Haiti

Men who have sex with men bear a significantly higher HIV burden with a HIV prevalence rate of 18.2% compared to the adult HIV prevalence rate of 1.9%. Stigmatization and violence are consistently reported by a majority of men who have sex with men. Eighteen percent of men who have sex with men report being a victim of physical violence and approximately 45% of men who have sex with men report ever having been raped. Stigmatization affect health seeking behaviour as 6% of men who have sex with men report being mistreated by a healthcare worker.

It appears that the first program aimed at preventing HIV infections among men who have sex with men was funded by the Ministry of Public Health and Population in 2012.  Targeted HIV programs for men who have sex with men are required given that the prevalence of HIV is 18 times higher in men who have sex with men compared to the general adult population in Haiti.

Information on migrant men who have sex with men is sparse. No information was found on HIV incidence or prevalence among migrant men who have sex with men.

Sex workers bear a significantly higher HIV burden with a HIV prevalence rate of 8.4% compared to the adult HIV prevalence rate of 1.9%. Stigmatization and violence are consistently reported by a majority of sex workers. Thirty five percent of sex workers report being a victim of physical violence and approximately 45% of female sex workers report ever having been raped. Stigmatization affect health seeking behaviour as 11% of female sex workers report being mistreated by a healthcare worker.

In Haiti, a strong reluctance to use condoms during sex persists even though three out of four people in Haiti know that using condoms consistently can prevent HIV infection. In a study in the region of Artibonite, Haiti, only 60% of clients said they always used condoms with sex workers. HIV prevalence among those clients was 7.2%. Seventeen percent of the clients had previously been tested for HIV, and only 33% said they always used condoms with their regular sex partners. One third of sex workers surveyed in 2006 confirmed having unprotected sex for more money. These trends highlight the need to focus more effective prevention efforts around sex workers and their clients.

It appears that the first program aimed at preventing HIV infections among sex workers was funded by the Ministry of Public Health and Population in 2012.

Information on migrant sex workers is sparse. No information was found on HIV incidence or prevalence among migrant sex workers.

Injection drug use in rare in the Caribbean. However, crack cocaine smoking and non-injection drug use has been increasing.

The main link between substance abuse and HIV acquisition in the Caribbean is indirect – through the exchange of sex for drugs or the effect of drugs and alcohol on inhibition and unprotected sex. As such, no information on HIV prevalence in injection drug users was found.

Though injection drug use is low, cocaine is the most frequently injected drug in the Caribbean including Haiti. However, in most countries outside the Caribbean and South America heroin is the injection drug of choice among injecting drug users. Cocaine injection tends to be associated with greater HIV risk behaviors than heroin. This may in part be because cocaine is often injected many times a da leading to neglecting safer injection techniques and is also associated with chaotic behaviors and trading sex.

In 2006 there was no reported injection drug use in Haiti.

Information on migrant injection drug users is sparse. No information was found on HIV incidence or prevalence among migrant injection drug users.

Haiti is the poorest country in the western hemisphere with over half of the country’s approximately 11 million people living on less than one dollar a day.  Approximately 150,000 people live with HIV in Haiti, making it the country with the heaviest HIV burden in the Caribbean. The HIV epidemic in Haiti is fueled by poverty, high illiteracy rates, inadequate health and social services and high internal migration.

Migrants typically have higher HIV prevalence than non-migrants but it is unknown whether HIV acquisition happens before or after migration. Since the beginning of the HIV epidemic, Haitians who migrated faced strong prejudice especially those living in the United States, who were then regarded as a high “risk group”.

Haiti has been ranked the most vulnerable country in the world to climate change. Haiti is prone to a wide array of environmental stressors, including flooding, droughts, hurricanes, earthquakes, and landslides. On January 12, 2010, Haiti was hit by a magnitude 7.0 earthquake destroying and damaging much of the previously existing physical infrastructure (including 30,000 commercial and government buildings) and resulting in an estimated 240,000 (other sources report 300,000 deaths) deaths and 300,000 injuries. The earthquake severely affected the health infrastructure in Haiti and resulted in access challenges to basic health care services. A cholera epidemic broke out in Haiti following the 2010 earthquake, and HIV, tuberculosis and malaria remain major public health problems.

Emigration from Haiti has been studied, especially as it relates to HIV. However, immigration to Haiti as it relates to HIV has not been well documented. In 2013, migrants to Haiti from the top 5 countries of origin; Venezuela, the Dominican Republic, the United Sates, Puerto Rico and Spain totaled approximately 18,000 people. The total number of migrants in Haiti is approximately 40,000 or 0.4% of the total population of Haiti. Meanwhile, emigration from Haiti totaled over 1 million in 2013. Migrants typically move to other cities or countries for political, economic or social reasons. Migration to Haiti is likely very low, accounting for less than 1% of the population, because of Haiti’s current economic situation. The GDP in Haiti has been declining since 1982 and political instability has been a challenge.

Haiti has one of the lowest income per capita in the world and faces immense challenges providing basic health services for its population. Roughly 40 percent of the population lack access to essential health and nutrition services. HIV, tuberculosis and malaria are major public health problems.  Haiti has struggled with poor health outcomes for decades and reports some of the world’s worst health indicators, which continue to affect development.

