The President’s Emergency Plan for AIDS Relief (PEPFAR), launched by the George W. Bush administration in 2003, is one of the most successful U.S. foreign aid programs in history. Over the last two decades, PEPFAR has shown how even the most marginalized groups can be cared for and saved from death. On the small island of Hispaniola, which hosts two economically disparate countries — Haiti and the Dominican Republic — PEPFAR has shown how emphasizing cross-border collaboration and partnership with civil society can solve the issue of migrant access to critical healthcare.
As a result of the economic disparity between Haiti and the Dominican Republic, many Haitians have been moving to the Dominican Republic for generations, seeking greater opportunity and stability. Although many Haitians have lived in the Dominican Republic for decades, they suffer from constant discrimination and violence, or “antihaitianismo.”
Haitians of all immigration statuses living in the Dominican Republic report being denied access to public services, including education and healthcare. This rejection and neglect of the Haitian community in the Dominican Republic had harmful effects on the health and well-being of Haitians and Dominicans.
Between 1996 and 2015, the Dominican Republic managed to reduce the HIV rate in its general population from 10,000 infections yearly to 3,500 infections. But then, after years of rapid decline, new infections began increasing. The rising infections led PEPFAR officials to conclude they needed to ensure access to treatment for everyone residing in the country, not just Dominicans.
As recently as 2018, people of Haitian descent living in the Dominican Republic (regardless of their status or the length of time they’d been in the country) suffered an HIV infection rate of 3 percent to 5 percent higher than any other segment of the population. That’s because, until 2019, the nation had virtually no HIV-prevention programs targeting Haitians. Antiretrovirals, the lifesaving drugs that combat AIDS, were mostly available in urban areas and to Dominican citizens only.
Meanwhile, HIV prevalence across the border in Haiti was almost double the rate in the Dominican Republic.
To control the spread of HIV on Hispaniola, PEPFAR officials realized that they needed both countries to collaborate. In 2018, PEPFAR officially designated Haiti and the Dominican Republic a country pair and created a cross-border task force to ensure that the two governments used of their respective health services, shared best practices, and worked together to control the epidemic.
Haiti focused on testing and treatment and educating those crossing the border on how best to prevent transmission and to handle infection if it occurred. The Dominican Republic began working to improve care for migrants and Dominicans of Haitian descent. By 2020, Haiti had made great strides: 84 percent of its population knew their status, up from 67 percent in 2018, while 86 percent of those infected were in treatment, up from 58 percent in 2018.
PEPFAR also understood the necessity of establishing trusted civil society apparatuses to support the healthcare challenge on Hispaniola. Organizations such as churches and grassroots nonprofits tend to be closer to, and often comprise, members of the societies they serve, so trust is much easier to establish. They also tend to have more frequent interactions with marginalized people, making them a better avenue for access and information sharing.
In 2018, PEPFAR started creating community care teams — groups of volunteers with long-standing relationships with the population. These teams began with two great advantages: They were trusted by the public and able to speak Creole. Their work included connecting migrants with PEPFAR care facilities; providing digestible and relatable information about HIV testing, treatment and care; and helping build trust between beneficiaries and service providers.
These groups could also collect detailed data and information about those they aimed to help, allowing them to identify gaps in service. By developing good metrics to track progress, they also helped improve accountability. Localization also led to better strategies for testing locals.
In 2019, only 42 percent of HIV-positive individuals among the migrant and Dominican Haitian population knew their status. Thanks to innovations such as partner and social-network testing, by 2021, that figure had increased to 93 percent.
As the global migrant population grows, the international community should use the lessons learned from PEPFAR’s engagement in Haiti and the Dominican Republic to ensure that marginalized populations have equitable access to care, that policies are coordinated, and that communities are engaged directly — and their concerns are heeded.