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AIDS epidemic is decimating Warao people

The indicators of the Orinoco Delta surpass the world average. Doctors believe these indigenous people are facing a much more aggressive strain that threatens the survival of an entire population. The authorities, meanwhile, have kept silence about this case. Here is the first installment of this investigative report.

28/11/2015

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Delta Amacuro. - The day Monsignor Felipe González asked the inhabitants of San Francisco de Guayo - an indigenous village located in the Orinoco Delta, at the northeastern corner of Venezuela - to describe what people felt before they died, they all began to name: "diaraya" (fever), "sojo" (diarrhea), "botukataya" (weight loss), "botobotoya" (weakness), "ataearakateobo" (dizziness). None of them mentioned the disease that encompasses all these symptoms. "Gentlemen, you are dying of AIDS", the priest said. In San Francisco de Guayo, as in other nearby communities, many people of the Warao ethnic group do not call HIV-AIDS by name but by the symptoms they experience.

Luis José Rodríguez, a doctor in the area, has had to give similar explanations to those of the priest. Warao natives only notice the sudden presence of the disease when the body begins to decompose. Rodriguez, 26, is doing his rural work practices in Guayo. He accommodates his glasses and continues in front of the computer, reviewing the list of cases of HIV patients, he is very aware of the episode because he recently gave the news to a patient from Jeukubaca, another community of the Antonio Díaz municipality in Delta Amacuro. "She received the news as if it was nothing", he recalls. "I asked her: 'Do you know what HIV-AIDS is?'. And she said: "No, I don't know". Reviewing this patient's history, they found that her former husband had died of HIV.

Pilot test

San Francisco de Guayo was one of the eight communities - the others were Jobure de Guayo, Jobure Island, Jobotoboto, Ibute, Usidu, Guayo, Jeukubaka, Ibuiruina - where at the end of 2011, Dr. Julián Villalba and other researchers of the Venezuelan Institute of Scientific Investigations (IVIC) and the Institute of Biomedicine of Universidad Central de Venezuela elaborated the research study "HIV-1 Epidemic in warao amerindians from Venezuela: spatial phylodynamics and epidemiological patters (2013)", which resulted in 55 indigenous people having the Human Immunodeficiency Virus.

The specialists were alarmed because 9.55% of the inhabitants of eight communities had contracted the virus. The highest prevalence in the world so far corresponds to a remote region: sub-Saharan Africa, with 5% of its population. The world average for 2013 - the latest figures available from the World Health Organization - was 0.8% in adults between 15 and 49 years, slightly higher than the Venezuelan population in the same range for 2005. Regarding the latter figure, some national health authorities state that it is 0.56%.

Genetic analysis of the virus's genome also suggested that the HIV epidemic in the Warao communities would double every 10 months. The prevalence of the virus was more significant in men (15.6%) compared to women (2.6%), all aged between 18 and 30 years. And the most affected community was Usidu (21.6% seropositivity).

The warao that were found positive in the IVIC study were infected with HIV-1 subtype B, which is the most common in Venezuela; and there was only one case of a woman with HIV-1 subtype C. This had already been reported in another study entitled "Evidence of at Least Two Introductions of HIV-1 in the Amerindian Warao Population from Venezuela (2012)".

This work was presented at meetings with the vice-ministers of health Miriam Morales and Claudia Morón, in 2012 and 2014, respectively. Of these health authorities, only Claudia Morón continues as vice-minister of Collective Health Networks. At that time, the officials assured that they would act, that a part of the institution already knew about the problem, and that they should plan a field research. In 2015 some specialists of these studies and anthropologists were commissioned to carry out another HIV study in Warao populations: Determinantes sociales (Fundacredesa), which hasn’t been yet published. They also met with representatives of the Ombudsman’s Office to discuss the situation. It is only known that after this they traveled to Tucupita, met with authorities and held seminars with community leaders.

Since then, however, nothing has changed. As the waters of the Orinoco River continue to flow, there are new stories of indigenous Warao people living with HIV. Over time, doctors have warned that new carriers of the virus carry in their blood a more aggressive variant that is killing them in five years or less. No entity is ensuring that everyone has access to treatment: "I have lived seven years here, I have heard that they have HIV and I have not seen them receive treatment. Four or five die every year", said Luis Tocoyo, a teacher at a school in Jobure, another community with a high prevalence in HIV cases.

