Cuba has the lowest percentage of its population, a total of 11,243,000 people, infected with the Human Immunodeficiency Virus (HIV) in the Western Hemisphere. Considering the adverse effects of the U.S.-led embargo against Cuba and the limited means under which the Cuban health system operates, what has brought about this success story in mysterious Cuba?
After Columbus arrived, the native population of Cuba endured decimating epidemics introduced from Europe. Yellow fever, due to a flavivirus, caused epidemics devastating troops in the Spanish-American War. Dengue fever epidemics still occur in Cuba. The National Commission on AIDS was established in Cuba in 1983 before Cuba had identified any Cuban nationals with HIV or AIDS. In 1981, the first case of HIV/AIDS was diagnosed in the U.S. Four years later, Cuba first diagnosed HIV/AIDS in a soldier returning from Mozambique in 1985. Large-scale testing of the Cuban population commenced in 1985. In 1986, Cuba, like many nations, was concerned that HIV may be a highly contagious virus (Ebola or Marburg virus) derived from Africa. Jorge Perez, M.D., an infectious disease expert who had trained at McGill University, was very suspicious, despite international agency assurances, that blood product transmission of HIV was possible. Perez ordered the destruction of all foreign-derived blood products in Cuba in 1983, two years before the first HIV-positive patient was diagnosed in Cuba. This preemptive destruction of foreign-derived blood products strained the Cuban health care system because blood products had to be rapidly replenished solely from the healthy people of Cuba. Fortunately, Perez’s “educated hunch” to destroy foreign-derived blood products allowed Cuba to escape the ravages of HIV transmitted to hemophiliacs and other blood transfusion recipients.
During 1985 and early 1986, a nationwide HIV screening program was initiated at a cost of U.S. $3 million dollars. HIV screening in Cuba was (and still is) required for all expectant females, sexual contacts of HIV patients and people with sexually transmitted diseases. Voluntary HIV screening was also encouraged. In 1985, condoms as a preventive measure for HIV/AIDS were introduced in Cuba, though routine condom use in Cuba has been hindered due to a “machismo” attitude of many Cuban men.
Over 23 million HIV tests have been performed on the Cuban population since 1986. About 75 percent of HIV/AIDS patients in Cuba are male. The prevalence of HIV in Cuban females is increasing. AZT (500 mg twice daily) is given to all HIV-positive expectant females from 14 weeks gestation until delivery by Caesarean section at 38–40 weeks. Vaginal delivery is not allowed; therefore, vertical transmission of HIV from mother to child is nonexistent. Intravenous drug abuse as a mode of transmission of HIV/AIDS in Cuba is virtually unheard of. The main path for HIV transmission in Cuba is sexual … which makes it unique in the HIV/AIDS world.
Due to the chronic recession of the Cuban economy, the U.S. embargo restricting availability of modern clinical laboratory testing and the simultaneous lack of antibiotics and prescription medications, Cuba—as it had done during other epidemics since 1900—instituted classic public health measures against HIV/AIDS in the late 1980s and early 1990s, including a vigilant quarantine of HIV-positive patients. The HIV quarantine facilitated the education of patients and their families about HIV, allowed for directly observed patient treatments and safeguarded the general population of Cuba.
In addition, all HIV-positive inmates at penal institutions were transferred to either the Habana AIDS Sanatorium or the IPK Tropical Medicine Institute. There were—and are—no HIV/AIDS patients in prisons in Cuba. While hospitalized, prisoners are watched by a police officer or security officer; they are not handcuffed to their beds or otherwise restrained.
Meticulous identification of every HIV-positive individual in Cuba allowed the tracking back to the “source” of the patient’s HIV infection, whether from overseas or in Cuba. Cuba has an extensive confidential database of HIV-positive individuals, along with all their intimate contacts who have contracted HIV or remain HIV-negative.
The first HIV/AIDS sanatorium in Cuba was located in rural Habana at Santiago de las Vegas. Because many HIV-positive patients housed at the 24-hectare (59-acre) “Los Cocos” sanatorium were originally domiciled in other geographic areas of Cuba, Perez noticed family members moving to Havana to be close to their HIV-positive kin. This migration of families to Santiago de las Vegas placed strains on this small rural town. Many of the family members were jobless, lacked local housing or food and wanted to enroll their children in local schools. The Los Cocos facility was administered to give HIV-positive patients mobility, friendship among fellow patients, and to produce food for local consumption at the sanatorium. Los Cocos originally had 150 small apartments to house HIV-positive patients and their families. The capacity of the Los Cocos facility was quickly exceeded, so high-level Cuban government officials decided to open sanatoriums throughout Cuba.
Although it was not his decision to authorize the sanatorium system, Perez was enlisted to implement the system for HIV/AIDS in 1986. Between 1986 and 1989, Perez urged the Cuban government to relax the absolute quarantine policy for HIV/AIDS patients in Cuba. He successfully lobbied for the quarantine policy of Cuba to be discontinued in 1994. Long-term residence at HIV/AIDS sanatoriums in Cuba is now voluntary. New housing units are being constructed at Los Cocos.
The goal of the Cuban sanatorium system was to have HIV-positive patients live in the regions of their original residences, close to their families. Sanatoriums were designed to provide proper nutrition, shelter and medication dispensation. There was to be no charge to the patients for their care at the sanatoriums. These sanatoriums further evolved into being patient, local public and international education resources. Many international health care givers have visited the Cuban sanatoriums. Perez personally traveled throughout Cuba and carefully selected the locations for these sanatoriums and annually visits all of them.
