Cuba Solidarity Homepage
Project USA/Cuba InfoMed
Tim Holtz, MD, MPH
One of the most interesting aspects of the Cuba Study Seminar was the discussion about HIV/AIDS in Cuba with the Ministry of Health, including a delayed but much anticipated trip to a rural sanitarium for HIV+ patients. Since the beginning of the epidemic in the Western Hemisphere, Cuba's approach to the HIV problem has been integrated into its comprehensive, nationalized health care system. Their policies towards HIV have been consistent with its policies towards other diseases and epidemics. In short, Cuba treated the introduction of HIV into the country as a public health emergency, instituting traditional public health control measures to contain the spread of the disease. They have been rewarded with one of the lowest prevalence rates of HIV infection in the world.
Dr. Rigoberto Torres, HIV specialist in the Ministry of Health, provided our group with the latest statistics from his country. As of mid-1997, there are 1,678 known cases of HIV infection (infection rate approx. 0.02%), with 609 persons carrying the diagnosis of AIDS. Only nine cases of infection have resulted from transmission through blood products, and there are only five cases of HIV infection known in children. The estimated ratio of homosexual to heterosexual transmission is 1:1, though independent outside sources estimate that heterosexual transmission is slightly more common (55%). In 1986, Cuba introduced a national screening program using domestically produced kits. So far, over 19.5 million ELISA tests for HIV infection have been performed, and many Cubans now regard getting an HIV test at their family physicians office a part of routine health screening.
The US embargo on Cuba has made caring for HIV+ patients in Cuba extremely difficult. It has jeopardized HIV diagnosis and follow up, HIV treatment, community HIV prevention, and protection of the blood supply. A majority of HIV lab tests and pharmaceuticals are produced by American companies, who are now forbidden to sell to Cuba. After the 1992 US ban on subsidiary trade, parts and equipment, reagents, and medications are now nearly impossible to obtain. For example, the Pharmacia-Upjohn merger eliminated supplies of reagents for bloodwork to follow patients' T cell counts. Viral load testing is unheard of in Cuba due to the trade blockade. Most importantly, vital HIV medications are virtually nonexistent. AZT is available for only a few select cases at inflated prices, and other nucleoside reverse transcriptase inhibitors such as ddI and ddC are unavailable. News of the new protease inhibitor combination therapies is just reaching the island, minus the actual medications. Other necessary drugs to treat AIDS patients, such as fluconazole and ganciclovir, are unavailable. Condoms are also extremely difficult to come by on the island.
The most controversial aspect of the Cuban national HIV/AIDS program is the use of sanitariums for people with HIV. Since the beginning of the policy in 1986, the potential "HIV epidemic" was treated like any other contagious, infectious disease, employing traditional public health measures. It was a health problem/public health problem with human rights dimensions, rather than a social problem/human rights problem with health repercussions. Quarantine was the initial reaction to a public health threat whose scope was unknown, which soon led to semi-isolation for patients known to be infected. The goal was to reduce the risk of transmission through case finding, isolation, medical treatment, education, and contact tracing. In 1989, with the arrival of Jorge Perez as the director of the Institute of Tropical Medicine, curtailment of civil rights was relaxed to allow patients to leave sanitoriums for extended periods without guides. Finally, in 1993, the ambulatory care treatment program was started, which allows patients to chose between living within a sanitarium, or living at home.
In Cuba, access to medical care is the right available to all persons with HIV. Though it is a cruel dilemma, they are able to chose between enjoyment of personal liberty and privacy by living at home, or taking advantage of their social rights to housing, food, income, recreation, a supportive environment and medical care by living in a sanitarium. A poor person in the US has no such choice. Sanitarium residents are provided with high caloric diets (not possible on the outside due to the economic situation), free medications (what is available), a partial salary, and care from a team of physicians, nurses, social workers, and psychologists. Currently approximately 70% of persons with HIV have elected to remain in the sanitariums as their primary residence. Sacrifice to the community is an integral part of post-revolutionary Cuba. Therefore, the sacrifice of personal freedom is perceived to be part of preserving public health and safety.
