– but fight far from over

In just under a decade, the reality of HIV has changed somewhat, but the fight is far from over. Minister of Health Dr Leslie Ramsammy points to a lower rate of infection and increased treatment and other services, but acknowledged that there were still many undiagnosed and untested cases in the country and that a fair section of the population continues to ignore the messages about condom use.

Dr Leslie Ramsammy

Guyana has recorded successes in its HIV fight over the past eight years or so, which Ramsammy easily rattles off with pride, including the widely praised Prevention-of-Mother-to-Child Transmission (PMTCT) programme and the dramatic decrease in the prevalence rate among risk groups, particularly Commercial Sex Workers (CSW). But the challenges are still very visible, and these include the high number of unsafe commercial sex transactions across the country, inadequate condom use, stigma and discrimination, unreported cases and increased costs in an already overburdened healthcare system.

Estimates indicate that Guyana spends roughly $5 billion on treatment and care of patients annually. This includes medication, medical supplies and lab tests for people categorized as having AIDS. Every new infection translates into additional expenses. However, these costs are largely met by donor funds.

Stigma and discrimination continue to pose serious challenges though it has been pointed out that families are now more accepting of their infected members and are increasingly opting to have them stay at home; this has been attributed to greater awareness of the disease.

Ramsammy told Stabroek News in a recent interview that HIV is as much a challenge now as it was when he took office, but he pointed to notable improvements such as greater access to care and treatment, saying the impact of actions taken years ago “is now being felt”. He said some people are misguided on the impact of local efforts to tackle the disease, cautioning that critics need to make assessments based on programmes implemented in earlier strategies and the progress recorded to date.  He said also that the prevalence among the risk groups has declined and referred to this as “anything but trivial”, noting that this has happened within the last decade.

He measured the deeper involvement of civil society as a major achievement saying that increasingly more people are getting onboard and are active. “There should be absolutely no one who can dispute the positive impact we have seen over the years, I am sure there are those who will want to make a case but they will lose,” the minister added.

Rate of infection
The current rate of infection is around 1.5 per cent which represents the findings on the ground using surveillance surveys and programmatic data; UNAIDS estimates it at approximately 1.8 per cent. Ramsammy said the difference in the numbers is not cause for alarm, as the numbers verify that national data is providing an accurate picture of what is happening.

Ramsammy was asked how the rate of infection has changed over the years and he immediately identified the risk groups including CSW, men who have sex with men (MSM) and the mobile population such as miners saying the change has been dramatic. In terms of the general infection rate, he said that had stood at around 2.4 per cent several years ago and was even higher at one point.

Similarly, prior to 2000 statistics indicated the rate of infection was miners at 9 percent; MSM at 26 percent; CSW at 48 percent and infected pregnant mothers at 7 percent. Currently the numbers are 2.4 for miners; 20 MSM; 18 for CSW and 1.1 percent for infected pregnant mothers.

“It has gone down,” the minister said of the overall prevalence rate and according to him this is also reflected by the number of deaths. Prior to 2001 between 800-1000 AIDS-related deaths were recorded every year and today there are between 200-300 deaths annually. The numbers aside, Ramsammy said there has been a number of interventions which is responsible for the changes and he cited increased condom use over the years. But he acknowledged that the at-risk population is not following the messages about condoms. Significantly, he said the prison environment has also changed and pointed out that prevalence in the prison population has also reduced over the years. Counselling and testing are provided within the prison system and they have had an impact, according to the minister. “We have been paying close attention to the prisons,” he added.

He cited heightened awareness and education among the critical factors in the visible changes saying that prior to 2000 there was a huge gap in knowledge and the information which was accessible to the public. He said the necessary information is now in schools and in homes, adding that not only adults are armed with the necessary information but also children. But he noted that “the awareness” has not translated to every citizen adjusting his/her behaviour, stressing that many still put themselves at risk even with all of the work the ministry and donors have done.

“Huge risk still remains and it is clear that not everyone is using a condom in risky situations, there are still too many risky engagements with commercial sex workers. We know that a significant number of persons still take chances and what is troubling is that many of them are doing so under the influence,” Ramsammy said. According to him, alcohol is playing a critical role in impairing judgment and it is leading to new infections.

Treatment
There are about 6,000 people in Guyana who are being managed with HIV. These are people who are living with the disease and are not on Anti-Retroviral Drugs (ARVs) but are being treated at clinics across the country. Ramsammy explained that persons categorized as HIV patients are considered okay because their CD4 (a white blood cell that fights infection) count is high and they also have no illnesses.  The goal, he said, is to ensure HIV patients are healthy so they are constantly monitored.

There are about 3,000 persons who are on  ARV treatment and among them are persons who are considered AIDS patients. He said persons considered AIDS patients are those who would have entered the system late at an advanced stage and those with drug resistance problems. In Guyana, both a clinical assessment and laboratory testing is done to determine whether a patient has AIDS. The clinical assessment establishes whether a patient is in the symptomatic stage and the laboratory testing involves checking a patient’s CD4. Patients with low CD4 counts dipping below 200 are considered AIDS patients.

Ramsammy said Guyana took the bold step of administering ARVs to patients whose CD4 dips to around 350, which at the time was not in keeping with international guidelines of using ARVs on patients with lower CD4 counts.

The point, he said, was to keep people healthy and avoid treating patients when they fall ill.

He said statistics prior to 2000 pointed to some 400 – 500 people changing from living with HIV to having AIDS each year, but that the data currently reflects around 50 patients changing annually.

He said treatment does not remove the probability of transmission but that it does reduce it, adding that the more people on treatment, the less chance of transmission in the health-care system. Currently, there are 14 specialized treatment centres in the country where persons are referred to for specialized care.

Ramsammy said there many other treatment centres and facilities across the country where people are treated, but emphasized that specialized care is only offered at the designated sites.

Asked about the assurances of persons in far-flung areas accessing care and treatment, he said, there are clinics in every region and a dedicated doctor for Regions One, Seven, Eight and Nine, who strictly covers those areas.

The doctor, according to Ramsammy, visits routinely and provides counselling, makes diagnoses and initiates treatment since health providers in those areas cannot initiate treatment. He said the doctor takes specimens which are tested in the city among other things. In addition, he said a specialist doctor visits all the communities occasionally.  He said too that people assume HIV numbers are very high in those areas, “but this is a presumption, it is not so”.

Previous studies have shown that between 60 to 70 per cent of people who were HIV positive were not being detected early enough.  “I suspect right now the number is below ten per cent,” Ramsammy added in reference to how many infected patients might be off the register. He said that undiagnosed patients pose serious problems including drug resistance among other issues.