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90-90-90 target still elusive

Associate editor – news/health

Monday, December 02, 2019

WHILE stakeholders at the national level are struggling to get 90 per cent of HIV-infected diagnosed Jamaicans on sustained anti-retroviral therapy, local NGO Jamaica AIDS Support for Life (JASL) has already achieved the Joint United Nations Programme on HIV/AIDS (UNAIDS) target.

In fact, JASL is also closer to the 2020 target of having 90 per cent of its more than 730 HIV-positive clients virally suppressed, when compared to the number achieved by the national programme.

The global UNAIDS charge is for 90 per cent of all people living with HIV to know their HIV status, 90 per cent of all people diagnosed with HIV infection to receive sustained anti-retroviral therapy, and 90 per cent of all people receiving anti-retroviral therapy to be virally suppressed — all by 2020.

But, as at the end of March this year, Jamaica had achieved only 84 per cent of individuals living with HIV diagnosed, 47 per cent of those diagnosed on anti-retroviral treatment, and 62 per cent of those on anti-retroviral treatment achieving viral suppression.

There are approximately 32,000 people believed to be living with HIV in Jamaica. As many as 5,300 people living with the virus in the country are unaware of their status. Only 12,700 of those diagnosed are on anti-retroviral treatment and as many as 14,000 people living with HIV were diagnosed with HIV and linked to medical care, and then lost to care. Just last year, 1,600 people were newly HIV-infected.

Recently, Minister of Health and Wellness Dr Christopher Tufton admitted that Jamaica will likely miss the UNAIDS 2020 target.

“For JASL, it has been going very well in comparison to what's happening nationally,” said JASL Executive Director Kandasi Levermore. “But we are still not there yet, because whereas we have achieved the second 90 — meaning more than 90 per cent of the clients who are in our care are on treatment — on the viral suppression side … we are about 74 per cent.”

Levermore, who heads the longest-serving non-governmental organisation offering full-service HIV education, treatment, care, and support in a non-stigmatising and non-discriminatory environment , was speaking to the Jamaica Observer at JASL's wellness centre in Kingston ahead of World AIDS Day, which was commemorated yesterday.

She said that achieving the first 90 is a bit difficult “because the denominator is of all persons who are possibly living with HIV, so we can only pick it up with those who come to us.

“But we do contribute to the first 90, because a lot of the work we do in prevention is HIV testing services, and so we are able to diagnose, but we're not able to track it because the denominator is a national denominator,” she said.

Levermore told the Observer that JASL has tried different models, and that after doing its research, it realised that there were two things that were important to its clients — support and nutrition. After acknowledging this, JASL saw a “dramatic turnaround”.

“Most of the persons who are affected are poor and so they don't necessarily have the right kind of support mechanism in place, and they don't have access to the proper nutrition.

“So we piloted a programme back in 2015, that we called the Comprehensive Health and Case Management Model. The clients, we recognised, have multiple, complex needs, so HIV is not necessarily their primary need, because if I am hungry in this moment, there's no way you're going to talk to me about anti-retrovirals. Who cares? I need food.

“That has been the kind of posture that we sense with the clients — if it is that their basic needs are not met, we cannot now add this layer of the needs around HIV to it,” the JASL executive director said.

She told the Observer that JASL started by looking at 90 clients whose clinical stagings were poor.

“Their viral loads were high and their CD4 (cells) were low, like way lower than the average. We tried to understand what their challenges were, and designed this programme where we tried to meet the needs of the client — and a big part of it was nutrition,” Levermore said.

She reported that by the end of the first year, 85 per cent of the clients had a boost in their CD4 count, and were doing better.

“So we are convinced that we cannot only deal with the clinical aspects of the individual, we had to put in things like treatment literacy. Doctors were not explaining to clients what was wrong and what the virus was doing to their body, and what they needed to do.

“They didn't even understand when we say CD4 load…so we had to boost our internal client education on understanding HIV,” she continued.

“We put in a nutritionist, we had someone come in, meet with the clients, look at the dockets, do the assessment and work out meal plans, and we provided the food to support the meal plans,” Levermore shared. “We did the counselling…and the living support — meaning we bought mattress, stove, fridge. We bought zinc and ply — everything.

This was when JASL saw the “dramatic turnaround” in its clients.

“And that, we felt, was what kind of created our own pivot to moving along with the 90-90-90 target, where we're all of a sudden now more able to retain clients, have clients coming out and meeting their appointments, because you tie up the appointments with the support…so all of a sudden people were maintaining the schedules,” she said, adding that JASL also provided travel stipends.

“People were becoming more empowered, people had the information, people felt better, and they kind of rolled out of their shells,” she recalled.

Senior medical officer for the health and wellness ministry's National HIV/STI Programme, Dr Nicola Skyers, told the Observer in a recent interview that the systems are in place at the national level, as testing is free, drugs are free, and psychosocial support, social workers and case managers are available.

However, she said there is still a fair amount of stigma and discrimination surrounding HIV in Jamaica and globally.

“With that, there is still some reluctance among some persons to test,” she said. “Outside of the stigma and discrimination, we're not a wellness people, we don't do annual checks — it's not until we are really sick that we really seek health care.

“So that, in addition to the stigma and discrimination surrounding HIV, still has an impact,” Dr Skyers said.

She shared, too, that the national programme needs HIV campaigns designed to encourage persons to get tested.

“So I think for us, we've had a hiatus with respect to public education, and that's something that we need to get back to and keep it in person's psyche so that persons become more willing to engage with the system,“ said Dr Skyers as she added that people can be tested in the public sector or at a private lab.

“There is still stigma and discrimination within the health care system, we know that there is also internalised stigma, again, because of how persons have viewed HIV over the years. So even persons living with HIV, sometimes they're not willing to come for care, because of the anticipated discrimination — real or perceived.

“I think also, our health care system in general...we are I think our system is stretched, as well,” she said, adding that this can have an impact on customer care, with existing barriers, making it more difficult or less likely in terms of people wanting to engage with a possibly unfriendly system.

On the issue of where Jamaica is in terms of viral suppression, the senior medical officer said the challenge is getting people to adhere to their medication.

Acknowledging that the public health care system is grappling with several issues besides HIV, Levermore said: “The system is kind of bombarded, and so, where they can, over time, they have been trying.

”They have now put in case managers, they have put in psychologists, they have a few social workers — still not enough to deal with the issues of the population, but they are recognising that the biomedical alone cannot work.”

She, therefore, urged Jamaica, on a whole — the communities, the churches, the community organisations, other civil society actors — to play their part in tackling the epidemic.