We were able to visit a sanitarium in Matanzas, several hours away from Havana, to avoid the often visited Santiago de las Vegas sanatorium. Though the front entrance was gated, there were no barbed wire fences to keep the patients in as has been previously reported. We were greeted by Dr. Ismael Torres, the director of the facility, who gave us a tour of the housing bungalows, consultation rooms, procedure room, kitchen and dining hall with AC, TV/video room, library, and recreation room. The compound was clean, bright, and well organized. The cabins were small, but neat. We were told that a major goal of the sanitarium is education for the residents, which was reflected in the well-stocked library. We were told that of 42 people in Matanzas province infected with HIV, 28 have elected to live in the sanitarium. Five persons carry an AIDS diagnosis, and 6 of the 42 are women. The residents with whom we spoke all appreciated the high quality care they received, the adequate living standards, and the plentiful supply of food (most Cubans live with ration cards). We were disappointed to find out that antiretroviral medications were not available to the patients in Matanzas province, yet heartened by the news that only 16 patients had died in 5 years.
As in any epidemic, we were told, the Cuban national AIDS policy is evolving. Public education is now a priority, as the majority of Cubans feel that since the HIV problem was adequately curtailed, they are not at risk. The opposite is true, in fact, for infection rates are slowly rising in the country. HIV infection among the homosexual population constitutes the fastest increase, as well as spread through prostitution. The expanding tourist industry has created new channels of spread of the virus that the Ministry of Health has had to deal with. In some ways, the previous successful control of HIV spread is now the greatest liability to keeping the public safe from infection. Community based education, case finding, and treatment is now being stressed, and the sanitoria are slowly being turned into a national network of ambulatory care centers. To combat the disease effectively, Cuban physicians and public health workers will require the free flow of scientific information and effective medical therapies that they are currently denied.
References:
Bayer R, Healton C. Controlling AIDS in Cuba: The logic of quarantine. NEJM 1989;1022.
Gordon AM. HIV infection in Cuba. JAMA 1987;258:3387.
Granich R, Jacobs B, Mermin J, Pont A. Cuba's national AIDS program: the first decade. Western J Med 1995;163:139-144.
Perez-Stable EJ. Cuba's response to the HIV epidemic. Am J Public Health 1991;81:563-567.
Santana S, Faas L, Wald K. HIV in Cuba: The public health response of a third world country. Int J Health Serv 1991;21:511-537.
Scheper-Hughes, N. AIDS, public health, and human rights in Cuba. Lancet 1993;342:965.
Swanson J, Gill A, Wald K, Swanson K. Comprehensive care and the sanitoria: Cuba's response to HIV/AIDS. J Assoc Nurses AIDS Care 1995;6:33-41.
Terry H, Galban E, Rodriguez R. Prevalence of infection with HIV in Cuba. PAHO Bulletin 1989;23:1-2.
Veeken, H. Cuba: Plenty of care, few condoms, no corruption. BMJ 1995;311:935-7.
Other references mentioning HIV in Cuba:
American Association of World Health. Denial of food and medicine: The impact of the US embargo on health and nutrition in Cuba. Executive Summary, March 1997
Garfield R, Santana S. The impact of the economic crisis and the US embargo on health in Cuba. Am J Public Health 1997;87:15-20.
Kirkpatrick A. Role of the USA in shortage of food and medicine in Cuba. Lancet 1996;348:1489-91.
Kuntz D. The politics of suffering: the impact of the US embargo on the health of the cuban people: report to the APHA of a fact-finding trip to Cuba, June 6-11, 1993. Int J Health Serv 1994;24:161-179.
Susser M. Health as a human right: an epidemiologist's perspective on the public health (Cuba and UK). Am J Public Health 1993;83:418-426.
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