Panel on International Collaborations: Perspectives from Haiti:1979-2008

Jean William Pape MDProfessor of Medicine

Division of International Medicine and Infectious DiseasesWeill Cornell Medical College New York, NY, USA

Director, Les Centres GHESKIO, Port-au-Prince, Haiti

Inaugural Meeting of the University Consortium for Global Heath University of California, San Francisco, September 7-9, 2008

Health Challenges in Haiti

Highest infantile and maternal mortality rateHighest prevalence of HIV outside of AfricaHighest prevalence of TB in the western

hemisphereMDs/10,000 inhabitants, ratio = 2.54 medical schools:

– 400 graduates/year + some from Cuba; – 65% leave the country within 5 years of graduation

Annual health expenditure/person: $US 8.0

Mortality in infants with diarrhea in Haiti

Mortality rate

0

5

10

15

20

25

30

35

40

45

50

1970 1975 1979 1980 1981 1985 1990 1995 1996 1998 2000

020406080

100120140160

1970 1980 1994 2000 2003

YearsInfantile Mortality

State University Hospital National infantile mortality

Haitian Study Group on Opportunistic Infections and Kaposi’s Sarcoma (GHESKIO) May 2, 1982

Mission– Services, Training, Operational Research

In Diarrheal diseases, HIV/AIDS, other STIs, TB,

Collaboration with – US universities: Cornell, Vanderbilt, University of Virginia, Harvard– French Institutions: Institut Pasteur, Fondation Merieux, Universite d’

Amiens– Local institutions: Ministry of Health, Haitian Medical Society and > 120

public and private institutions

Support – Care: USAID; GFATM; PEPFAR;UN agencies; – Research: NIH;ANRS – Training: Fogarty; USAID; – FHAME: Local private foundation dedicated to GHESKIO

What is necessary for a successful collaboration? 1) Must focus on a defined project with specific and measurable

outcomes2) True collaboration: clear advantages for both parties on day 13) Credible: based on the credibility of the entities involved 4) Long term investment: no hit and run deal: Necessary to show results

of the intervention: 10-20 years5) Comprehensive: Holistic approach ideally involving 3 aspects:

research , training and patient care6) Be relevant: must address what is identified in the country as a public

health problem7) Oriented towards capacity building: human resources, training,

equipment, infrastructure8) Must rest on strong ethical standards9) Must have support of the Ministry of Health and reliable institutions

and communities10) Long term success: depend on ability to retain key staff , create role

models and a new generation of well-trained , dedicated staff

What often inhibits collaboration?

Types of partners involved: credibility is essential Undelivered and broken promises: must be direct

and straight about expectationsInsufficient support from foreign site Government interference: Avoid politics at all

costsFight among international partners

Benefits by GHESKIO/Haiti of international collaboration

Research: focused on major public heath issues: infectious diarrhea, HIV/AIDS, TB, STI with development of integrated model for prevention and care

Patient Care:– National center for diarrheal diseases, HIV/AIDS,TB, STI, Malaria– Only lab with capacity to do :

TB culture and sensitivity and species differentiation PCR tests for HIV, TB HIV resistance testing Malaria resistance testing

Training: National Training center – Multiplication of training by Cornell Fogarty fellows– Creation of first in country MPH program with focus on Global Health

National Impact– National reduction of mortality associated with infantile diarrhea– HIV:

National decrease in the prevalence of HIV Massive scale-up of prevention and care

– National reduction of STIs with national plan to eradicate congenital syphilis

GHESKIO Formal Training in 2007(HIV counseling, TB, OIs, HAART, PMTCT)

* College students, Youth association, Press workers, Teachers, Community LeadersCollege students, Youth association, Press workers, Teachers, Community Leaders

  92 - 95 96 - 99 2000 - 2002 2003 2004 2005 2006 2007 TOTAL

Laboratory Technicians 137 220 233 128 111 60 98 51 1038

Social Workers 385 301 41 84 60 29 44 31 975

Nurses 409 501 771 300 342 534 239 132 3228

Physicians 629 906 293 116 101 132 143 101 2421

Pharmacists - - - 7 12 20 9 48

Others (*) 140 173 219 13 58 99 4 706

Community Activities CAB (*)

26 571 10227 2000 3600 2260 3992 2736 25,412

TOTAL 1726 2672 11565 2847 4234 3085 4635 3064 33,828

GHESKIO Centers

- PEPFAR - FM

National Expansion services for Prevention and Care of HIV/AIDS/TB/Malaria (MOH/GHESKIO network)

