Epidemic

Commentary







Cuba's Response to the HIV

Epidemic

Eliseo J. Perez-Stable, MD



Introduction idential parks, the first of which is located

in Santiago de Las Vegas in rural Havana

Cuba's response to the human immu- Province. The facility, popularly known

nodeficiency virus (HIV) epidemic has as "Finca Los Cocos," contains adequate

been unique. Mass testing for HIV anti- housing, better than average nutrition,

bodies, for the most part compulsory, and sports and exercise facilities, and medical

a mandatory relative quarantine of all per- care. Quarantined persons are paid their

sons testing positive is official policy." 2

salary in full or given a stipend if they had

Educational interventions using the elec-

been unemployed. Five additional quar-

tronic and printed media and school-based

antine facilities in Central and Eastern

programs were widely implemented in

1988 as a secondary component of HIV Cuba are currently in use.

transmission control. Cuba's policy high- Sexual contact with foreigners during

lights a historical and intriguing question international travel or in Cuba was the

in public health practice: How much can principal risk factor in 217 HIV positive

and should personal liberty and freedom persons. According to the Cuban Ministry

be curtailed for the public good? of Public Health (MINSAP) authorities,

As a Cuban American who has re- 122 HIV infections were directly attrib-

ported on health care in Cuba,3-5 I discuss uted to Cuba's military and political in-

the topic of Cuba's response to the HIV volvement in Africa. Of the 315 infected

epidemic based on interviews in October men, 105 are gay or bisexual with an av-

1988 with Dr. Hector Terry M6linert, the erage of nine lifetime sexual partners. By

Vice-Minister of Health for Hygiene, Epi- comparison, heterosexuals of either sex

demiology, and Health Education, who infected with HIV reported an average of

has been in charge of coordinating policies 3.7 lifetime partners.' Anal intercourse

regarding control of the HIV epidemic; with heterosexual men has been reported

interviews with clinicians involved in the as a common practice by 53 percent of the

care of HIV infected persons; and on re- 119 infected women.'

view of official documents. The MINSAP categorically states

that illicit intravenous drug use does not

exist in Cuba and thus is not a risk factor

Cuba 's Strategy for HIV infection. Infected blood prod-

ucts, neonatal transmission, and occupa-

Cuba's strategy for HIV control is tional exposure account for only 11 HIV

based on testing the entire adult popula- positive persons. In 23 (5.3 percent) HIV-

tion and restricting all seropositives to fa- infected individuals, risk factors were un-

cilities located in rural areas. Between known. '

1986 and 1989, 5,117,250 persons had HIV

tests in Cuba, over 75 percent of the pop-

ulation 15 years of age and older. ',6 A total Address reprint requests to Eliseo J. Perez-

of 434 persons, 315 men, and 119 women Stable, MD, Division of General Internal Med-

had been identified as HIV positive for an icine, Department of Medicine, University of

overall seroprevalence of 0.00009 percent California, 400 Parnassus Avenue, Room

A-405, San Francisco, CA 94143-0320. This pa-

(all but one are HIV-1). per, submitted to the Journal January 23, 1990,

Government policy is to quarantine was revised and accepted for publication Jan-

all seropositive persons in controlled res- uary 8, 1991.





American Journal of Public Health 563

P6rez-Stable



A total of 63 cases of acquired immu- ternational standard has been conducted prevention of Pneumocystis carinii pneu-

nodeficiency syndrome (AIDS) was re- in collaboration with the Oswaldo Cruz monia without any associated social

ported by Cuba to the World Health Or- Foundation in Brazil and Sweden's stigma.

ganization (WHO) as of December 1989.7 Health Ministry and, according to MIN- The MINSAP contends that manda-

Pneumonia due toPneumocystis cannii is SAP authorities, Cuba's domestically de- tory lifetime quarantine is the only

the most frequent index diagnosis for veloped tests are comparable. Concerns method of guaranteeing that HIV-in-