A more aggressive strain

A person with HIV can be infected for eight to ten years without any symptoms and yet transmitting the virus. Someone infected with the most common strain in Venezuela, HIV-1 subtype B, could live that long without treatment, but the Warao are experiencing symptoms of AIDS in less than five years.

Flor Pujol, biologist at the Laboratory of Molecular Virology of the Venezuelan Institute of Scientific Research (IVIC) and one of the researchers of the study "The evolving HIV-1 epidemic in Warao Amerindians is dominated by an extremely high frequency of CXCR4-utilizing strains (2015)", explains that in the samples of the warao, Dr. Héctor Rangel, from the same laboratory, analyzed the covering of the genome, which is the part where the virus binds with its receptor to the co-receptors, and the result was that 90% of the samples were X4, a more virulent strain of the virus. Those affected with this strain manifest symptoms more quickly. In the Warao this transition to the deadliest virus occurs faster. This can occur when the person has been infected by more than one strain of the virus. Cases like this have been detected in Cuba and the research was published in EbioMedicine under the title of "CRF19_cpx is an Evolutionary fit HIV-1 Variant Strongly Associated With Rapid Progression to AIDS in Cuba". The Warao, in addition to having a more aggressive variant of the virus, have high prevalence of tuberculosis, hepatitis B, among other diseases that further gloom the situation.

In the studies mentioned above, it is highlighted that one of the subgroups of HIV found in the patients of the Orinoco Delta is made up of people from the communities of San Francisco de Guayo and Usidu, and the other subgroup by inhabitants of Jeukubana and the Jobure Island. Based on this information, migratory movements and transmission routes were determined through the phylogenetic history of the virus: A route called GU probably began in San Francisco de Guayo in 2005, from there the virus spread to Jobure Island, Jobure de Guayo and Usidu. Then from Usidu it passed towards Jobure de Guayo, Jobotoboto and Kuberuna. And another route, called JE, perhaps started in Jeukubaka also in 2005, from where it spread to Cambalache (Bolívar State), Jobure Island, Nabasanuka and Usidu. Finally, from Nabasanuka there was a transfer towards Caño Yeri. Apparently, the connection between both transmission routes is minimal.

Phylodynamic analyzes suggest that the virus was introduced into Warao populations in early 2000. After going through its initial phase of slow growth, it reached San Francisco de Guayo and Jeukubaka around 2005. It has been ten years since it began its exponential growth phase of expansion.

In 2007, the Venezuelan Red Cross had identified 15 cases of HIV in the communities of San Francisco de Guayo, Murako, Jobure, Jobure Island, Murako, Ajimurina, Merejina, Kuamujo, La Mora and Guayaboroina. At that time Dr. Oriana Contreras worked first as a rural doctor in the Guayo hospital and then supporting a project of the International Red Cross, which deepened the search for serious diseases. Thus, she found AIDS, but also some cases of syphilis. The authorities of the Delta Amacuro Regional Health Directorate then began to discredit her as a professional until the very day of her departure.

At the end of the project, Contreras was vetoed by the regional health director for that time, Luis Beltrán Gómez. He told her that she could exercise no further, that she should not have reported the case. "How was I going to face the authorities of the Ministry of Health in Caracas?", Contreras recalls eight years after that scene.

According to Pujol, the virus entered the community almost fifteen years ago and has evolved very quickly. The scenario, as she well knows, is devastating: the magnitude of the epidemic, the speed with which it is being transmitted and especially the aggressiveness of the strain.

The community in front of Jeukubaca disappeared two years ago. Many of its inhabitants died of AIDS, as confirmed by a list with the statistics of deaths kept by the Guayo hospital. Most of the deceased were men and the remaining women left the place.

One of the inhabitants of Jeukubaka reported through TaneTanae, a local media outlet, that half of the parishioners in his community have died with clear symptoms of AIDS: "Narciso, an aunt of mine, her son Jesus, her daughter-in-law Amelia and now another son, Rafael, all died... Avilio, a grandson, Jaime, his father, and cousins ??Juan Méndez, Julio and Elio, they also died; the latter was the head of the community".

Fr. Ernesto "Kiko" Romero, recently appointed vicar of Tucupita, said that he once spent 40 days in a community and there were 12 deaths among young people with HIV. "The Ministry of Health is prohibited from saying that there are cases of HIV and indigenous people do not call HIV by name, but they call it tuberculosis, diarrhea. I repeat it in all the homilies", says the priest.

