Conspiracy of silence fueling Florida TB?
Infection rates among Haitians frightening’
To an extent far greater than previously supposed, HIV infection is fueling TB rates in Florida’s Haitian community, says a Florida TB expert who has completed a retrospective analysis of Haitian TB patients living in the state.
Even more strikingly, one interpretation of the data suggests that many of the HIV infections have been acquired here in the United States following immigration, not in Haiti, as is usually assumed. Whether or not that interpretation proves true, the study findings portray a foreign-born community that is extraordinarily marginalized, with poor access to health care services, says Michael Lauzardo, MD, the senior physician with the Florida TB Control and Refugee Health program who undertook the study.
By looking back at the records of Haitians in Florida who presented for care at a TB clinic, Lauzardo found HIV seropositivity rates among those here for less than a year were about 25%; among those here for one to two years, 36%; and for those here six to ten years, 70%. Among certain high-risk groups — e.g., males ages 25 to 44 — HIV infection rates were a breathtaking 76%, regardless of their length of stay here.
"These numbers are terrifying. They’re some of the highest rates of co-infection rates of TB and HIV in the world, including sub-Saharan Africa," he says. "But despite the bad news, the data also show that with [HIV-related] interventions, we can really make a big impact in this community. Hopefully, this study will give us the impetus we need to get in there and do more."
Conventional TB control methods, such as trying to do better contact investigations, may not have nearly as much effect, he adds, because untreated HIV appears to be the spark that’s igniting TB.
What’s pushing the HIV rates so high?
Lauzardo says when he first sat down to look at the data with state TB medical adviser David Ashkin, MD, the two concluded they were just seeing the result of the well-known lag time between HIV infection and first appearance of opportunistic infections, such as TB. By that logic, the Haitians were arriving here already infected with HIV and TB; as time passed, their immune systems weakened, and they became more likely to progress from TB infection to TB disease.
But then Lauzardo says he spotted a paper in which researchers tracked seroconversion rates among HIV-discordant couples in Haiti. Researchers there found it took only five years for the seronegative member of the couple to go from initial HIV infection to AIDS, and just three years following infection with HIV to break down with TB.
Assuming the Haitian population here "maintains its medical integrity" and responds according to the roughly same time line, Lauzardo began to believe the data didn’t add up — at least not without factoring in the possibility that ongoing transmission here was pushing the numbers higher.
"I’m reaching a little bit," he concedes. "But as you move from rural to urban areas in Haiti, HIV rates do typically go up. Why should it be any different in Miami or Fort Lauderdale?"
What compounded the impact of urban crowding is the extreme isolation of the Haitian community in Florida, Lauzardo says. "They tend to be very, very marginalized, much more so than any other group from Latin America," he says. "They just don’t tie into resources the way other groups do."
Because many Haitians in the United States are here illegally, part of that isolation may stem from fear of sanctions should they try to seek health care.
There’s another problem, too, he says: a reluctance among both Haitians and their health care providers to talk about AIDS. "I grew up in South Florida when Haitians began coming over," Lauzardo says. "It was very taboo to equate homosexuality and Haitians. A lot of that was probably justified; but now, I worry that we may have gone overboard, so that now that we’re ignoring a major health threat."
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