HIV High in Dominican Republic/Prisons
Florida doctor tries to rescue Dominican jails from HIV quagmire
By Antigone Barton
Palm Beach Post Staff Writer
Sunday, October 01, 2006
"....The Caribbean has the second-highest prevalence of the virus in the world, and the island of Hispaniola, which the Dominican Republic shares with Haiti, has the highest prevalence of HIV in this hemisphere...."
A statue of Christ stands over the crumbling beige walls of this nation's largest prison, a jarring symbol of divine protection for a place that has earned notoriety as a hell on earth.
Inside the gates of La Victoria penitentiary, 4,000 inmates live packed into a space built to punish 1,000. The stench of pit toilets fills dark, barely vented cells. Concrete slabs and floors serve as beds. Meals are scooped from a dirty plastic barrel.
Two hours from U.S. shores, recognition of the most basic human rights is still a work in progress here.
Efforts to control the spread of infectious diseases lag even further behind.
The rate of drug-resistant tuberculosis is known to be one of the highest in the world here, where prisoners jam together against the bars of narrow cell doorways for air. Twice as many people are infected with HIV in the Caribbean each year than in all of North America, but doctors at La Victoria don't have any idea how many prisoners have the virus.
And the consequences of this prison's failings aren't contained within its walls.
Wednesdays and Sundays every week are visiting days, when in a respite of the misery here, the gates of this prison are opened to 2,000 visitors: wives, girlfriends and hundreds of prostitutes who serve a dozen men or more each during a visit. The supply of condoms at the prison ran out five months ago.
Still, as of Labor Day weekend, prison officials said not a single prisoner was known to be infected with the virus that leads to AIDS.
That is when an American doctor named John May paid another one of his visits, bringing support and supplies, including rapid HIV testing kits.
May is chief medical officer for South Florida-based Armor Correctional Health Services, which provides medical care to inmates at six institutions in Florida, including Palm Beach and Broward county jails, and he has been serving prisoners in the United States the last 14 years.
He also is the medical director of Health Through Walls, a nonprofit organization he founded last year to bring donated supplies and expertise to prisons in the Caribbean and Africa. In that capacity, and for five years before that on his own, he has visited some of the most miserable penal institutions in the world.
They are humanitarian missions, but, he points out, they also bolster the cause of public health in the United States.
Prison rates five times higher
At any prison, where people of high risks and low resources are concentrated, the rate of HIV can be as much as five times that of the general population. The Caribbean has the second-highest prevalence of the virus in the world, and the island of Hispaniola, which the Dominican Republic shares with Haiti, has the highest prevalence of HIV in this hemisphere.
The bright lights of Santo Domingo's hotels and casinos reveal no sign that so dire a situation exists in this capital city and U.S. travelers' destination, where middle-aged American men scuttle to their rooms with young girls, and garishly adorned male prostitutes called "sanky pankies" cater to foreign visitors.
But as the AIDS epidemic turns a quarter of a century old, sex tourism and immigration continue to speed the spread of the virus from one country to another.
Improving treatment of infectious diseases in developing countries, May says, not only helps otherwise abandoned people but also can stem the spread of HIV and tuberculosis in the United States.
May speaks quietly, and pauses to think first. But he smiles quickly, and the sum of his words betray ebullient optimism and unyielding determination. When he describes dismal circumstances, he talks of "opportunities," and when he discusses even worse circumstances, he talks of "missed opportunities."
Early in his medical career, he saw this opportunity in jails and prisons: "You have a defined group of people, and you are able to make an enormous difference in their lives."
Through studies focusing on prisoners, he became an expert in the causes and effects of gun violence, and he speaks excitedly on the subject before apologizing for digressing.
It was at an International AIDS conference in South Africa that he saw a presentation about prison conditions in the Dominican Republic.
During the past six years, May has hooked up with nongovernmental organizations in Tanzania, Jamaica, Haiti and the Dominican Republic, and through that help learns to navigate the gaps and roadblocks of those countries' developing and inconsistent bureaucracies.
In the Dominican Republic, he found Martha Butler de Lister, a former head of the national AIDS program. Now she runs Fundacion Genesis, an organization that links nonprofit groups with resources. A doctor and public health specialist, she treated some of the earliest AIDS patients, before the disease had a name. In 1985 her 25-year-old cousin in New York died of AIDS. Her commitment to fighting the epidemic grew as she saw numbers projecting that the disease would overtake her country's resources.
Now the Dominican Republic faces the quarter-century mark of the HIV epidemic with at least 66,000 of the nation's 8.7 million people known to be infected and estimates that as many as 95,700 carry the virus. At the same time, resources to treat the virus and prevent its spread are reminiscent of early 1980s in the U.S.
The drug cocktails that have saved the lives of American HIV patients for a decade have been available only to the most privileged patients in the Dominican Republic until the past several years. Many patients continue to do without the medicine, making them all the more likely to transmit the disease.
"Many people continue to die," Butler de Lister said. No one really knows how many have truly died of AIDS "because of stigma."
"Most people die of anything else but AIDS. However, some studies in Santo Domingo have signaled AIDS as the lead cause of death of women in reproductive age."
When a friend introduced her to May six years ago, she said, "this guy was worried about prisons and I had no interest in prisons. I was interested in developing the response to AIDS in this country. But I decided to be supportive of this American who wanted to go to jail. The first time we went to La Victoria I will never forget."
It was 2000. They visited the prison and saw a man dying of AIDS, locked in a ward with contagious tuberculosis patients.
"The funny part, they thought they were doing the right thing," Butler de Lister said.
They saw a clinic without sterilizing equipment and tuberculosis-infected prisoners sharing suffocatingly close quarters with healthy prisoners. Inmates cared for each other, even stitching wounds closed.