Haiti’s health care system is made up of the following four sectors:

• The public sector, which has been significantly downsized in the aftermath of the 2010 earthquake;
• The private nonprofit sector, made up of non-governmental and religious organizations;
• The mixed nonprofit sector, whose staff is paid by the State but whose management is private; and
• The private for-profit sector, which is made up of physicians, dentists, nurses, and other specialists who work in medical offices or clinics in large cities and the country’s capital.

An estimated 80% of the equipment in public health institutions is defective or out of order.  There is also a severe shortage of health workers, low retention of nurses and doctors, and gaps in services across all levels of the health system.

Haiti’s health infrastructure has not kept pace with Haiti’s population growth from 7.5 million people in 1993 to 11 million in 2018. The January 2010 earthquake destroyed much of Haiti’s already struggling health infrastructure. Fifty health centers, part of Haiti’s primary teaching hospital, and the Ministry of Health were all destroyed in the earthquake. Approximately 30,000 commercial and government buildings were destroyed and an estimated 240,000 people died (other sources report 300,000 deaths) and another 300,000 were injured. Included in the human loss were civil servants, health professionals, medical and nursing students.  A few months after the earthquake, Haiti’s health care infrastructure was put under enormous strain as  result of the country’s first cholera outbreak in a century. As of January 2014, 8,534 deaths and 697,256 cholera cases were reported by the Haitian Ministry of Public Health and Population.

Government spending for health is low and only represents 6 percent of all government expenditure for the country. There is still heavy reliance on international funding to provide Haitians access to health care services. Given Haiti’s weak economy, limited resources and competing social needs, public spending on health will likely continue to remain low.

Haiti faces enormous challenges in providing access to health care services for its population. Outmigration or emigration from Haiti has bene well documented. However, information on migrants currently living in Haiti is extremely sparse.

HIV-related stigma is one of the most significant barriers to HIV prevention in Haiti.  Stigma is a barrier to accessing prevention services, testing, treatment, and care for many people living with HIV in Haiti. Although new HIV infections have decreased by 25% and AIDS-related deaths have decreased by 24% since 2010, access to basic health care services continue to be a problem in Haiti. Policy interventions such as HIV education to help reduce stigma, improve access to HIV services and prioritize access to health care for key populations such as men who have sex with men and vulnerable groups such as women should be developed and implemented to help reduce the burden of those living with HIV.

UN AIDS has prioritized same-day antiretroviral therapy initiation and rolling out viral load testing as a way to achieve the 90–90–90 target. In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) and partners launched the 90–90–90 targets; the aim was to diagnose 90% of all HIV-positive persons, provide antiretroviral therapy for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020.

Haiti ranks 163 out of 188 countries on the United Nations’ human development rankings. Most adults are unemployed and more than 70% live in U.N.-defined extreme poverty in Haiti. Safe drinking water and sanitation facilities are lacking for most people. 40% of Haitian households have inadequate shelter and face food insecurity. Policy interventions aimed at tackling poverty and unemployment, sanitation, food insecurity and housing will help to address the social determinants of health and impact the health of people living in Haiti, including persons living with HIV.

Poverty and gender disparity in HIV acquisition are linked in Haiti. Poverty contributes to early sexual debut among Haitian girls and encourages multiple sex partners and partnerships with older men to meet basic survival needs. Commercial sex is legal and a pattern of “end of the month” prostitution has been observed, typically in women who are unable to pay rent or buy basic supplies. Gender disparity and sexual violence is a significant issue for HIV acquisition. Higher HIV rates are reported for young women aged 13-24 compared to men of the same age in Haiti. The adult prevalence of sexually transmitted infections is 10% in Haiti and heterosexual transmission accounts for more than 90% of HIV cases. Policy interventions should prioritize women and girls in HIV prevention efforts.

Migrants to Haiti have not been well documented or studied. It is known that migrants typically have higher HIV prevalence than non-migrants but it is unknown whether HIV acquisition happens before or after migration. Given that globally HIV prevention efforts have resulted in overall decreases in HIV incidence and prevalence, the epidemic continues to disproportionately affect populations such as migrants, women, men who have sex with men, sex workers and injection drug users.  These populations should be prioritized in HIV policy interventions given that the impact of HIV burdens key populations due to stigma, access to health services and socioeconomic factors.

Haiti has a severe shortage of health workers, low retention of nurses and doctors, and gaps in services across all levels of the health system. Haiti’s ratio of health professionals to population size is low with just 6 health professionals per 10,000 people. Attracting and retaining qualified health care professionals is an ongoing struggle.

Brain drain has severely affected Haiti’s supply of qualified workers. Haiti is one of the largest exporters of a qualified workforce in the world. It is estimated that about one third of university graduates in Haiti emigrated after the January 2010 earthquake. Brain drain becomes a problem if the inflow of skilled people through immigration is not enough to compensate for the outflow of people. Policies that encourage the return of skilled migrants should be pursued to increase the labour supply and help to rebuild critical infrastructure across Haiti. Encouraging skilled migration to Haiti can be done by building trust in public institutions and making efforts to improve the socio-economic environment. An assessment of human resource needs in Haiti should be completed to help prioritize gaps in labour supply.

Creative policies to encourage the return of skilled labour to Haiti may help to increase the supply of skilled labour. Providing incentives to return to Haiti may encourage the inflow of new economic, social and cultural capital into the country. Pursuing this policy angle will require attractive incentives as migrants from Haiti tend to become long-term or permanent migrants in their countries of destination.