Trends and Disruptions in Antiretroviral Treatment Enrollment in Haiti, 2018-2024

Haiti's unprecedented sociopolitical upheavals have severely impacted health care services. Limited research exists on HIV clinic operations under such strain. We examined the potential interruptions to antiretroviral treatment (ART) provision through discrete time periods using Haiti's national HIV surveillance system. We analyzed weekly count data from HIV clinics (January 2018-December 2024). Time segments were bounded by the COVID-19 emergency period (April 2020-September 2020), hospital strikes (November 2020), the presidential assassination (July 2021), protests over increases in fuel prices (September 2022), and intensifying gang violence (March 2024). We accounted for autocorrelation in weekly time series and measured immediate, level, and trend changes in new ART enrollment. We triangulated this series with Google's weekly cell phone mobility reports to cross-validate our event selection. In Haiti, ART enrollment declined 25% from 13,304 (CY2018) to 11,773 (CY2024) people per year (mean = 222 people/week in 2024). Only the fuel protests had an immediate impact on ART enrollment (β = -111.1 [95% CI: -179.3, -42.9]) and this was isolated to the largest clinical electronic medical record. Mean weekly ART enrollment in most periods was lower. Trend visualization suggests that historical patterns of disruption followed by numerical rebound may have changed after the gang violence in 2024. ART enrollment declined substantially in Haiti from 2018 to 2024. Future work should discern whether the epidemiology of HIV transmission is changing after accounting for these health systems disruptions.