Deficiencies in Epidemiological Profile abound PERSPECTIVES BY PREM MISIR, Ph.D.
Guyana Chronicle
September 10, 2003

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Guyana has taken the lead in the fight against Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS). This, however, gets lost in the scramble for power by petty and premature politicians and some media operatives who spew daily inaccurate knee-jerk reactions through the media. Too much wasted time is spent on personalized and na´ve politicking, to the detriment of addressing serious social issues, as HIV/AIDS. The newspapers, through their letter columns, sustain a political scorecard that feeds on insular content. The letter columns of both major newspapers are excessively filled with anti-national political materials, leaving minimum space for addressing social issues. In a society that currently has an estimated 2.7% (UNAIDS/WHO estimate) of its adult population living with HIV/AIDS, the Guyanese media, arguably, may have failed the people of this country in their informational, communicational, and educational capacity to consistently disseminate and discuss the HIV/AIDS implications. The media can help to eliminate the stigma and discrimination faced by people living with HIV/AIDS. Editors and owners of the media need to reassess their existing over-politicized orientations and consider a generic approach to the issues. This society, at this time, is over-politicized.

HIV/AIDS globally
AIDS, spreading unobserved since the late 1970s, was not clinically identified until 1981. This identification happened when the Centers for Disease Control and Prevention (CDC) published a paper in Morbidity and Mortality Weekly Report. This paper showed abnormal clusters of opportunistic diseases among homosexual men in New York and California.

By 2002, the sustained impact of HIV continues to devastate large parts of the world, compromising and stigmatizing millions living with this dreadful disease. At the end of 2001, globally, the number of people living with HIV/AIDS was 40 million, with 37.1 million adults, 18.5 million women and 3 million children less than 15 years old. About 3 million AIDS deaths occurred worldwide at the end of 2001.

HIV/AIDS in Guyana
In Guyana, at the end of 2001, estimates of adults and children living with HIV/AIDS were 18,000, with 17,000 adults (aged 15-49), 8,500 women (aged 15-49), and 800 children (aged 0-14). About 1,300 AIDS deaths, comprising both adults and children, occurred in Guyana during 2001. The estimated number of living orphans aged under 15 at the end of 2001 was 4,200. These are children whose mother or father or both parents succumbed to AIDS. For antenatal women tested between 1992 through 1997, the HIV prevalence varied from 4% through 7%. In 1990, HIV prevalence among sex workers tested was 25% compared to 44% of those tested in 1997. An estimated 25% of male Sexually Transmitted Infections (STI) clinic patients and 18% of female STI clinic patients tested in Georgetown in 1997, were found to be HIV-Positive. Both global and Guyana statistics were sourced from the Epidemiological Fact Sheet 2002 Update of the UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance.

Gaps in the HIV/AIDS epidemiological profile
This Fact Sheet implies that regular behavioral surveys are not conducted in Guyana whereby behavior trends could be monitored and appropriate interventions identified. Based on a MICS/UNICEF study in 2000, only about half the females aged 15 through 49 had no serious misconceptions about AIDS transmission and prevention. According to the Epidemiological Fact Sheet 2002 Update, little or no information is documented on knowledge of HIV prevention methods, average age at first sexual experience, risky sexual behavior in the last 12 months, young people with multiple partners in the last 12 months, condom use in last risky sexual behavior, condom use among single young people during premarital sex, proportion of men having sex with a sex worker in the last 12 months, and if they had sex whether they used a condom, proportion of male-male sex in the last 12 months, and proportion of injecting drug users sharing injecting equipment in the last month. These information gaps in the national epidemiological profile in Guyana must urgently be corrected, in order to introduce the best prevention intervention practices. The National AIDS Program Secretariat (NAPS) needs to quickly effect the necessary corrective action to the behavioral profile and monitor this situation consistently.

Anti-retroviral therapy as treatment
With currently no cure for HIV/AIDS, prevention intervention, care and treatment, and impact alleviation must incorporate some strategic components of any plan aimed at addressing the problem. For those stricken with the virus, affordable treatment and care become imperative. Guyana has led the way in providing treatment for HIV. But before I expand on Guyana's leadership in this respect, let us briefly examine the pathogenesis of HIV.

The HIV infection destroys the immune system through disabling and killing the immune cells called CD4+ T cells. A person without the HIV infection would normally have 800 to 1,200 CD4+ T cells per cubic millimeter of blood. However, when a person's CD4+ T cell count drops below 200 cubic millimeter of blood, the person becomes vulnerable to opportunistic infections and cancers that characterize AIDS.

HIV comes from a group of viruses called retroviruses, having genes made up of ribonucleic acid (RNA). Humans have genes made up of deoxyribonucleic acid (DNA). The HIV can only reproduce itself inside cells. So when the virus enters the immune cell, it utilizes an enzyme known as reverse transcriptase to transform the RNA to DNA. This conversion incorporates the person's genes that compose the cells.

