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Haiti is the poorest and most heavily HIV-burdened country in the Western hemisphere, with even less health infrastructure than many countries of sub-Saharan Africa. Since the early 1980s the HIV epidemic has affected the poorest communities in Haiti, who lack access to even basic healthcare. Large-scale HIV treatment requires that basic healthcare services be built and scaled up simultaneously with HIV-prevention and -care programmes. Such improvement in access to general healthcare will require substantial investments in health infrastructure, service delivery and human development. This study describes the contribution of the non-governmental organization, Zanmi Lasante (ZL) to the HIV prevention and treatment scale-up and to the ongoing efforts to improve primary healthcare (PHC) services in the public health system in Haiti. The model depends on community health workers (CHWs) who supervise antiretroviral therapy (ART) and provide community outreach, including active case finding and outreach to marginalized populations. Zanmi Lasante has recruited, trained and financed a large cadre of CHWs to provide such linkages between communities and health centres in rural Haiti. The study analysed key components of their work - their self-perception, their role in enhancing community uptake of services and their role in targeting vulnerable groups. We found that most patients at risk were properly identified at a community level. The CHWs are facilitating the uptake of PHC services, including by the most vulnerable households. The general training of CHWs has created a positive self-definition in these cadres of their medical, patient support and health service roles; although with some variability across different groups. The results of this study will be used to emphasize, standardized and strengthen the biosocial training of CHWs. [ABSTRACT FROM AUTHOR]

Objective: To develop a risk assessment algorithm that will increase the identification and treatment of women with cervical infection in rural Haiti. Methods: Study participants were randomly selected from new patients who accessed services at a women's health clinic in rural Haiti between June 1999 and December 2002. This case-control study included women who tested positive for chlamydia and/or gonorrhoea based on the Gen-Probe PACE 2 laboratory test as cases. Controls were women who tested negative for both of these infections. Results: Women from this area of rural Haiti had a limited level of education and lived in impoverished housing conditions. The sensitivity estimates of Haitian Ministry of Health and WHO algorithms for detecting chlamydia and/or gonorrhoea were generally low (ranging from 16.1% to 68.1%) in this population. Risk scores based on logistic regression models of local risk factors for chlamydia and gonorrhoea were developed and sensitivity estimates were higher for algorithms based on these risk scores (up to 98.8%); however, specificity was compromised. Conclusions: A risk assessment algorithm to identify women with chlamydia and/or gonorrhoea is more sensitive and less specific than the syndromic management approach advocated by WHO and adapted by the Haitian Ministry of Health. Using a risk assessment tool with high sensitivity based on local risk factors of cervical infection will maximise access to care, improve outcomes, and decrease morbidity in women who have cervical infection in rural Haiti. [ABSTRACT FROM AUTHOR]

Discusses community-based approaches to AIDS prevention in resource-poor settings such as Haiti. Issue of access to highly-active antiretroviral therapy (HAART); Topic of directly observed therapy with HAART (DOT-HAART); Expansion of the HIV Equity Initiative; Objections to the use of HAART in resource-poor settings; Idea of rethinking costs and benefits.

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities.

Introduction: While travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals., Methods: Eight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti's section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests., Results: All five geographic access measures were highly correlated (range: 0.78-0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND., Conclusion: While the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Following the massive 7.0-magnitude earthquake that devastated much of the Haitian capital city of Port-au-Prince on January 12, 2010, the Haitian health system and its medical education programs were fragmented, fragile, and facing a significant, overwhelming demand for clinical care. In response, the authors of this paper and the institutions they represent supported the development of a teaching hospital that could fill the void in academic training capacity while prioritizing the health of Haiti's rural poor-goals aligned with the Haitian Ministry of Health (MOH) strategy. This bold initiative aimed to address both the immediate and long-term health care needs within post-disaster Haiti through a strategic investment in graduate medical education (GME). Here, the authors describe their approach, which included building consensus, aspiring to international standards, and investing in shared governance structures under Haitian leadership. The Haitian MOH strategy and priorities guided the development, implementation, and expansion of solutions to the ongoing crisis in human resources for health within the acute context. Local leadership of this initiative ensured a sustained and transformative model of GME that has carried Haiti beyond acute relief and toward a more reliable health system. The enduring success can be measured through sustained governance systems, graduates who have remained in Haiti, standardized curricula, a culture of continuous improvement, and the historic achievement of international accreditation. While ongoing challenges persist, Haiti has demonstrated that the strategy of investing in GME in response to acute disasters should be considered in other global settings to support the revitalization of tenuous health systems., (Copyright © 2020 by the Association of American Medical Colleges.)

