.
KER: (Through Translator) Yes, it requires a lot of work.
KNOX: He takes his HIV drugs every day without fail.
KER: (Through Translator) Every day. Every day. I manage myself. I need to see the future of my children.
KNOX: You're kind of a miracle.
KER: (Through Translator) Yes, I am a miracle. I compare myself to a second Lazarus.
KNOX: Rising from the dead like Lazarus.
KER: (Through Translator) Yes, yes.
KNOX: I ask St. Ker if he still has the coffin he showed me back in 2001.
KER: (Through Translator) We sold it. We sold the coffin. Somebody else used it, not me.
KNOX: Yeah. You don't need it anymore.
KER: (Speaking foreign language)
KNOX: Today, there are thousands and thousands of modern-day Lazaruses in Haiti, and fewer these days are getting to the final stages of AIDS before they're rescued by HIV drugs.
UNIDENTIFIED WOMAN #1: (Foreign language spoken)
KNOX: In Haiti's sprawling capital of Port-au-Prince, Dr. Vanessa Rouzier shows me around the country's biggest AIDS clinic.
DR. VANESSA ROUZIER: It's one of our busiest clinics where we see over 200 patients per day.
KNOX: One reason it's so busy is that being infected with HIV has lost a lot of the terrifying social stigma the disease had when it was always fatal.
ROUZIER: People can come and be comfortable about coming because, yes, we've done a lot of promotion to decrease stigma but also because they know that there is something that can be done for them. And it's free, and it's available, and it works.
KNOX: But it's not always easy. Many of the patients at this center have both HIV and tuberculosis. And often, they have a nasty, multidrug-resistant type of TB.
UNIDENTIFIED WOMAN #2: What is your first name?
KNOX: Rouzier stops to greet a round-faced little boy named Faustin. He stares up with big eyes from his mother's lap.
ROUZIER: This is one of my challenging patients who was very sick. He was on death's door.
KNOX: Faustin got drug-resistant TB from his father, who's under treatment for HIV. The little boy has had a rocky course.
ROUZIER: He wasn't walking. He wasn't talking when I started treating him two years ago, and now he's going to school.
KNOX: A decade ago, there were a lot of skeptics who said HIV treatment in the poorest countries just wouldn't work, but Rouzier and AIDS doctors around the world have proved them wrong.
ROUZIER: Our outcomes are just as good as in the U.S. Our one-year and five-year adult survival rates are over 80 percent and for children 90 percent, which is just as good as in the U.S.
KNOX: And now, Haiti wants to do another once-unimaginable thing: start treating HIV patients early, before the virus has damaged their immune systems.
PAPE: The most important gesture we can do is start treatment as early as we can.
KNOX: That's Dr. Bill Pape again, founder of the Port-au-Prince AIDS treatment center and one of those who promised President Bush back in 2003 that HIV treatment would work in developing countries. Now Pape wants to move toward the same goal that AIDS specialists in New York City, San Francisco and Washington, D.C., have: universal treatment of everybody infected with HIV as early as possible. They're convinced that will break the back of the pandemic. New infections will start to dwindle because the drugs will prevent people from infecting others.
PAPE: I think we would need to treat at least half of all the HIV-infected patients, and I don't think we are there yet.
KNOX: But Pape thinks that's within reach. Right now, about 38,000 Haitians are getting HIV treatment. U.S. health officials based in Haiti think that can be doubled within the next two years, and that would be just over half of all the Haitians now infected with HIV. Richard Knox, NPR News. Transcript provided by NPR, Copyright National Public Radio.