In addition to the establishment of the provincial sanatorium system, Perez destigmatized HIV /AIDS in Cuba. Worries about HIV/AIDS being highly contagious and an imminent threat to the public health of the general population of Cuba lessened as Perez demonstrated that the overwhelming majority of HIV-positive individuals in Cuba acted responsibly and were able to return to work, school, live with their families and be treated as outpatients in an ambulatory setting. Today, many HIV-positive patients elect to voluntarily continue to live and work in the sanatoriums to help their country prevent and control HIV nationwide. Sanatoriums also assisted Cuba in determining local sources of HIV who had not been diagnosed, treated or educated about their HIV status and the impact it has on HIV/AIDS spread.
In addition to government programs regarding HIV/AIDS in Cuba, Alberto Montano, a U.S. citizen living in Miami, founded the Cuba AIDS Project in 1995, after discussing his plans with Perez and Father Fernando de la Vega of Monseratte Church in Havana, who had opened his church’s doors to AIDS sufferers. In 1997, Alberto sought my help. I have had a lifetime interest in HIV/AIDS in Cuba and the country itself, and my credentials as a pathologist were useful. Alberto lacked health care credentials and needed a physician in the U.S. to add credibility to his efforts through the Cuba AIDS Project. Alberto remained the director of the Cuba AIDS Project until his death in 1999. Sor Fara, an influential dedicated nun in Habana, also has greatly assisted Cuba’s efforts to control HIV/AIDS.
Cuba now produces sufficient quantities of seven anti-viral medications—AZT, D4T, DDI, DDC, 3TC, nevirapine and indinavir—domestically for use in its patients. Cuba also intends to produce nalfinavir, abacavir, efavirenz and novatec. Since 1986, Cuba has realized the importance of a nationwide supportive infrastructure for HIV patients and their families. Support facilities for proper nutrition, patient education, prevention and caring, partnered with preventive or interventional therapeutics, are the best way to offer hope to people with HIV/AIDS and to control HIV/AIDS prevalence, morbidity and mortality in any country. Cuba has understood and implemented these concepts for many years. Preventive therapeutics includes prevention of opportunistic infections. Interventional therapeutics includes treatment of opportunistic infections (mycobacteria, pneumocystis), malignancies and sexually transmitted diseases (syphilis, herpes, gonorrhea), as well as the HIV infection itself with anti-HIV medications.
Cuban-produced anti-HIV medications already have resulted in a significant decrease in morbidity and mortality among HIV/AIDS patients in Cuba. Cuban authorities anticipated a death rate of 25 percent for people with AIDS, but to date there has been a death rate of only 7 percent.
Behavioral changes (monogamous relationships, abstinence, etc.); increased counseling and voluntary testing for HIV; the delivery of medications, food and nutritional supplements, including vitamins (hunger is a potent driving force for people to enter the sex business fueling HIV spread); condom use; and informational materials to the people of Cuba—all must be increased to assure adequate control of HIV/AIDS in the population and optimal management of any patient’s disease. Educational materials in Spanish regarding HIV /AIDS should be provided extensively to nongovernmental organizations (NGOs), including the HIV/AIDS support group at the Monseratte Church (Galiano at Concordia Streets) in Central Habana. Many members of the Monseratte Church support group are in a desperate situation because the majority of them are gay or bisexual, AfroCuban, HIV positive or have AIDS, unemployed, homeless, marginalized by their families, disenfranchised by the government, and have no Miami–U.S. dollar support connection.
The efforts of Father Fernando de la Vega at Monseratte Church and Sister Sor Fara should not be underestimated as an effective mechanism to restore a sense of hope and community among homeless, hungry, despairing, sick HIV/AIDS patients in Havana. Local community NGOs for HIV /AIDS patients should be established in all major cities in Cuba. (The Cuba AIDS Project is planning to help start these support groups in Santiago de Cuba and Cienfuegos). The Church offers a renewal in faith, love, patience and hope for the future while ameliorating the persecution, suffering and disenfranchisement HIV/AIDS patients and their families often experience in many countries, including Cuba. The people of the U.S., through the Cuba AIDS Project, have an opportunity to present, through their care, donations and support, the “greatness and compassion of the people of the USA” directly to the people of Cuba.
Public campaigns for prevention of HIV need high priority because any funds spent are cost-effective. Preventive and interventional therapeutics must be partnered with overall prevention programs. Treatment offers hope to HIV patients and their families for a future in which HIV will be transformed into a chronic disease (such as diabetes) that can be managed, permitting people to return to school and work, and enjoy a wholesome life.
The enormous increase in tourism to Cuba from many countries, such as Europe, Canada and the U.S., mandates that Cuba maintain and continuously improve its HIV/AIDS program. Currently, it is estimated that 80,000 U.S. citizens travel to Cuba annually. After the U.S. embargo against Cuba is lifted, there may be millions of U.S. citizens visiting Cuba each year. The U.S. does not need to have HIV/AIDS endemic and highly prevalent in its neighboring country of Cuba, with millions of U.S. citizens visiting in the post-embargo era, contracting the virus, and then returning to the U.S. infected with new genetic strains of HIV-1 to be further disseminated within the country.
The Cuba AIDS Project continues its efforts to bring U.S. awareness to the uniqueness of HIV/AIDS in Cuba. U.S. citizens are eligible to travel to Cuba and help in its humanitarian efforts under the Cuba AIDS Project USA Treasury Specific License, as long as all travelers comply with all U.S. laws, rules, regulations and orders regarding Office of Foreign Assets Control-licensed humanitarian travel to Cuba. More information about HIV/AIDS in Cuba and the Cuba AIDS Project can be found at www.cubaaidsproject.com or by contacting Byron L. Barksdale, M.D., at 308-532-4700, CubaAIDS[at]aol[dot]com.