Background: Uterine fibroids, the most common cause of gynecologic surgery, have a reported cumulative incidence of 59% among Black women in the U.S. Uterine fibroids negatively impact the quality of women's lives. No study has been found in the literature about fibroids in Haiti. We conducted a mixed methods study to assess the burden and risk factors of uterine fibroids, as well as their effects on women's quality of life., Methods: A convergent mixed methods study was conducted between October 1, 2019 and January 31, 2020 at MUH's (Mirebalais University Hospital) OB-GYN outpatient department. Quantitatively, in a cross-sectional study 211 women completed consecutively a structured questionnaire. In-depth interviews with 17 women with fibroids and 7 family members were implemented for the qualitative component. Descriptive statistics were calculated for clinical and social demographic variables. Logistic regression was performed to examine associations between fibroids and related risk factors. An inductive thematic process was used to analyze the qualitative data. A joint display technique was used to integrate the results., Results: Of 193 women analyzed 116 had fibroids (60.1%). The mean age was 41.3. Anemia was the most frequent complication- 61 (52.6%). Compared to women without uterine fibroids, factors associated with uterine fibroids included income decline (AOR = 4.7, 95% CI: 2.1-10.9, p = < 0.001), excessive expenses for transport (AOR = 4.4, 95% CI: 1.6-12.4, p = 0.005), and family history with uterine fibroids (AOR = 4.6, 95% CI: 1.6-13.6, p = 0.005). In contrast, higher level of education and micro polycystic ovarian syndrome were associated with lower prevalence (AOR = 0.3, 95% CI: 0.1-0.9, p = 0.021) and (AOR = 0.2, 95% CI: 0.1-0.97, p = 0.044), respectively. The qualitative findings delineate how contextual factors such as health system failures, long wait times, gender inequality and poverty negatively affect the quality of women's lives. The poverty cycle of uterine fibroids emerged., Conclusions: A vicious cycle of poverty negatively impacts access to care for uterine fibroids in Haiti. Health insurance, social support, and income generating activities may be keys to promote social justice through access to adequate care for women with uterine fibroids in Haiti.

The present study aims to: (1) estimate the levels of internalizing symptoms and externalizing behaviors among youth affected by HIV in central Haiti; and (2) examine the risk and protective factors associated with these outcomes to identify potential areas of intervention for HIV-affected youth. Baseline data for 492 youth affected by HIV (ages 10-17) and their 330 caregivers were collected for a pilot study of a psychosocial support intervention. Participants were recruited from a list of HIV-positive patients receiving care at Partners In Health/Zanmi Lasante clinic sites. Internalizing and externalizing behaviors were assessed using the Strengths and Difficulties Questionnaire. Demographic, economic, and social indicators were collected using a structured questionnaire administered by trained social workers. Youth affected by HIV in central Haiti displayed high levels of internalizing and, to a lesser degree, externalizing symptoms. Multivariate regression analysis demonstrated risk factors most strongly associated with internalizing symptoms (socioeconomic status, parental depressive symptoms) and externalizing behaviors (household living arrangements, such as living with a stepparent). Social support had a protective effect on externalizing behaviors for both caregiver (β=-0.03, p=0.01) and self-report (β=-0.05, p<0.0001). High levels of psychological distress were observed in this population, especially with respect to internalizing outcomes. Interventions should address the economic security, mental health, and access to antiretroviral therapy for families affected by HIV, as well as emphasize the importance of building supportive caregiver-child relationships to decrease the psychological symptoms and impact of other life stressors experienced by youth affected by HIV in Haiti and similar resource-limited settings.

