Efforts towards Universal Access can only succeed if HIV prevention, care and treatment are included in emergency programs.
HIV and Emergencies: One Size Does Not Fit All (Overseas Development Institute, 2009)
Earthquakes, hurricanes, tsunamis, tornadoes, and floods all bring pictures to mind of toppled buildings, impassable streets, broken limbs, and crushed skulls. Mothers crying for their children; children crying for their mothers. Fathers digging through rubble searching for them both. Relief workers arriving by helicopter. Doctors Without Borders. The American Red Cross. The Red Crescent. Many people die. And many are saved. Embedded in those graphic images of death and destruction and of those trying to save lives in the immediate aftermath of a rapid-onset natural disaster is the unseen and seldom-discussed “collateral mortality” that accompanies such emergencies: loss of continuity in care for those living with HIV. That loss has severe ramifications in the battle against HIV.
Antiretroviral drugs (AVRs) are medicines that prevent the reproduction of retroviruses like those that cause AIDS. Researchers believe that high levels of adherence to antiretroviral drug regimes—uninterrupted treatment—are necessary to prevent the emergence of drug-resistant viruses and to achieve suppression of HIV in an individual. Indeed, strong evidence exists that keeping the viral load—the amount of HIV nucleic acid (RNA) in a patient’s system—as low as possible for as long as possible can decrease the complications that go along with HIV disease, slow the progression from HIV infection to AIDS, and prolong life. Many researchers also believe that maintaining a suppressed viral load makes an individual less likely to transmit the virus to others.
In August 2005, Hurricane Katrina—believed to be the largest natural disaster in American history—made landfall in the state of Louisiana. Hardest hit was its “ Crescent City,” New Orleans. According to author Bonnie Goldman:
Until the morning of Aug. 29, New Orleans was the center for HIV care in Louisiana, with many of the state’s 15,000 HIV-positive residents. The city had the highest number of newly diagnosed cases and the second-highest HIV/AIDS case rate in the state, below only the Baton Rouge area. It is no surprise, then, that the city served as the headquarters for the Louisiana state HIV/AIDS program, or that it was the primary setting for HIV research in Louisiana. Snapshots of Hurricane Katrina’s Effect on the AIDS Community: Louisiana (Sept. 8, 2005) available at thebody.com.
When the storm passed, New Orleans was a deserted city, 80 percent of which was under water. According to a Kaiser Foundation report:
[H]urricane Katrina inflicted massive damage on three of the poorest States in the country: Louisiana, with a poverty rate of 22 percent; Mississippi, with a poverty rate of 23 percent; and Alabama, with a poverty rate of 20 percent. Katrina also caused the evacuation of a major American city, where 23 percent of residents lived in poverty before the levees were breached. Of the 1.1 million Americans forced to leave their homes in New Orleans and other devastated areas, the majority appear to have relocated elsewhere within their States. Perhaps as many as half a million have been relocated to Texas and other States of refuge, many of which have high rates of poverty themselves (22 percent of Texans live in poverty). Kaiser Foundation, Addressing the Health Care Impact of Hurricane Katrina (2005).
HIV/AIDS care in New Orleans was profoundly different post-Katrina, as an article by Rex Wockner reveals ( New Orleans AIDS Agencies Struggle (Apr. 5, 2006) Windy City Times. Beth Scalco, then director of Louisiana’s Office of Public Health HIV/AIDS Program, reported that, “Five of our 10 community-based prevention contractors basically went out of business due to heavy damage to their buildings and because they experienced a big loss of their staff in terms of people who decided not to return to New Orleans.” All HIV services were shut down for several weeks after Katrina. “Some were out of service longer than others, depending on their location, if they were able to get staffing back and if they actually had any clients,” according to Noel Twilbeck Jr., executive director of the NO/AIDS Task Force. In addition, Scalco reported, “In the evacuation turmoil, people often did not pack everything they needed. A lot of people also were unable to access medications [elsewhere]. It also takes some people a lot of time to re-engage with medical care, which means they could be going several months without medication.” There were some individuals who stopped taking their drugs “because they had never revealed their HIV status to the friends or family members to whose homes they evacuated.” As a result, some people with HIV went without their antiretroviral drugs with the attendant treatment interruptions immediately after the storm and for months thereafter, according to Scalco.