Undoubtedly, what is happening in the indigenous communities of the Orinoco Delta is an HIV epidemic. There, all the elements encompassing the term are absolutely fulfilled: disease spread over a certain period, in a specific geographical area, which simultaneously affects many people and exceeds the expected number of people. The prevalence of the virus for these communities is far higher than national and even international standards.

From Cambalache to Guayo

Most of those infected arrive at the hospital already in the last stage of AIDS, where one of the symptoms is a non-stop diarrhea. "When they arrive with a chronic diarrheal syndrome that is more than a month old, one asks, are you married? 'Yes'. Concubine? 'Yes'. What is your husband's name? Does he live with you? Many, many times the husband is in Bolívar, he is in Cambalache", explains Dr. Rodríguez.

Cambalache is a landfill located in the state of Bolívar, about 260 kilometers from San Francisco de Guayo, where many of the Warao who go to this place return with HIV. This is the case of a young woman who was hospitalized. Now she has a six-month-old son, also infected, and her husband stayed in Bolívar: "He comes, finds another woman and infects her", explains the religious sister Ilvia Rosa, who belongs to the Tertiary Capuchin congregation, present in Guayo from 1951.

Prostitution and drug trafficking are commonplace in this garbage dump. In fact, it was reported in the same study, HIV-1 Epidemic in warao Amerindians from Venezuela: spatial phylodynamics and epidemiological patterns (2013), that 53% of HIV-positive individuals in Delta Amacuro had visited this community. There is speculation that these trips to Cambalache are the cause of the widespread propagation of the virus among the Warao population. Another place where they acquire the virus is the city of San Felix, also in the state of Bolívar.

The anthropologist Luis Felipe Gottopo explains that the transmission and spread of the virus may be related to the exodus to Tucupita, Ciudad Guayana and Barrancas from a part of the Warao population after the cholera epidemic that broke out between 1992 and 1993. At that time at least 500 warao lost their lives.

Another hypothesis points to ships that transport goods related to the mining industry and whose routes cross or approach the Orinoco Delta. "Do you see those boats?", asks Jacobus de Waard, a Dutch biotechnologist who currently runs the Tuberculosis Laboratory at the Institute of Biomedicine of the Universidad Central de Venezuela, while one passes in front of him. "They bring tuberculosis, HIV, hepatitis and a week without sexual activity. They enter without any sanitary control".

Many of the sailors come from the Philippines, an Asian country, and go through these locations in search of sex. It seems likely that warao people imported the virus from one of these places and that when they returned to the Orinoco Delta, proliferation began.

"Ten years ago, Guyana was the country with more HIV cases in Latin America, now they have more control, but we don't know what's going on at the border", notes Jacobus. Pujol also reaffirms that they do not know what strain of the virus is circulating in Guyana.

A non-stopping epidemic

Samples were taken for a new study in July 2015. After analyzing the HIV tests applied to 666 Warao individuals, aged 15 to 50, from the 15 communities located in the radius of the San Francisco de Guayo hospital (Guayo, Usidu, Ibute, Jobotoboto, Jobure Island, Jobure de Guayo, Guayaboroina, Teikuburojo, Jeukubaka, Ibuiruina, Murako, Kuamujo, La Mora, Merejina and Jabana de Merejina) belonging to Padre Barral parish, the doctors found a prevalence of 7% (48 cases), which continues to be higher than the estimated in Venezuela and in the rest of the world.

The doctors also concluded that the communities with the highest prevalence of HIV infection are Jobure de Guayo, Usidu and San Francisco de Guayo; that men are more prone to infection than women and that the highest prevalence of HIV is found in the 15 - 24 age group. Mortality of HIV infection in the last 8 years is high and the prevalence of HIV infection in the studied communities has persisted over the last 3 years.

At the same time, the group that worked in the 11 communities located within the radius of the Nabasanuka hospital (Arawabisi, Bamutanoko, Bonoina, Burojosanuka, España, Kuarejoro, Kuberuna, Manakal, Nabasanuka, Siawani, Winikina) in the Manuel Renaud parish, carried out the tests of HIV to 361 waraos from which 6 were positive (4 men and 2 women) for a prevalence of 1.69%. The figure is significant considering that these are more remote communities that had apparently been without any cases until 2012. It is also the first time that HIV cases associated with TB (tuberculosis) have been detected in Manuel Renaud parish, which means that people have both diseases, since having HIV makes them more susceptible to acquire other illnesses.

