Clinical Services

GHESKIO’s initial work defined the etiology of severe diarrhea and dehydration in Haitian infants. GHESKIO introduced oral rehydration therapy, which resulted in a decrease in the hospital infant mortality rate from 40% to <1% within two years. Nationwide expansion of the GHESKIO program resulted in a 50% decrease in infant mortality in Haiti by the mid-1990s. The studies of diarrhea in infants led to similar studies in adults and the recognition of AIDS in Haiti.

GHESKIO published the first comprehensive description of AIDS in a tropical resource-poor setting in 1983 in the New England Journal of Medicine. The story of HIV/AIDS in Haiti has since been inseparable from that of GHESKIO. GHESKIO has been the major source of information on the evolving AIDS epidemic in Haiti and a partner with the government and other organizations in combating the epidemic for over 30 years. GHESKIO researchers identified contaminated blood transfusions as a major mode of HIV transmission in 1985, and then worked with the Haitian Government to place the Haitian Red Cross in total control of blood banking. In the 1990s, GHESKIO conducted clinical trials to define effective therapeutic and preventive interventions for HIV. In 2005, GHESKIO documented the success of antiretroviral therapy (ART) in a resource-poor setting, and GHESKIO published ART treatment initiation criteria in 2010, which prompted the World Health Organization to change international guidelines.

GHESKIO opened the first HIV Voluntary Counseling and Testing (VCT) Center in Haiti in 1985. The number of people seeking HIV testing at GHESKIO has continued to increase, reaching more than 175,000 in 2017. A GHESKIO–Ministry of Health project successfully reduced the rate of transmission of HIV from pregnant mother to child from 30% to <4% in 2009. As HIV care and prevention services have expanded, HIV prevalence has decreased from 6.2% (1993) to 2.2% (2012), and is currently estimated to be even lower.

GHESKIO works with the Haitian Government to implement its prevention and care model to a network of more than 27 hospitals and healthcare centers throughout the country. GHESKIO provides training, supervision, administrative support, financial oversight, and continuing quality control for all HIV and TB clinical services provided at these sites.

Haiti has reached near-universal ART coverage, with 95,447 patients receiving ART (February 2017); 29% of whom are being treated in the GHESKIO Network.

Tuberculosis is a major cause of morbidity and mortality worldwide. According to the World Health Organization, only 6.3 million new cases of TB were reported in 2016 compared with the estimated incidence of 10.4 million. In the region, Haiti has the highest TB incidence and prevalence (194 per 100,000 population and 254 per 100,000, respectively).

GHESKIO has been providing TB testing and treatment since its inception.

After the earthquake in 2010, about 1.5 million people lost their homes and were moved to camps for internally displaced persons. An estimated 3,000 TB patients stopped receiving medication and dispersed to crowded refugee camps. It was subsequently found that TB incidence in Port-au-Prince doubled, with an outbreak of multidrug-resistant TB (MDR-TB). This is likely a result of higher case detection as well as an increased burden of disease.

In response, GHESKIO opened a 100-bed TB tent field hospital in May 2010 and increased TB treatment capacity from 600 to 1,800 patients per year. In 2012, GHESKIO documented a rate of 768 TB cases per 100,000 individuals in the neighboring ‘City of God’.

Currently, GHESKIO is the largest TB center in Haiti and diagnoses approximately 3,000 patients per year, and treats up to 50 MDR-TB patients.

Although the most common form of TB can be treated in six months, MDR-TB requires a significantly longer and more intense treatment, lasting up to 18 months to two years. GHESKIO runs one of only three MDR-TB hospitals in the country, which houses up to 33 patients in an open, sunlit space that provides a home for patients receiving treatment.

In addition to testing and treatment, GHESKIO has carried out extensive research on TB over the past three decades, of which the findings have been published in prominent medical journals.

Cardiovascular disease (CVD) is now the leading cause of mortality in Haitian adults. Cardiovascular diseases, including myocardial infarction, heart failure, stroke, and cardiac death, are the leading cause of adult mortality in Haiti, but little is known about disease onset, time course, and risk factors such as hypertension and harmful diet.

Preliminary data suggest that hypertension is the single most important CVD risk factor in Haiti and may be driven by poverty-related social and environmental determinants. However, the prevalence, incidence, major risk factors, and social and environmental determinants are unknown. Longitudinal cohort studies are urgently needed to address these knowledge gaps to develop interventions to prevent CVD and improve health outcomes of Haitians in both Haiti and in the U.S.

GHESKIO is currently working on research to fill this gap by establishing a longitudinal cohort to study the natural history of CVD in Haiti. The cohort will include 3,000 adults >18 years of age in Port-au-Prince using multistage random sampling, and will follow them for 2–3.5 years, depending on the timing of study enrollment.

We anticipate that hypertension prevalence will be ≥10% in 18–30 year olds, that hypertension incidence will be >10 events per 1,000 person years, and that both prevalent and incident hypertension will be associated with poverty-related social and environmental determinants. We will also examine the association of determinants and risk factors with CVD.

Specific aims of the study:

Establish a population-based cohort of 3,000 adults in Port-au-Prince and assess the prevalence of CVD risk factors and diseases and their association with social and environmental determinants.

Cardiovascular risk factors include hypertension, diabetes, obesity, dyslipidemia, kidney disease, poor diet, cigarette smoking, physical inactivity, and inflammation.

Cardiovascular diseases include myocardial infarction, heart failure, stroke, and CVD mortality.

Determinants include stress, social isolation, depression, food insecurity, and lead exposure.

Determine the incidence of CVD risk factors and diseases and their association with social and environmental determinants.

This study will provide important insights into the epidemiology of CVD in Haiti. Our ultimate goal is to translate new research findings from this study into pragmatic prevention and treatment interventions to fight the CVD epidemic in Haiti and in Haitian immigrants in the U.S.