43 HIV sites supervised by GHESKIO

11 Malaria sites

Multidisciplinary mobile teams essential for supervision, monitoringand continued on the job training

3.1%4.5%6.0%6.2% 3.5%

5.6%6.1%

7.6%

0.0%2.0%4.0%

6.0%8.0%

10.0%12.0%

14.0%16.0%18.0%

1993 1996 2000 2003

HIV SYPHILIS

National HIV Seroprevalence studies in Haiti (1993 – 2006)

0

0.5

1

1.5

2

2.5

3

Urban Rural Total

HIV

Prev

alen

ce (%

)

Women Men Both

National HIV and syphilisSeroprevalence 1993-2003*

National HIV seroprevalence: DHS (2005-2006)**

* *5250 women and 4855 men*Pregnant women at 1st prenatal visit

New Focus of Global Heath at GHESKIO

Eradication of congenital syphilis, MDRTB, HIV/TB interaction, dengue, nutrition, women health issues (cancer)

Create new training programs addressing the country’s needs:– In-country MPH program focused on GH issues: nutrition, health systems,

health inequities, implementation science– Work with local medical schools to:

Develop new curriculum based on the needs of the country and Create other category of personnel: nurse practitioner

Use HIV/AIDS support to improve overall heath system

Work to empower communities to be involved:– Increase hospital deliveries, – HIV: ART adhere, early care, combined HIV/TB approach – Create model of services delivery in slums

The first GHESKIO Generation

Dr Marie-Marcelle Deschamps

Assistant Director 1983-present

Marie Eugenie Beaulieu MT, Head of the lab 1979-present

Dr Rose Irene Verdier

Head Clinics 1984-present

Dr Reynold Grand Pierre Head of Expansion of services1988-present

Yonie Cadot, Head Nurse1979-present

Antiretroviral Therapy in 1,000 AIDS patients in Haiti

Patrice Sévère, M.D., Paul Léger, M.D., MacArthur Charles, M.D., Ph.D., Francine Noël, M.D., Gerry Bonhomme, M.D., Gyrlande Bois, M.D., Érik George, M.D., Stefan Kénel-Pierre, B.S., Peter F. Wright,

M.D., Roy Gulick, M.D., Warren D. Johnson, Jr., M.D., Jean William Pape, M.D., and Daniel W. Fitzgerald, M.D .

Dr Patrice Sévère, Coordinator CTU

Dr Francine Noël, Head, Pediatrics

Dr Paul Léger, Clinical Data Coordinator

Clinical Trial Team

Alexandra Apollon, MT Laboratory

Dr Cynthia Riviere, Coordinator ACTG

MacArthur Charles MD, PhD, Laboratory

Dr Jean Juste, Coordinator, CIPRA

Important Collaborators

Warren D Johnson Jr, Cornell

Peter F Wright, Vanderbilt

Alain Mérieux, Fondation Rodolphe Mérieux

Other collaborators David Haas, Janet Nicotera

Other collaboratorsDaniel Fitzgerald, Roy Gulick

Other collaboratorsEmilio Brignoli, Guy Vernet

GHESKIO Institute of Infectious Diseases and Reproductive Health (IMIS)

Vision and plans for trans-national scale-up:Trans-Caribbean HIV/AIDS Initiative (TCHARI) Founders

Jean William Pape MD, Professor of Medicine, Weill Medical College of

Cornell University, NY , USA, and Director, GHESKIO Centres, Haiti, Chair

Brendan Bain MD, Professor of Medicine, The University of the West Indies, Jamaica

Courtenay Bartholomew MD, Professor of Medicine, Medical Research Foundation of Trinidad and Tobago

Antonio de Moya PhD, Presidential Council on AIDS (COPRESIDA), Dominican Republic

Ms. Linda Jackson, Office of AIDS Research, National Institutes of Health

Yasuhiro Yamamura PhD, Professor, Ponce School of Medicine, Puerto Rico

Carmen D. Zorrilla MD, Professor of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, Puerto Rico

Stewart Smith, TCHARI Regional Coordinator

SummaryMuch has been done in Haiti to control major

diseases in the most difficult conditionsInternational collaboration has been essential Success can be defined by:

– Initial staff who remain involved and – Capacity to attract new ones

Much needs to be done and the UCGH can be an important partner: What works in Haiti can work anywhere else