HIV weakens the immune system. According to the World Health Organization, "infected patients are up to 50 times more likely to suffer from tuberculosis in their lifetime". Not surprisingly, most TB cases in HIV-infected people are registered again in sub-Saharan Africa, where 80% of TB patients are also likely to be infected with HIV.

After analyzing the results, the doctors determined: the highest HIV prevalence is found in the age group between 22 and 50, most people with HIV (5) had made trips outside their community and 4 reported having had contact with multiple partners. As for the sexual tendency, 3 they said they were heterosexual, 1 homosexual and 2 bisexuals. None had tuberculosis.

The communities with the highest HIV incidence were Nabasanuka (3 cases representing 5% prevalence), Burojosanuka (2 cases representing 6.6% prevalence) and Bamutanoko (1 case representing 5.26%). They are strong evidence that what is happening in the Orinoco Delta is an epidemic, and it's putting the survival of an entire indigenous people at risk.

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Many of the sailors come from the Philippines, an Asian country, and pass through these locations in search of sex. It seems likely that warao people imported the virus from one of these places and that when they returned to the Orinoco Delta, proliferation began.

"Ten years ago, Guyana was the country with more HIV cases in Latin America, now they have more control, but we don't know what's going on at the border", notes Jacobus. Pujol also reaffirms that they do not know what strain of the virus is circulating in Guyana.

A non-stopping epidemic

Samples were taken for a new study in July 2015. After analyzing the HIV tests applied to 666 Warao individuals, aged 15 to 50, from the 15 communities located in the radius of the San Francisco de Guayo hospital (Guayo, Usidu, Ibute, Jobotoboto, Jobure Island, Jobure de Guayo, Guayaboroina, Teikuburojo, Jeukubaka, Ibuiruina, Murako, Kuamujo, La Mora, Merejina and Jabana de Merejina) belonging to Padre Barral parish, the doctors found a prevalence of 7% (48 cases), which continues to be higher than the estimated in Venezuela and in the rest of the world.

The doctors also concluded that the communities with the highest prevalence of HIV infection are Jobure de Guayo, Usidu and San Francisco de Guayo; that men are more prone to infection than women and that the highest prevalence of HIV is found in the 15 - 24 age group. Mortality of HIV infection in the last 8 years is high and the prevalence of HIV infection in the studied communities has persisted over the last 3 years.

At the same time, the group that worked in the 11 communities located within the radius of the Nabasanuka hospital (Arawabisi, Bamutanoko, Bonoina, Burojosanuka, España, Kuarejoro, Kuberuna, Manakal, Nabasanuka, Siawani, Winikina) in the Manuel Renaud parish, carried out the tests of HIV to 361 waraos from which 6 were positive (4 men and 2 women) for a prevalence of 1.69%. The figure is significant considering that these are more remote communities that had apparently been without any cases until 2012. It is also the first time that HIV cases associated with TB (tuberculosis) have been detected in Manuel Renaud parish, which means that people have both diseases, since having HIV makes them more susceptible to acquire other illnesses.

HIV weakens the immune system. According to the World Health Organization, "infected patients are up to 50 times more likely to suffer from tuberculosis in their lifetime". Not surprisingly, most TB cases in HIV-infected people are registered again in sub-Saharan Africa, where 80% of TB patients are also likely to be infected with HIV.

After analyzing the results, the doctors determined: the highest HIV prevalence is found in the age group between 22 and 50, most people with HIV (5) had made trips outside their community and 4 reported having had contact with multiple partners. As for the sexual tendency, 3 they said they were heterosexual, 1 homosexual and 2 bisexuals. None had tuberculosis.

The communities with the highest HIV incidence were Nabasanuka (3 cases representing 5% prevalence), Burojosanuka (2 cases representing 6.6% prevalence) and Bamutanoko (1 case representing 5.26%). They are strong evidence that what is happening in the Orinoco Delta is an epidemic, and it's putting the survival of an entire indigenous people at risk.

(*) This report is the first of four installments conducted during the Diploma of Investigative Journalism, which is offered by the Institute of Press and Society (IPYS) in alliance with the Universidad Católica Andrés Bello (UCAB).



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