GHESKIO focuses on the most vulnerable populations, including women, adolescents, and children, all of whom are particularly vulnerable to HIV disease.

GHESKIO has the largest pediatric AIDS clinic in the Americas and provides multiple services to mothers and their infants. GHESKIO treats HIV-positive children from 0–10 years of age in need of antiretroviral therapy and has served about 1,000 children and infants since 2003. GHESKIO also treats approximately 200 cases of childhood TB (including MDR-TB) annually.

GHESKIO’s Mother’s Program supports the clinical and psychosocial needs of pregnant women and new mothers. ‘Mothers Clubs’ meet monthly so that women can learn skills for safe and appropriate prenatal care, receive education on optimal infant nutrition, and access opportunities to share experiences and build a support network. Life-skills training focused on empowerment and self-confidence builds self-esteem and enables women to improve their health and their lives. Since implementing the Mothers Clubs and providing antiretroviral therapy prophylaxis, the transmission of HIV from mother to child at GHESKIO has decreased from 30% to ~4% and instances of infant malnutrition have been cut by up to 50%, resulting in healthy and thriving children. Since 2010, GHESKIO has served more than 3,600 mother-infant pairs.

In addition to the Mother’s Program, GHESKIO’s conducts community-outreach activities and home visits by community health agents who screen and refer to clinic children under 5 years of age for malnutrition, respiratory illness (such as pneumonia and TB), and diarrheal diseases. Children also receive preventative health services such as vaccination, de-worming, and oral rehydration salts where appropriate in the community.

GHESKIO conducts research and training to answer relevant questions regarding pediatric health. Research seeks to improve services and to develop models of care that can be reproduced on a national level. Of particular research focus is pediatric HIV/AIDS, TB diagnostics and treatment in children, causes of pneumonia in children, acute diarrhea, and malnutrition.

GHESKIO is the technical arm of the Ministry of Health in Haiti for primary needs, which include vaccination, de-worming, nutrition, and preventive health services.

The first report of clinical cholera in Haiti occurred on October 19, 2010, only 10 months after the earthquake. Following its emergence in the Artibonite Valley in central Haiti, infections spread to all ten Departments of Haiti within 100 days, and by December 2nd 2017 there were 815,378 suspected cases and 9,742 deaths reported by the Ministry of Health—the largest cholera epidemic in recent history.

GHESKIO immediately established an emergency cholera treatment center in Port-au-Prince. GHESKIO launched a comprehensive cholera program in City of God, including the provision of chlorinated water, building of latrines, and establishing rehydration posts. A 250-bed tent hospital was set up at its facility in downtown Port-au-Prince, admitting patients from many regions of the Metropolitan area. Community health workers were trained as regards to the symptoms of cholera, how to prepare oral rehydration fluids, and when to refer patients to GHESKIO. Since 2014, a 24-hour, permanent, 100-bed acute diarrheal treatment center has been built at GHESKIO and, since June 2017, is the only one that remains open.

The oral cholera vaccine (Shancol) was introduced into City of God by GHESKIO in April 2012, and 91% of 52,000 volunteers had received two doses of the vaccine by July 2012. The demonstration trial was conducted with Partners in Health (PIH), Cornell University, Harvard University, and the Haitian Ministry of Health, and included persons living in rural Haiti. GHESKIO conducted a complete door-to-door census of City of God using hand-held communication devices. Dr. Roger Glass, Director of the NIH Fogarty International Center, stated, “The experience in Haiti by this pioneering group has demonstrated that the many preconceptions and objections raised about the difficulty of delivering mass cholera vaccinations to a population can be overcome and that the vaccine can be delivered effectively to large numbers of people. The Haitian example will provide a model for other countries to emulate in the years ahead.”

Haiti has the highest reported incidence of cervical cancer of any country in the world, with 94 cases per 100,000 population. Cervical cancer is the leading cause of cancer death in Haitian women with an estimated 1,500 deaths annually. This is 50 times higher than the rate in the United States, where cytology based cervical screening with Pap tests has dramatically decreased cervical cancer mortality. Women in Haiti have not benefited from Pap test screening due to lack of health care infrastructure and trained pathologists; there are only four pathologists in this country of 10 million people. As a consequence, most women in Haiti have never been screened for cervical cancer.

The situation in other developing countries is similar. Cervical cancer remains a leading cause of mortality among women of reproductive age in the developing world. An estimated 500,000 new cases of cervical cancer will occur worldwide this year, with 85% of these occurring in resource-poor countries.

Progress in cervical cancer prevention is being made in Haiti and many other developing countries. The introduction of simple and cost effective “screen and treat” strategies and human papillomavirus (HPV) vaccination offer tremendous opportunity.

• Cervical visual inspection with acetic acid (VIA) can detect early dysplastic (precancerous) lesions before the development of invasive cancer. The test can be performed by nurses, and treatment offered the same day with cryotherapy of the cervix. VIA has been successfully introduced into many developing countries with great success.
• Rapid screening tests for cervical HPV infection may be even more effective. Squamous cell cancers of the cervix are causally linked with infection with HPV. Studies show that screening women for cervical HPV infection and treating HPV-positive women with cryotherapy decreases the incidence and mortality from cervical cancer.
• The Global Alliance for Vaccines and Immunizations (GAVI) recently announced efforts to provide the HPV vaccine to 72 of the world’s poorest countries. Trials have shown that administration of this vaccine against high risk HPV, including types 16 and 18, reduced the incidence of both high risk HPV infection and HPV-related cervical intraepithelial neoplasia (CIN). GAVI is working to decrease the price of the vaccine and to develop programs for its administration in poor countries.