AIDS in Cuba, and only two cases of Ka- have been raised regarding both sensitiv- fected persons will behave in a sexually

posi's Sarcoma have been reported. ity and specificity of the Cuban testing responsible way. MINSAP's greatest

procedures.2 Currently, there are 45 lab- fear is that of irresponsible sexual behav-

oratories capable of performing HIV tests ior among men characterized by the ma-

Reliability, Validity of with one acting as the national reference. chismo cultural trait who are likely to

Epidmiologic Data Each positive ELISA assay is confirmed seek extramarital sexual partners. In the

two additional times, and the Western blot view of Dr. Terry Molinert, lifetime quar-

Representatives from the WHO and antine will radically alter the threat of the

the Pan American Health Organization assay is routinely repeated at least once.' HIV epidemic in Cuba by restricting the

(PAHO) have confirmed the reliability of personal liberty of these individuals. He

epidemiologic statistics on other diseases credits Cuba's policy with the prevention

made available by the MINSAP in several Possible Advantages of Cuba's of up to 4,000 new HIV infections, but no

reports.8-10 In a systematic review of HIVPolicy data are available to support this state-

health care services in Cuba, Navarro" ment. If Dr. Terry Molinert is correct,

praised the high priority placed by the Cuban health officials expect to have Cuba's policy may be justified.

MINSAP in establishing a reliable system HIV test results on most of the adult pop-

for gathering morbidity and mortality sta- ulation by the end of 1990, and will thus

tistics covering the entire Cuban popula- have the most complete population-based Possibl Di&advanges of

tion. Although the incomplete and unreli- country-wide serologic study in the world. Cuba's Poly

able nature of much of the reported Identification of seropositive individuals

epidemiologic data from developing coun- before HIV transmission has become Although the goal of compulsory

tries continues to be a problem, Cuba has widespread and may allow for an effective testing may seem justifiable for public

established a system capable of collecting infection control strategy to be imple- health reasons, little can be said in defense

reliable and valid information. Numerous mented.21 As a result of widespread se- of lifelong guarantine. HIV-infected indi-

independent reports about Cuba3,4-5s9,11-17 rotesting, the risk of HIV transmission by viduals have been confined without,any

and the health profile of Cuban immigrants infected blood products has been mini- legal basis or precedent in the Cuban Con-

entering the United States in 198018 sup- mized, and women found to be positive at stitution. If there was a strong public

port this contention. prenatal screening are offered a therapeu- health justification for this restriction of

Gordon19 has questioned the validity tic abortion. Testing of sexual contacts of human rights in a selected group of indi-

of reports of low prevalence of HIV in- HIV-positive individuals has led to the im- viduals guilty of no illegal act, then quar-

fection in Cuba. He based this on the pres- plementation of focused education and antine should be critically evaluated. Un-

ence of unequivocally positive tests for counseling in order to promote changes in fortunately, there is little basis on which to

HIV antibodies in four of 990 (0.4 percent) sexual practices of those found to be neg- justify this drastic measure, and in con-

Cuban immigrants who entered the US ative and prevent the potential for explo- trast, several factors emphasize its defi

during the 1980 Mariel boatlift.20 This es- sive transmission of HIV. ciencies.

timate is not substantially different from Historical precedents for this type of

that reported by Cuba in the initial testing The fact that Cuba reports a low public health measure include the estab-

of persons at highest risk. Considering that prevalence of HIV infection and incidence lishment of colonies for persons with lep-

the 1980 immigrants were predominantly of AIDS implies that there is a window of rosy which may have contributed (along

men of less privileged socioeconomic sta- opportunity to prevent widespread trans- with the ravages of the bubonic plague) to

tus, many of whom had been in prison and mission. Efforts at educating the popula- the virtual elimination of leprosy in Eu-

institutions for the mentally ill, and a sub- tion have been implemented after manda- rope during the Middle Ages.24 Cuba's

stantial number were homosexual or bi- tory testing and quarantine were policy of lifelong quarantine for HIV-in-

sexual, Gordon's estimate of HIV infec- established as policy. However, while ed- fected persons is the first effort in the 20th

tion may represent a selection bias. ucation is essential, other voluntary ef- century at isolating large populations for a