Aims: The goals of this study were to (1) estimate the prevalence of HIV infection among women accessing services at a women's health center in rural Haiti and (2) to identify economic risk factors for HIV infection in this population., Methods: Women who accessed healthcare services at this center between June 1999 and December 2002 were recruited to participate. The analysis was based on data from a case-control study of sexually transmitted diseases (STDs) in rural Haiti. HIV prevalence in the study population was 4%., Results: In multivariate analyses, partner occupation was associated with HIV infection in women, with mechanic (OR 9.0, 95% CI 1.8-45) and market vendor (OR 4.2, 95% CI 1.6-11) reflecting the strongest partner occupational risk factors. Partner's occupation as a farmer reduced the risk of infection in women by 60% (95% CI 0.14-1.1). Factors indicating low socioeconomic status (SES), such as food insecurity (OR 2.0, 95% CI 0.75-5.6) and using charcoal for cooking (OR 1.7, 95% CI 0.72-3.8) suggested an association with HIV infection., Conclusions: Given pervasive gender inequality in Haiti, women's economic security often relies on their partners' income earning activities. Our findings show that although factors reflecting poverty are associated with HIV-positive status, stronger associations are observed for women whose partners indicated a more secure occupation (e.g., mechanic or market vendor). Policies and programs that expand access to education and economic opportunities for women and girls may have long-term implications for HIV prevention in Haiti and other resource-poor settings.

The study is an analysis of baseline data from a pilot psychosocial support intervention for HIV-affected youth and their caregivers in Haiti. Six sites in Haiti's Central Department affiliated with Partners In Health/Zanmi Lasante (PIH/ZL) and the Haitian Ministry of Health were included. Participants were recruited from a list of HIV-positive patients receiving care at PIH/ZL. The baseline questionnaire was administered from February 2006 to January 2007 with HIV-affected youth (n = 492), ages 10-17, and their caregivers (n = 330). According to findings at baseline, the youth reported high levels of anxiety, including constant fidgeting (86%), restlessness (83%), and worrying a lot (56%). Their parents/caregivers also reported a high level of depressive symptoms, such as low energy (73%), feeling everything is an effort (71%), and sadness (69%). Parents' depressive symptoms were positively associated with their children's psychological symptoms (odds ratio [OR] =1.6-2.4) and psychosocial functioning (OR =1.6 according to parental report). The significant levels of anxiety and depression observed among HIV-affected youth and their caregivers suggest that psychosocial interventions are needed among HIV-affected families in central Haiti and other high HIV burden areas. The results suggest that a family-focused approach to service provision may be beneficial, possibly improving quality of life, as well as psychosocial and physical health-related outcomes among HIV-affected youth and their caregivers, particularly HIV-positive parents.

Objective: To develop a risk assessment algorithm that will increase the identification and treatment of women with cervical infection in rural Haiti., Methods: Study participants were randomly selected from new patients who accessed services at a women's health clinic in rural Haiti between June 1999 and December 2002. This case-control study included women who tested positive for chlamydia and/or gonorrhoea based on the Gen-Probe PACE 2 laboratory test as cases. Controls were women who tested negative for both of these infections., Results: Women from this area of rural Haiti had a limited level of education and lived in impoverished housing conditions. The sensitivity estimates of Haitian Ministry of Health and WHO algorithms for detecting chlamydia and/or gonorrhoea were generally low (ranging from 16.1% to 68.1%) in this population. Risk scores based on logistic regression models of local risk factors for chlamydia and gonorrhoea were developed and sensitivity estimates were higher for algorithms based on these risk scores (up to 98.8%); however, specificity was compromised., Conclusions: A risk assessment algorithm to identify women with chlamydia and/or gonorrhoea is more sensitive and less specific than the syndromic management approach advocated by WHO and adapted by the Haitian Ministry of Health. Using a risk assessment tool with high sensitivity based on local risk factors of cervical infection will maximise access to care, improve outcomes, and decrease morbidity in women who have cervical infection in rural Haiti.