After the storm, thousands of New Orleanians spent days in the Superdome and the Convention Center without access to basic necessities. The sight of a child that caught the attention of the television cameras very vocally expressing his concern that his grandmother needed her diabetes medicine could have been echoed many times over.
Hurricane Katrina provided the public health community with a number of lessons. One of the recommendations that the Trust for America’s Health (TFAH) developed was to establish clear preparedness standards for all states, explaining that preparedness varies from state to state and community to community. Yet the U.S. Department of Health and Human Services has not established clear benchmarks and objective standards for preparedness in states. Those objectives, whenever forthcoming, should focus on outcome results from real-life drills and exercises. Current benchmarks are often process-oriented and are not clear predictors of how well a state will respond to an emergency. TFAH further recommended that states upgrade surveillance systems so they meet national standards and are interoperable between jurisdictions and agencies to ensure rapid information sharing. Trust for America’s Health, On the Third Anniversary of Hurricane Katrina, Trust for America’s Health Questions State of National Emergency Preparedness (2008). Insuring access to a stockpile of medication to address chronic illness is another of their recommendations.
With the recommendations emerging from the Katrina experience as standards, the world of health care and emergency preparedness was struck with another test. On January 13, 2010, an earthquake measuring 7.3 on the Richter scale struck Haiti, inflicting severe devastation in the capital, Port-au-Prince, and Haiti’s West Province. As many as 3 million people potentially were affected by this massive earthquake. The internal damage to hospitals and health care was as devastating as the quake itself, with medical structures being unsafe for existing patients. The conditions may be even more disastrous for an already vulnerable community—Haitians living with HIV/AIDS.
UNICEF estimates that 5.6 percent of the pre-earthquake 15- to 49-year-old population was HIV-positive, including about 19,000 children. HIV/AIDS is the nation’s leading contagious cause of death, making the loss of AIDS services particularly dangerous. Many of the clinics that were destroyed were HIV/AIDS clinics, and many of their staff members were killed. According to reports, almost no one seemed to have access to ARVs. However, in one area of Haiti an emergency plan was in effect to address hurricanes. That plan was activated and the organization in charge was able to administer almost 900 doses of ARVs on a daily basis. Clearly, the issue of providing effective heath care during emergency situations continues to present issues that are not consistently resolved, resulting in “collateral mortality.”
The recommendations set out by TFAH are clear and concise. What might be added is the technology of electronic medical records with biological identification. Consider the possibility of being able to identify, by fingerprint, those who perished in Haiti. The Health Information Management Systems Society’s definition of EHRs reads:
The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow.
State-of-the-art technology has added the element of biological identification. Such systems currently are in development and should be incorporated into emergency-preparedness plans to guarantee the right health care during emergencies.
The Overseas Development Institute offers specific elements that it recommends states include in their preparedness plans to address rapid-onset natural disasters: (1) contingency-planning options for all situations to ensure continued supply and access to ARVs, especially in areas suffering repeated natural disasters; (2) access to food assistance for people on antiretroviral therapy; (3) access to free condoms; (4) continuation and reinforcement of anti-stigma campaigns; (5) dialogue and collaboration between actors in the humanitarian and HIV response; (6) targeting of people living with HIV for specific and long-term support; and (7) recognition that the importance of transactional sex as a way of “coping” has been underestimated and needs more policy attention.
Despite these recommendations, many government-maintained disaster-preparedness plans are silent on HIV even as they provide specific recommendations addressing cancer, deafness and hearing impairment, diabetes, hereditary blood disorders, high blood pressure, and “special populations” (a designation in which persons living with HIV/AIDS are not included) during emergencies. Meeting their obligation to guarantee the right to health for their citizenry requires states to include persons living with HIV/AIDS in their disaster planning—be it to address natural disasters or conflict situations—without further delay. “Collateral mortality” is an unacceptable loss of life.
Andre W. Rawls is the past president of the National Alliance of State and Territorial AIDS Directors (2007). Shelley D. Hayes is chair and a founding member of the ABA AIDS Coordinating Committee and a member of the Section of Individual Rights and Responsibilities Section Council.