AIDS clinic
dispute in Puerto Rico forces rationing of medicine

The United States has halted payments to a Puerto Rican AIDS program, forcing clinics to ration medicine for hundreds of HIV-positive poor people and other organizations to cut back on food and other services they provide to patients.

Officials in the U.S. island territory blame the FBI for the situation, saying agents conducting a fraud investigation seized documents in a December raid that were needed by clinics in the capital area to get reimbursement for anti-HIV drugs and services they give patients. The law enforcement agency denies the assertion.

Patient advocates blame the San Juan city government and other island agencies, saying the problem is a result of mismanagement in a program that has a history of corruption.

The 21 clinics, which are privately run under the administration of the San Juan city government, say they stopped receiving reimbursement from the United States in late 2006. Rationing and cutbacks began in recent weeks as their budgets started to run low.

''People's lives are in danger,'' said Anselmo Fonseca, codirector of an AIDS advocacy group.

Some clinics have reduced their hours, staff levels, and the amount of medicine they distribute, while others say they will be forced to do the same within days.

''We've maxed out two lines of credit and we've had to start fund-raising,'' said Dr. Jose Vargas Vidot, director of the Community Initiative clinic in the Hato Rey neighborhood. ''We can hold out maybe another 15 days.''

Puerto Rico, which has a population of nearly 4 million, has an AIDS rate nearly double that of the U.S. mainland. Intravenous drug use has helped push the AIDS infection rate in Puerto Rico to 26.4 per 100,000, according to statistics from the Centers for Disease Control.

The island also has a per capita income about half that of the poorest U.S. states, and a majority of Puerto Ricans live below the poverty line set by the American government.

The Caribbean territory receives $58 million annually under the Ryan White CARE Act, a U.S. program that provides money to clinics and organizations that provide food and other services for indigent patients.

Since 2005, invoices in the AIDS program from Puerto Rican health agencies have incurred extra scrutiny in Washington because of past management problems, said Tina Cheatham, a spokeswoman for the U.S. Health Resources and Services Administration.

A scandal broke in the 1990s after 12 administrators of the now-defunct San Juan AIDS Institute were exposed for embezzling $2.2 million in federal funds. Yamil Kouri, the former director, was convicted in 1999. He was released from prison in October after serving half of a 14-year sentence.

In December, FBI agents raided four San Juan city government health offices that manage the AIDS funds as part of a fraud investigation. No arrests have been made and authorities have declined to discuss the investigation.

But Maria del Carmen Munoz, San Juan's director of federal affairs, said agents seized invoices and other documents that the local government needed to process claims for reimbursement to the clinics despite warnings about the potential outcome.

Munoz said health officials had to request new invoices from the clinics and scrutinize their authenticity more thoroughly out of concern over the investigation, a process that takes a lot of time.

''We are hopeful that within this month, all the ... invoices will be paid,'' she said.

FBI spokesman Harry Rodriguez declined to discuss the investigation but said the law enforcement agency ''takes the appropriate measures to ensure the public is not affected in any way.''

So far, about 2,000 patients in the San Juan area face rationing of their medication, receiving only enough to last five to seven days each month, according to Fonseca. Clinics in other parts of the island are receiving the Ryan White funds and operating normally.

Last week, Bill's Kitchen, which offered nutrition counseling for nearly 1,000 HIV patients, canceled the service and laid off six employees. The group has hundreds on a waiting list for food that is now provided only by donors, said director Sandy Torres.

The Caribbean Youth House, a clinic in suburban Corozal, has had to cut back staff dramatically and turn away about 15% of its 700 patients, said its director, the Reverend Samuel Agosto.

''We're in the middle of a terrible crisis where patients are missing their treatment and the disease will gain the upper hand,'' Agosto said. ''When they come back to their treatment they won't be the same.''

Cheatham said problems in distributing funds from the U.S. program are not uncommon, and the agency is offering technical assistance to help the city make payments. But some advocates question whether delays would be tolerated on such a wide scale in the United States.

''One of the most difficult things is getting the mainland to recognize Puerto Rico as being part of the country,'' said Guillermo Chacon, vice president of the New York-based Latino Commission on AIDS. (Michael Melia, AP)