The goals of the current study were to: (1) estimate the prevalence of forced sex among women accessing services at a women's health clinic in rural Haiti; and (2) examine factors associated with forced sex in this population. Based on data from a case-control study of risk factors for sexually transmitted diseases (STDs), a cross-sectional analysis to examine factors associated with forced sex was performed. A number of factors related to gender inequality/socioeconomic vulnerability placed women in rural Haiti at higher risk of forced sex. The strongest factors associated with forced sex in multivariate analyses were: age, length of time in a relationship, occupation of the woman's partner, STD-related symptoms, and factors demonstrating economic vulnerability. The findings suggest that prevention efforts must go beyond provision of information and education to the pursuit of broader initiatives at both local and national levels. At the community level, policy-makers should consider advancing economic opportunities for women who are vulnerable to forced sex. Improving access to community-based income-generating activities may begin to address this problem. However, the viability of these local projects depends largely upon Haiti's 'macro-economic' situation. In order to ensure the success of local initiatives, external humanitarian and development assistance to Haiti should be supported. By broadening the definition of "prevention" interventions, we may begin to address the systemic problems that contribute to the occurrence of forced sex and the increasing incidence of HIV infection throughout the world, such as gender inequality and economic vulnerability. Taking into account factors influencing risk at the local level as well as the macro-level will potentially improve our capacity to reduce the risk of forced sex and the spread of STDs, including HIV infection, for millions of women living in poverty worldwide.

Like tuberculosis, human immunodeficiency virus (HIV) disease is associated with poverty and social inequalities, conditions that hamper the delivery of care. Like tuberculosis, treatment of HIV infection requires multidrug regimens, and the causative agent acquires drug resistance, which can be transmitted to others. A pilot project in rural Haiti introduced DOT-HAART (directly observed therapy with highly active antiretroviral therapy) for the care of patients with advanced acquired immune deficiency syndrome. A similar DOT-HAART effort was launched in Boston for patients with drug-resistant HIV disease who had experienced failure of unsupervised therapy. In both settings, community health promoters or accompagnateurs provide more than DOT: they offer psychosocial support and link patients to clinical staff and available resources. DOT-HAART in these 2 settings presents both challenges and opportunities. These models of care can be applied to other poverty-stricken populations in resource-poor settings.

In 2000, acquired immunodeficiency syndrome (AIDS) overtook tuberculosis (TB) as the world's leading infectious cause of adult deaths. In affluent countries, however, AIDS mortality has dropped sharply, largely because of the use of highly active antiretroviral therapy (HAART). Antiretroviral agents are not yet considered essential medications by international public health experts and are not widely used in the poor countries where human immunodeficiency virus (HIV) takes its greatest toll. Arguments against the use of HAART have mainly been based on the high cost of medications and the lack of the infrastructure necessary for using them wisely. We re- examine these arguments in the setting of rising AIDS mortality in developing countries and falling drug prices, and describe a small community-based treatment programme based on lessons gained in TB control. With the collaboration of Haitian community health workers experienced in the delivery of home-based and directly observed treatment for TB, an AIDS-prevention project was expanded to deliver HAART to a subset of HIV patients deemed most likely to benefit. The inclusion criteria and preliminary results are presented. We conclude that directly observed therapy (DOT) with HAART, "DOT-HAART", can be delivered effectively in poor settings if there is an uninterrupted supply of high-quality drugs.