Nevertheless, validation of Cuba's re- forts to stop transmission of HIV,22 such public health reason. More recently, quar-

ports of HIV/AIDS is difficult, given the as contact tracing, have also been empha- antine has been used in individual patients

economic and information blockade that sized. The relativelyyoung age ofthe pop- with a focused goal such as enforcing

hinders scientific exchange. ulation and the marked increase in syphilis treatment of a noncompliant patient in-

Cuban scientists developed a domes- rates during the past decade would indi- fected with tuberculosis or to segregate a

tic version of the enzyme-linked immuno- cate that prevention of ulcerative sexually patient with a highly communicable dis-

sorbent assay (ELISA) and Western blot transmitted diseases should be a priority ease (e.g., typhoid fever).2' Quarantine

tests for detecting HIV antibodies. Col- for the MINSAP. The policy of compul- rarely has been used for patients with a

laboration with US-based scientists was sory testing may be more acceptable if the sexually transmitted disease.

prohibited by the 30-year-old economic goal in identifying HIV-infected individu- Data on the test characteristics of the

embargo imposed by the US Government. als was to be able to offer them secondary ELISA and Western blot tests for detect-

Validation of the Cuban tests with an in- prevention with zidovudine23 or primary ing HIV antibodies in populations with a





564 American Journal of Public Health May 1991, Vol. 81, No. 5

Commentwy



pretest likelihood of infection of at least 1 conceive. The disappearance and tran- The public health strategy of tracing

percent show that the sensitivity and spec- sient reappearance of individuals from sexual contacts of all HIV-positive indi-

ificity approach 100 percent.25 However, their homes will not go unnoticed by the viduals requires the full-time deployment

when the population prevalence is as low officially instituted Committees for the of 450 nurses and 200 epidemiologists by

as it has been observed in Cuba (0.00009 Defense of the Revolution (CDR). Al- the Cuban Ministry of Health.1 During the

percent), the proportion of false positive though originally conceived in 1960 to in- course of our conversation, Dr. Terry Mo-

results are likely to be higher.25 Based on crease surveillance of political activity linert stated in a frustrated and tired voice

the known test characteristics, Bayer and against the Cuban Revolution, the CDRs that 90 percent of his time was now con-

Healton2 estimated that between 21 and 53 have an important role in many aspects of sumed by the HIV program. Although

persons may have been inaccurately des- Cuban life (e.g., immunization and hy- these efforts are admirable and reflect the

ignated HIV positive and, as a conse- giene campaigns, prevention of crime by high priority placed on HIV control, in a

quence, quarantined. This is probably an establishing neighborhood watch, and set- nation with limited resources and with

overestimate of the number of false posi- tling disputes between neighbors).5,13,17 public health problems with greater con-

tive HIV tests because repeated tests are Many of the older supporters of the rev- sequences on morbidity and mortality,

conducted after the person has been con- olution are active participants in the CDR other aspects of health care may suffer.

fined. However, the fact remains that and thrive on the verbal communication of

some persons may be inappropriately unpublished news. Thus, although Dr. Missed Oppoz1unities

quarantined because of an inaccurate test Terry Molinert emphasized the impor-

result. Cuban authorities expressed con- tance of avoiding stigmatizing seroposi- In 1987, Cuba published an annotated

cern regarding false positives and have tive individuals by identifying them in compendium of the English literature on

limited confinement to persons with three public, I doubt that this information will AIDS for distribution to health profession-

positive ELISA tests and an unequivocal remain confidential. als at a nominal cost.27 However, efforts

Western blot. Dr. Thrry M6linert stated that Cuba's to educate the general population were de-

Perhaps as a concession to some in- current HIV policy is under constant re- layed. In manyways, Cuba seems to be an

dividual liberties, Cuba's current policy vision and subject to change as conditions ideal place to test the implementation of a

allows for weekend passes in the company evolve. The fact that an effective vaccine community-wide educational campaign

of a health care technician, medical stu- against or a pharmacologic cure of HIV is on HIV, its cause, methods of transmis-

dents, or spouses. In the words of Dr. unlikely in the near future has led to re- sion and consequences, with the goal of

