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At a Glance:

Amid severe gang violence and socio-political turmoil in Haiti, researchers from , together with CID PhD Affiliate , published a paper last month in Lancet Regional Health Americas titled "." GHESKIO, a Haitian-led, Haitian-run healthcare and research organization, has provided free, high quality healthcare to hundreds of thousands of the most vulnerable patients in Port-au-Prince for over 40 years. They continue to seek ways to provide better care within an increasingly challenging context. Their recent paper demonstrates that GHESKIO’s model of community-based HIV care can expand access to treatment and sustain strong patient outcomes even in some of the most challenging socio-political circumstances in the world.

A healthcare system in collapse

Less than 700 miles off the southernmost point of the US (a distance similar to going from northern to southern California) is one of the world’s most fragile countries. For decades, Haiti has experienced compounding layers of crises from massive earthquakes, tropical storms, and disease outbreaks, to a legacy of foreign interference, corrupt leadership, and violent political unrest.

Within the last three years alone, Haitians experienced the assassination of President Jovenel Moïse, followed shortly by a devastating earthquake and then a tropical storm. In absence of a functional government and military, a proliferating now controls much of the capital, affecting nearly every aspect of life. Ordinary Haitians fear leaving their homes for basics like food and water, much less to go to work or send their children to school. One in two Haitians, or out of Haiti’s population of 11 million, face acute food insecurity, and since 2021, over Haitians (over 6% of the population) have been internally displaced. 

Blockaded roads, severely disrupted supply chains, and the constant risk of violence have posed particularly grueling challenges to a healthcare system that is near collapse. Hundreds of thousands continue to live in camps, some of which were built in the aftermath of the 2010 earthquake and have grown in subsequent disasters. Dire conditions in these camps have fueled new outbreaks of diseases, including scabies and impetigo among children, as well as diarrhea, respiratory infections, and tuberculosis within an already vulnerable population.

A healthcare and research center that continues to open its doors

In the face of these extraordinary challenges, GHESKIO (pronounced guess-key-yo, a French acronym for the Haitian Group for the Study of Kaposi Sarcoma and Opportunistic Infections) has continued to open its doors, providing thousands of people with free, high-quality healthcare every month. Founded in 1982 by seven Haitian doctors, it was the world’s first organization dedicated to fighting AIDS, during a time when the terms HIV and AIDS had just been coined and the diseases were barely understood. It is now one of the largest centers for HIV and tuberculosis care and research in the Americas and has published over 300 papers, some of which have influenced the WHO guidelines on HIV, tuberculosis, and cholera. 

Since its founding, GHESKIO’s philosophy can be encapsulated by an expression that Rochelle Sun has heard Dr. Jean Pape, one of GHESKIO’s founding doctors and a pillar of the global health community, return to again and again. Amidst meetings that have devolved into minute logistical parsing of what is possible and what is not, he will bring the conversation back to, “How do we roll out the red carpet for them?”  The underlying ethic is: life is so hard for our patients outside of the center, we want them to feel like they are truly valued inside. This is GHESKIO’s bottom line, and over the last forty years their work has built a tremendous amount of trust and respect within their community.

Dr. Patrice Joseph, the paper’s lead author, described in a recent conversation that over the past three years more than twenty GHESKIO staff have been kidnapped by gangs. But in each of these cases, GHESKIO–including Dr. Joseph himself–has negotiated the release of the staff members without having to pay any ransom, due to their long-standing work in the community. Gang members are diffused throughout the community and their families have benefited from GHESKIO’s wide range of health and social services. Some of their children also attend GHESKIO’s school for disadvantaged children. “It doesn’t make any difference, when someone shows up at the center they show up as a patient,” says Dr. Joseph.

But GHESKIO continues to operate at tremendous risk and personal cost. The sound of gunfire is normal background noise. Over half the staff have fled the country and those that remain show up every day facing the risk of kidnapping or death. Even despite the protection they receive from the community’s trust, Dr. Pape’s own son was last November and kept captive for three months. He was eventually released after four ransom payments were made.

Against these inhuman odds, GHESKIO has continued not only to provide health services, but adapt these services in order to maintain patient care within a national healthcare system near collapse.

GHESKIO’s model of community-based HIV care

For effective HIV treatment, patients need to take medication regularly in order to keep their viral load suppressed. A lapse in medication for a month could jeopardize not only the patient’s health but also the health of their loved ones. GHESKIO determined that to reduce barriers to care, they would have to expand access to HIV services by bringing care closer to their patients.

They designed a differential service delivery (DSD) for HIV care in which a patient was given the choice of where to receive their antiretroviral therapy (ART):

1. the regular facility visit at the GHESKIO center in Port-au-Prince
2. a visit at a local community site
3. a home visit

In 2019, GHESKIO began piloting decentralization to community-based sites in nine locations where patient density was the highest. In 2020, they began implementing a large-scale shift from facilities to these community-based sites. Each community site was staffed with at least one nurse and one GHESKIO-trained community health worker. They would open 6 days a week and be equipped with basic medical equipment, a small pharmacy, and a computer with internet access for GHESKIO medical records. Appointments were scheduled for a given date but not a specific time, and patients would receive phone call reminders ahead of each scheduled appointment. Patients could also visit without prior arrangement.

By the end of the study period, a cohort of 18,625 patients made an HIV visit. Over half of these patients attended a community-based visit at least once, and about one-third of HIV visits were conducted in a community site or home visit. Despite the challenges to traveling around Port-au-Prince, nearly 90% of the patients who remained in the health network region were retained, and a median of 85% of attended visits were on time. The viral suppression rate was nearly 90% among patients with on-time final visits. 

GHESKIO believes that community visits made it possible for many patients to receive timely ART refills and remain connected with the healthcare system.

What this means on a global scale

The Joint United Nations Programme on HIV/AIDS(UNAIDS) has set . Their recent highlights that ending AIDS is a political and financial choice, and that we live in a world where it is feasible to end the disease by 2030. In order to do this, it will be necessary to provide effective HIV services in settings of conflict and socio-political unrest.

While community-based care for patients with HIV is not new, GHESKIO’s particular model provides evidence that DSD can be implemented in highly-volatile contexts, while maintaining high rates of patient engagement and viral load suppression. Their work underscores the importance of flexible and resilient healthcare delivery models as part of the path towards 95-95-95.

Amidst a constant stream of headlines quantifying the scale of violence and tragedy in Haiti, it is imperative to highlight stories like GHESKIO’s–of Haitians rising to meet extraordinary hardship with extraordinary grit, innovation, and humanity. Their dedication to the most vulnerable amongst their fellow Haitians is a model to the entire global health community of what it truly means to provide care.