"Four Pillars" of the HIV Equity Initiative

1 – AIDS prevention and treatment in the context of primary care
2 – Advancing tuberculosis care
3 – Improving screening and treatment of sexually transmitted infections
4 – Emphasis on women's health

1 – AIDS prevention and treatment in the context of primary care
The provision of general medical services is the fundamental intervention necessary for engaging the community and improving overall well-being. ZL's mandate to fight AIDS in Haiti is thus underpinned by improving access to comprehensive primary health care. As ZL expanded across the Central Plateau, it has registered a steady increase in the number of HIV tests performed (more than 40,000 in 2004 HOW MANY IN 2005 OR 2006), the number of HIV-positive patients monitored (more than 8,000 at the end of 2004) and the number of HIV-positive patients on antiretroviral therapy (more than 2,000 at the end of 2005).

2 – Advancing tuberculosis care
Tuberculosis is the leading cause of death among HIV-positive people worldwide. Haiti has the highest prevalence rates in the Western Hemisphere of both HIV and TB, and we thus battle the two diseases in tandem. Tuberculosis detection and treatment skyrocketed at each of the expansion sites after ZL introduced appropriate diagnostics, medications, and personnel, including community health workers to provide directly observed therapy. In 2004, more than 1,500 patients were treated for tuberculosis; one-third of these patients were also HIV-positive.

3 – Improving screening and treatment of sexually transmitted infections
Untreated sexually transmitted infections (STIs) can elevate the rate of HIV transmission up to tenfold, cause cervical cancer and infertility, and put pregnant women and their babies at increased risk for preterm delivery, miscarriage, and neonatal complications. ZL has developed a comprehensive women’s health program that centers on the aggressive screening and treatment of STIs. In 2004, over 38,000 patients were screened for STIs, and 500 women were screened for cervical cancer. New algorithms for the screening and treatment of chlamydia and gonorrhea, two very prevalent and difficult to identify STIs in Haiti, have improved ZL’s detection rate to nearly 98 percent.

4 – Emphasis on women's health

• Reducing maternal mortality
  Childbirth is the second leading cause of death for women in Haiti, who are forty times more likely to die from pregnancy-related complications than are women in the United States. Family planning services and timely OB/GYN care dramatically improve the survival and well-being of women and their families. Each Zanmi Lasante site is staffed by a family planning nurse as well as community health workers who travel throughout the countryside teaching men and women about sexually transmitted infections (including HIV), distributing condoms and oral contraceptives, and referring pregnant women and others to ZL clinics. To reach even more communities, PIH/ZL also trains a network of traditional birth attendants to assist with home births and refer high-risk pregnancies. ZL has four full-time OB/GYN doctors on staff, and two of its sites have fully-equipped operating rooms that can accommodate Cesarean sections and other OB/GYN emergencies. In 2004, Zanmi Lasante saw more than 25,000 pregnant women.
  
  
• Preventing mother-to-child transmission of HIV
  Mother-to-child transmission of HIV at birth or through breastfeeding, now nearly unheard of in the United States, remains a ranking problem in most of Haiti. In addition to its comprehensive women’s health services, Zanmi Lasante’s targeted efforts to reduce viral transmission from mother to infant has resulted in a local vertical transmission rate of under 2 percent. All pregnant women are tested for HIV; in 2004, 150 HIV-positive pregnant women were identified and treated with antiretroviral therapy. Monthly education sessions for pregnant women and new mothers are a popular forum for sharing information about safe pregnancy, HIV prevention, and childcare. Infant formula and all the necessary supplies for safe formula-feeding (including access to clean water) are provided to all HIV-positive mothers to prevent postpartum transmission of HIV via breast milk.
  
  
• Earlier HIV diagnosis for newborns
  In 2004, ZL piloted an inexpensive test to confirm an infant’s HIV serostatus within one to four months of birth. Previously, an infant’s serostatus could not be confirmed until 18 months of age, which delayed care and treatment for infants who had in fact contracted the virus from their mothers. In 2004, 89 infants were tested; all ZL sites are now performing this test for HIV in babies born to HIV-infected mothers.

The key to the HIV Equity Initiative’s success lies in its comprehensive approach: nutritional and social support are provided along with life-saving medicines and treatment is closely linked to prevention and to other health services. Community health workers provide the “missing infrastructure” that is often posed as an obstacle to AIDS care in poor countries. This community-based approach works so well that during the 2004 coup d’etat in Haiti not a single PIH AIDS patient missed a dose of medication.