Terry M6linert, "the technicians do not consideration of the quarantine policy. preventing new transmissions. The popu-

accompany them into the bedroom," and MINSAP authorities tentatively plan to lation is literate, has few concerns about

at least one woman has been documented reintroduce selected HIV-infected indi- the basic necessities of life, and electronic

to seroconvert following weekend visits viduals to their communities after a de- and printed media are widely available at

by her quarantined husband. Thus, Cu- fined period of quarantine. As of this writ- a reasonable cost.

ba's policy is one of relative quarantine ing, a final decision on revision of the The main thrust of the educational

and, although new HIV transmission may quarantine policy has not been made. campaign as ofJune 1990 has been 33 tele-

be decreased, it is unlikely to be com- vision and several hundred radio pro-

pletely eliminated. Economic Costs grams about HIV. The programs have

The success of quarantine will also varied from innovative pilot projects to

depend on restricting new sources of HIV The decision to develop HIV-testing Spanish translations of inappropriate Eu-

infections. Being an island with an author- capacity and to initiate a campaign to test ropean film clips. Nationally televised

itarian socialist government, travel in and every potentially sexually active person in two-hour programs have featured bland

out of Cuba is somewhat limited. As part Cuba has been an expensive policy. Com- panel formats with experts from the MIN-

of the current policy, Cuban citizens trav- pared to other countries in Latin America, SAP and depend heavily on the impor-

eling or working abroad will be periodi- Cuba invests a substantially higher pro- tance of the authoritative expert to com-

cally tested for HIV antibodies. As the portion of national resources in health municate information about HIV.

Cuban economy struggles to establish care. In 1983, the Minister ofHealth stated Physicians and public health experts

sources ofhard currency other than sugar, that 7.8 percent of the government budget wearing their white coats responded to

policy makers expect the tourist industry was spent on health care,26 and in 1989 questions using predominantly technical

to expand and assume a much more prom- nearly 12 percent of the government bud- terminology and few graphics to illustrate

inent role in the economy. Although the get was spent on health. concepts. The program I viewed included

success of the tourist industry will depend Dr. T&rry M61inert estimates that the discussions of the epidemiology of HIV in

in part on normalization of economic re- cost of developing a domestic ELISA, Cuba, the sanatorium in Havana prov-

lations with the United States, and this Western blot assay, and antigen tests and ince, methods of transmission, methods of

seems unlikely to occur in the near future, establishing the facilities for testing was preventing transmission, use of zidovu-

Dr. Terry M6linert stated that tourists will approximately $3 million. Mass HIV test- dine, treatment of opportunistic infec-

not be tested for HIV antibodies under ing and the consequences of identifying tions, and a description of the interna-

any circumstances. This means that the seropositive persons was estimated by Dr. tional consequences of the HIV epidemic.

potential for new transmission of HIV TUrry M6linert to cost about $2 million per The information was presented in a ratio-

would continue despite the quarantine year since 1986. Since HIV tests are un- nal manner with emphasis on the facts.

policy. likely to end with complete testing of the The educational campaign is actively pro-

Guarantees of confidentiality for population, maintenance of the HIV sur- moting the importance of responsible in-

HIV positive persons with a policy of rel- veillance program will continue to require dividual behavior and the inherent limita-

ative quarantine seem at best difficult to financial resources. tions of the MINSAP to protect the





May 1991, Vol. 81, No. 5 American Journal of Public Health 565

P6rez-Stable



population from HIV. The programs are vention, and occupational safety) were Canbbean: 25 years of Cuban health care

prerecorded, and thus potentially contro- dominated by the element of personal re- (letter). N Engl J Med 1984; 311:60.

versial issues are not discussed or are ed- sponsibility. Tesh argues that the socialist 5. Perez-Stable EJ: Community medicine in

ited out. Production of more sophisticated perspective would hold that change in be- Cuba. J Community Psychol 1985; 13:124-

137.

and creative educational programs taking havior results from economic change in 6. Ministerio de Salud Publica (MINSAP): In-

advantage of Cuba's established film in- the society. Focusing on personal respon- forme Anual 1987. La Habana 1988; Direc-

dustry were not mentioned by Dr. Terry sibility implies a "your-fault" assumption cion Nacional de Estadisticas.

