HIV Treatment in Central America is ‘Limited,’ Varies From Country to Country, Study Shows
Many people in Central America have "limited" access to HIV care and "almost no access" to antiretroviral drugs, according to a new study published in the Aug. 15 edition of the Journal of the American Medical Association, Reuters Health reports (Reuters Health, 8/15). In a "Letter From Central America," researchers from the United States and all seven of the countries in Central America outline the health care framework of each of the countries, as well as what each country offers in the way of "HIV-specific services," such as viral load testing, antiretroviral drugs and drug regimens to prevent vertical transmission. Health care in Central American countries is typically provided in three ways: through the country's ministry of health, through its social security system or through private clinics and hospitals. The ministry of health system provides government-funded care to all citizens, "regardless of their ability to pay," through a network of hospitals, community health centers and primary care clinics. With the exception of those in Costa Rica, the majority of citizens in each country obtain health services through health ministry facilities. Each country, with the exception of Belize, also provides health care through its social security system, which usually serves "a stratum of the working class, midlevel professionals and their families." With the exception of Nicaragua, social security hospitals in the countries are separate from health ministry facilities and derive their funding from a combination of government money and employer and employee contributions. The number of people who use each system depends on the country's health care framework and the economic resources of the individual citizens. The countries' individual health care systems and their provisions for HIV care are outlined below:
- Guatemala: The majority of HIV-positive Guatemalans obtain health care through the country's Ministry of Health system. Ministry of Health facilities in Guatemala do not offer CD4 cell count and viral load testing and do not provide antiretrovirals to HIV-positive patients. The facilities provide zidovudine to HIV-positive pregnant women to prevent vertical transmission and also offer medicines for opportunistic infections, although these "are not always available." Social security facilities provide both CD4 cell count and viral load testing, offer antiretroviral treatments and dispense zidovudine to HIV-positive pregnant women. Private medical facilities offer all HIV-specific services.
- Belize: The authors state that the HIV/AIDS program offered by Belize's Ministry of Health focuses on case finding and reporting, perinatal transmission and contamination within the blood supply. Health ministry facilities provide "basic" lab tests but do not screen for CD4 cell counts or viral load levels. In addition, the facilities do not offer antiretrovirals and do not have a treatment program for HIV-positive pregnant women. Although the health ministry hospitals provide antituberculosis therapy, medicines for opportunistic infections are "often unavailable." Private hospitals in Belize do not offer any "HIV-dedicated services" and the country's social security system does not typically provide health care. Belize has an estimated adult HIV infection rate of 2.01%, the highest of the Central American countries.
- El Salvador: El Salvador's Ministry of Health facilities do not provide CD4 cell count or viral load tests and do not offer antiretrovirals, although zidovudine is "occasionally" offered to HIV-positive pregnant women. Antituberculosis medicines are "readily available," but treatments for opportunistic infections may "occasionally be interrupted." The country's social security facilities offer CD4 count testing, but do not screen for viral load levels. Social security facilities offer zidovudine to HIV-positive patients and to HIV-positive pregnant women. Private facilities provide all HIV-dedicated services.
- Honduras: Health ministry clinics and social security facilities do not screen for CD4 cell counts or viral load levels, do not offer antiretroviral treatment and do not provide drug therapy to HIV-positive pregnant women. Antituberculosis medicines are "widely available" in health ministry facilities, but the availability of regimens to treat opportunistic infections is not reliable. HIV-positive individuals using private facilities have access to antiretrovirals and can obtain CD4 cell counts in Honduras, but viral load screenings must be sent to a laboratory in the United States.
- Nicaragua: Health ministry facilities and social security clinics do not provide CD4 cell count or viral load screenings, do not provide antiretrovirals and have no drug regimens to prevent vertical transmission. There are "frequently shortages" of medicines needed to treat opportunistic infections, although antituberculosis drugs are "fully available." In the private sector, antiretrovirals are available but CD4 cell count and viral load testing is not.
- Costa Rica: Costa Rica offers universal access to its social security health system, which offers a "broad availability" of health services for people with HIV. The system provides testing for CD4 cell counts and viral load levels, offers antiretroviral treatment, provides zidovudine and some combination therapy for HIV-positive women and offers medicine to treat tuberculosis and other opportunistic infections. Individuals obtaining care in the private sector can receive all HIV-specific services.
- Panama: Ministry of Health clinics do not offer CD4 cell count or viral load testing, but do provide zidovudine to HIV-positive pregnant women and other HIV-positive patients. Medicines to treat opportunistic infections, including tuberculosis, are available. The country's social security facilities provide CD4 count and viral load testing, antiretroviral therapy and zidovudine for pregnant women. All HIV-specific services are available in the private sector.
Access to Drugs, More Training Needed
The authors conclude that the level of care for HIV patients in each of the Central American countries depends largely on the economic resources within each nation and the access to care enjoyed by the citizens of each country. Individuals who receive health services through the social security system "enjoy a wider range of health services and medications" than those receiving care from health ministry facilities. The authors note that Costa Rica's health care system is especially "well-developed" and offers a "multidisciplinary approach to HIV care." Because HIV-positive Costa Ricans have access to a wide range of HIV-specific services, they often experience "virologic and immunologic responses to treatment similar to those reported from developed nations," the authors state (Wheeler et al., JAMA, 8/15). "We need to expand our training efforts for doctors and nurses in Central America so they are more familiar with how to use them, and we need to build upon some of the success stories, such as the Costa Rica experience, and the social security system in Panama," Dr. David Wheeler, lead study author, said (Reuters Health, 8/15). Noting that the price of antiretrovirals is "beyond the reach of all but the most wealthy" in Central America, the authors suggest that developed nations offer assistance in the form of "favorable drug pricing" and access to drug therapy. They also suggest increased opportunities for professional training for Central American health care workers and grants to "build on successful components of the HIV health care infrastructure" (JAMA, 8/15).