"It was a system organized by anomalies, marked by corruption and inhumanity," she said. With horrific conditions prevailing throughout the prison, it was hard to know where to start.
"But the interesting part of John's approach was that it was simple, not expensive," she said.
It included a list of 10 questions for incoming inmates, she said. "You could find out if a person had a communicable disease or a chronic illness," she said. Before May's arrival, the prison's approach to learning that information, Butler de Lister said, consisted of "zap, zero, nothing."
Since that visit, May has brought sterilizing equipment and an X-ray machine to the prison. Prison officials say they use the health screening questions he gave them. A doctor's apartment was set up so that a physician could remain on site, and tuberculosis patients in the most contagious stage of the disease are now separated from other patients.
"What I learned about the way John works is that it's gentle," Butler de Lister said. "Usually when you come from a developed country, you're like, 'I know what I'm doing and this is how it works.' John doesn't do that. But slowly and surely he made them change their attitudes."
Staff seeks help (don't interfere)
On this visit, Butler de Lister and her sister, Grace Butler Mejia, who helps run Fundacion Genesis, joined May. May also brought another physician from Armor, Dr. Ana Viamonte Ros, and a copy of the American Correctional Association's standards for prison operation, including health care, printed in Spanish.
Before he headed for La Victoria, he had an appointment to give the book to the prisons director general at a government headquarters building in the city, where the power was out and a generator supplied electricity for lights but not air conditioning.
The director general, Juan Ramon de la Cruz Martinez, welcomed May and his group into a sweltering conference room and thanked him for his help. He said his staff could use whatever training and supplies May could provide as long as they didn't interfere with existing programs. The government's own efforts to improve prison life and health care were coming along, Martinez said.
"I am saying that," he conceded, "in a building without power."
Although others in the meeting agreed that the government is improving its penal facilities, beginning with smaller ones, the ward for the most contagious tuberculosis patients at La Victoria is about as good as life gets at this prison, about 11 miles away from the downtown headquarters.
A 10-by-20-foot cell with two tiers of concrete slabs serving as beds for about 20 men, it is starkly bare of any comfort or clue that it is a ward for people convalescing from a ravaging illness.
But May's biggest concern was that prisoners were being placed in the highly contagious ward without first being tested to confirm that they had tuberculosis and were unlikely to object to being left there.
"Because," he said, "it's nicer here than anywhere else."
The prison has an HIV doctor now who comes twice a week. He said he had five HIV patients, but they were all released.
Now, he says matter-of-factly, he has no HIV patients.
"Ask him how often he tests," May said.
All the time, the doctor replied.
But the first patient in line for a rapid HIV test probably had the virus, May said.
A gaunt man, he stared listlessly at the floor. He was 34, had been in prison for five years and signed his name on a consent form with three small x's. Due to be released in November, he had been hiding for three weeks and turned up weak, wasted and feverish the day before.
He hadn't been tested for HIV or TB but had been sent to the ward for contagious patients. "He might not have TB, but I'm certain he has HIV. He should not be with TB folks. If he didn't have tuberculosis before, he has it now," May said.
The test strip, which can take 20 minutes to show results, began to show the man was HIV positive moments after a drop of his blood touched it.
Gazing sadly at his feet, the prisoner shuffled into another room, where two patients lay on gurneys and a guard behind a desk napped with his head cradled in his arms, a hypodermic syringe on the desk inches from his elbow.
Back in the testing room, some of the patients lined up for a test had consent forms they had signed three months earlier.
Tests weren't available then, a staff member explained.
"And yet," May noted, "we were just told that they test all the time."
May asked for a tour after the inmates left to stand in line for lunch.
In a padlocked infirmary in a separate building around the corner from the clinic, about 30 men lay on concrete slabs, their bodies wasted, their eyes staring from hollowed sockets.
Block letters painted on the wall proclaimed La Hygiene es Salud (Hygiene is Health).
Some of them had HIV, the staff member leading the group told May.
"See the disconnect?" May said. "They told us no one had HIV."
A standard for careK
Only the first from the morning's 14 inmates tested was positive. Prisoners smiled, laughed with relief, raised their arms in victory, as they learned their tests were negative.
"Ask him if he's having sex here in the prison, and ask him if he's using protection," May said to a translator.
Si, and no, the man answered.
"Tell him that he's fortunate this time, but maybe not next time," May said.
The day after May's visit, the Dominican Republic's Presidential Council for AIDS announced it planned to screen the 4,000 inmates in La Victoria for HIV. The testing would be carried out in a recently installed lab on the premises.
"Which we did not see because the door was locked, and no one had the key," Butler de Lister said.
The council also said that everyone who needed medication would get it.
The patient who tested positive the day of May's visit could not get treatment, though, until a doctor wrote a letter to prison headquarters, which in turn would have to mail a letter back, giving permission.
The request can't be sent through e-mail, Butler Mejia said, "because no one knows how to use a computer, and the power is out most of the time."
His treatment in limbo, the prisoner had been returned to the tuberculosis ward.
"There have been improvements, but they don't always work perfectly," May said.
He returned to the United States with a vial of the man's blood, which, tested in a lab here, showed he had advanced AIDS.
"The strategy now is to focus on a few patients, like this one, and demonstrate appropriate care and service for the other patients," he said. "The ethical need to do something for this man will serve as an example of what needs to be done."
He will return to La Victoria in a couple of weeks to treat the prisoner.
"I really want to demonstrate that we can be successful and really push them to succeed," he said.
In the United States, this prisoner could survive, May said.
But at La Victoria?
"I'll do my damnedest."