M61inert in future plans. At the start of the and contradicts the premises of a socialist 7. World Health Organization: Global Pro-

1988 school year, an HIV educational society. Examples of structural changes, gram on AIDS. Update AIDS Cases.

campaign directed at fifth graders was not implemented in Cuba, that may lead to Geneva: WHO, 1990.

8. PanAmerican Health Organization: Health

launched with school teachers as the prin- modification of individual behavior in- conditions in the Americas, 1960-1972.

cipal source of information. School-based clude the level of tobacco production and Washington DC: PAHO, 1974. Scientific

education offers promise to equip the pop- enforcement of laws requiring seat belts. Pub. No. 287.

ulation with accurate information and to Although individual behavior change is 9. Roemer M: Health development and polit-

dispel misbeliefs regarding the epidemic. perceived by MINSAP to be essential to ical policy: The lesson of Cuba. J Health

Promotion of the sale and use of con- reduce nicotine dependence, HIV control Politics Policy Law 1980; 4:570-580.

10. PanAmerican Health Organization: Health

doms by Cubans presents a particularly policies are primarily based on govern- conditions in the Americas, 1981-1984.

difficult challenge to MINSAP. Condoms ment imposed factors. In Cuba there ex- Washington DC: PAHO, 1986. Scientific

are readily available at any pharmacy, but ists the intangible public perception that Pub. No. 500.

there are no vending machines in discreet the MINSAP is "responsible for taking 11. Navarro V: Health, health services and

locations. Thus, in order to purchase a care of our health," and thus the issue of health planning in Cuba. Int J Health Serv

condom, an individual must personally re- personal responsibility for behavior 1972; 2:397-432.

quest it of the pharmacist, as in the case of change remains unanswered. 12. Ubell RN: High-tech medicine in the Car-

ibbean: 25 years of Cuban health care (Spe-

many prescription medications. The logis- Although I discussed the HIV quar- cial Report). N Engl J Med 1983; 309:1468-

tical barrier of asking for a condom is com- antine policy with other health authorities, 1472.

pounded by the social stigma that has been family members, friends, and many regu- 13. Danielson R: Cuban Medicine. New Brun-

traditionally associated with condom use lar working citizens, I detected not a hint swick: Transaction Books, 1979.

in Latin America.28 In addition, the ma- of disagreement. I found this attitude im- 14. Conover S, Donovan S, Susser E: Reflec-

chismo culture may further inhibit the use pressive given the spectrum of public tions on health care in Cuba. Lancet 1980;

2:958-960.

of condoms by both men and women opinion on many issues voiced by the Cu- 15. Guttmacher S: The prevention of health

when participating in high-risk sexual ban people. The quarantine policy, if risks in Cuba. Int J Health Serv

practices.29 effective, eliminates the presence of free- 1987;17:179-189.

living seropositives in Cuban society and, 16. Summerfield D: Cuban health record chal-

in a subtle way, removes the responsibility lenged (Round the World). Lancet April

1989; 1:834-835.

Promotion of Behavioral of behavioral change from the individual. 17. Kates N: Mental health services in Cuba.

Change Although the threat of quarantine may Hosp Comm Psychiatry 1987; 38:755-758.

serve as a coercive force to alter high-risk 18. Centers of Disease Control: Follow-up on

Prior to the past decade efforts to ed- sexual behaviors among certain individu- the health status of the Cuban refugees.

ucate the public about preventable causes of als, the quarantine policy may paradoxi- MMWR 1980; 29:343-344.