Currently, scientists are developing drugs to make people living with HIV/AIDS live longer, and strenuously pushing to develop a cure. At this time, people living with the HIV infection have to use antiretroviral medicines. Antiretrovirals slow the progression of HIV to a full-blown AIDS condition.

The antiretroviral drugs prevent the virus from reproducing itself. Unfortunately, antiretroviral drugs do not destroy the virus. Three types of these drugs are available: the first is the Nucleoside Reverse Transcriptase Inhibitors. These Inhibitors block an HIV enzyme called reverse transcriptase that helps the virus to reproduce itself. The second is the Non-Nucleoside Reverse Transcriptase Inhibitors. These also block the HIV from making copies of itself, but in a different way. The third is the Protease Inhibitors. These stop the HIV enzyme called protease which helps the virus to reproduce itself.

It should be noted that these three kinds of drugs may stop HIV from reproducing itself. The medicines have greater efficacy when used together. When the medicines are combined for usage, they are referred to as 'cocktails' or 'combination therapy' or Highly Active Antiretroviral Therapy (HAART). Clearly, one drug may not do the job. The antiretroviral medicines attempt to keep the viral load low, and the CD4+ T cell count high. The viral load is the amount of HIV in the blood. The CD4+ count tells how well the body is combating the HIV infection.

The GUM Clinic's triple therapy treatmen
The Georgetown Public Hospital Corporation's GUM Clinic administers a triple antiretroviral therapy to 123 patients. Several patients from different parts of the country attend the Clinic. The GUM Clinic soon may be decentralized to provide easy accessibility to HIV-Positive patients living outside of Georgetown. The cost to the Hospital amounts to US$600 per year per one combination therapy per patient. The Clinic does not have a Viral Load Calculator to determine the viral load and equipment to measure the CD4+ T Cell count. However, the patient, prior to treatment, participates in counseling where viral load, CD4+ T Cell, antiretroviral therapies, and the need to comply with the combination therapy regimens, are explained. In the absence of equipment to evaluate the antiretroviral therapy, the physician, generally, asks the patient about adherence to his medication regimen. In general, the physicians use clinic-based symptoms to evaluate effectiveness of the therapy. The full story is not told in assessing clinic-based symptoms. Therefore, the Viral Load Calculator and CD4+ T Cell count equipment now have become a 'procurement' priority for evaluating the effectiveness of antiretrovirals, given the increasing number of patients using the GUM Clinic and the increasing rate of HIV infection.

The New GPC
Again, the antiretroviral drugs are quite expensive and outside the reach of the poor with HIV infection. However, Guyana through the New Guyana Pharmaceutical Corporation (New GPC), is the only manufacturer of antiretroviral drugs in the Caribbean. The New GPC now manufactures 10 antiretroviral drugs, three of which are combination therapies. The Ministry of Health purchases the 10 antiretrovirals from the New GPC. The New GPC's antiretroviral drugs have been approved by the Government Analyst's Department.

The PMTCT Program
In its continued fight against the HIV infection, the Ministry of Health launched the Prevention of Mother to Child Transmission of HIV (PMTCT). This pilot PMTCT Program was initiated through eight (8) antenatal clinics in Regions 4 and 6 in November 2001, and to date have provided services to about 6,000 women, with about125 of them identified as HIV-Positive. President Bush's recent HIV/AIDS initiative, initially allocating $3.4 million to Guyana, will be used to develop the national expansion of this PMTCT Program.

Overall, the Bush initiative involved $15 Billion over 5 years at $3 Billion per year, earmarked for Haiti, Guyana, Botswana, Cote d'lvoire, Ethiopia, Kenya, Tanzania, Uganda, Zambia, Mozambique, Namibia, Nigeria, Rwanda, and South Africa. For Guyana, this has to be a welcome initiative. But we need to know now that Bush in his Budget Estimates for Fiscal 2004 to Congress, already has a proposed cut in his annual allocation for this HIV/AIDS initiative to about $1.9 billion instead of the $3 Billion. Guyana, therefore, needs to utilize a contingency funding approach in this battle against HIV/AIDS from Fiscal 2004, rather than relying solely on the United States for financial support.

Launching of this national initiative for Guyana took place on September 3, 2003. The national PMTCT Program is expected to enhance quality access to preventative intervention to all women seeking antenatal services. The Department administering the national PMTCT program must identify appropriate locations and organizational structures to ensure that women from all ethnic groups have quality access.

HIV infection preventable
As we approach another World AIDS Day on December 1, let us focus on the fact that HIV infection is preventable, mainly via behavior change. The agencies tasked with fighting HIV/AIDS, must understand the factors that influence behavior and behavior change. The NAPS needs to lead the way in designing behavioral intervention programs, incorporating best practices in prevention and to develop a complete national epidemiological and behavioral profile. The vulnerable populations, in addition to their participation in prevention intervention programs, also, must be encouraged through appropriate pre-test and post-test counseling protocols, to present themselves for HIV testing. Guyana already has too many HIV-Positives in its population, largely due to high-risk sexual behaviors.