19. Gordon AM, Paya R: Controlling AIDS in

morbidity and mortality have received rel- cally permit most Cubans to feel they are Cuba (letter). N Engl J Med .1989; 321:829-

atively few resources compared to high tech personally invulnerable to the HIV epi- 830.

curative technologies.5,12,30 Forexample, an demic. This may be the greatest challenge 20. De Medina M, Fletcher MA, Valledor MD,

anti-smoking educational campaign was facing the MINSAP in implementing ed- Ashman M, Gordon AM, Schiff ER: Sero-

launched in Cuba in 1983,30 even though ucational campaigns about HIV. El logic evidence for HIV infection in Cuban

cigarette consumption has been a wide- immigrants in 1980. Lancet 1987; 2:166.

21. Mills M, Wofsy CB, Mills J: The acquired

spread epidemic in Cuba foryears. In 1982, immunodeficiency syndrome: Infection

Cuba ranked third in the world in the per Acknowledgments control and public health law (Special Re-

capita adult consumption of cigarettes per This paper would not have been possible with- port). N Engl J Med 1986; 314:931-936.

year with 2587,31 and the inevitable lung out the cooperation of Dr. Terry M6linert and 22. Cates W, Bowen GS: Education for AIDS

cancer epidemic has followed.6 Related to others at the MINSAP. Drs. Barbara Marin and prevention: Not our onlyvoluntaryweapon.

Thomas Coates made critical comments on an Am J Public Health 1989; 79:871-874.

HVtransmission, the rate of reported cases earlier draft. Dr. Perez-Stable is a Henry J. Kai- 23. Volberding PA, Lagakos SW, Koch MA,

of syphilis have increased dranatically from ser Family Foundation Faculty Scholar in gen- et at Zidovudine in asymptomatic human

7.2/100,000 in 1970 to 84.3/100,000 in 1987, eral internal medicine. immunodeficiency virus infection: A con-

and during the 1980s the number of reported trolled trial in persons with fewer than 500

cases has doubled.6 Clearly, promotion of References CD4-positive cells per cubic millimeter. N

1. Cordoves R: Contra el flagelo mortal. (Ep- Engl J Med 1990; 322:944-949.

condom use may potentially result in ben- idemiologia Cubana) Bohemia 1989; 24:20- 24. Richards P: The Medieval Leper and His

efits beyond the prevention of HIV trans- 25. Northern Heirs. Cambridge, England:

mission. One must ask the question of what 2. Bayer R, Healton C: Controlling AIDS in D.D. Brewer Ltd, 1977; 178 pp.

are the appropriate priorities in health care Cuba: The logic of quarantine (Special Re- 25. Lo B, Steinbrook RL, Cooke M, Coates

expenditures? port). N Engl J Med 1989; 320:1022-1024. TJ, Walters EJ, Hulley SB: Voluntary

In a report on health education in 3. Perez-Stable EJ, Pedraza RO: Tuberculo- screening for human immunodeficiency vi-

sis in Cuba (Pulmonary Perspective). Am rus (IV) infection. Ann Intern Med 1989;

Cuba, Tesh30 found that health promotion Rev Respir Dis 1984; 130:520-523. 110:727-733.

campaigns (anti-smoking, accident pre- 4. Perez-Stable EJ: High-tech medicine in the 26. Del Valle S: Speech at the inaugural session





566 American Journal of Public Health May 1991, Vol. 81, No. 5

Commcntaiy



of Health for All international conference. humana. La Habana 1987; Editorial:Cien- tion of AIDS among Black and Hispanic

La Habana 1983; Ministerio de Salud tifico-Tecnica. men. Am Psychol 1988; 43:871-877.

Pblica:25-36. 28. Marin BV: AIDS prevention in non-Puerto 30. Tesh S: Health education in Cuba: A pref-

27. De Quesada Ramirez E, Galban Garcia, Rican Hispanics. Washington, DC: Govt ace. Int J Health Serv 1986; 16(1):87-104.

Cddiz Lahens A: SIDA: infecci6n-enfer- PrintingOffice 1990;35-52. Pub. No. 90-1627. 31. Collinshaw N, Mulligan L: Recent trends

medad por el virus de la immunodeficiencia 29. Peterson J, Marin G: Issues in the preven- in tobacco consumption-Canada and

other countries. JAMA 1984; 252:23-24.









May 1991, Vol. 81, No. 5 American Journal of Public Health 567