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US could learn from Cuban AIDS policy


Accepted: 9 June 2003.

One of the few nations in the world where the AIDS epidemic has been kept at bay is Cuba, where government will, enforced and encouraged HIV testing and availability of treatment has resulted in an infection rate that is one-tenth of that seen in the USA. ‘‘The US can learn a lot of things from Cuba about HIV/AIDS’’ said Dr. Byron Barksdale, MD, a pathologist in North Platte, Nebraska, and director of the Cuba AIDS Project. The US-based non-governmental agency assists Cuba in providing drugs, diagnostic equipment and other humanitarian aid to the island. The efforts are permitted despite a decades-long US embargo against the island.

Dr. Barksdale acknowledged that the authoritarian measures used in Cuba – compulsory testing, weeks of required in-sanatorium disease education and possible quarantine – will not play well in most western democracies. But, he said, the Cuban experience does indicate that intensive education about HIV has benefits, and that concept can be exported outside the island. Dr. Barksdale said it is in the interests of the USA to make sure Cuba keeps its AIDS epidemic under control because when the embargo is finally lifted, millions of Americans are expected to visit Cuba each year: those who fled Fidel Castro's communist revolution a generation ago and haven't seen their homeland or relatives since; those who wish to enjoy the beaches of Cuba and those who are traveling to the island which is becoming a beacon for sexual tourism. ‘‘We want to help Cuba keep a lid on this problem’’ he said.

The key point in controlling AIDS that could be exported from Cuba to the US, Dr. Barksdale said at the annual meeting of the American Association for the Advancement of Science in Denver, Colorado, is the concept of intensive education of people who are newly diagnosed with HIV infection. He said that those people must spend 6–8weeks at a sanatorium where their infection is treated with antiretroviral drugs that are manufactured in Cuba; where patients are given lessons on what the disease is, how it affects the person who has been infected and how a person can prevent transmitting the disease to others using safe sex practices that include proper use of condoms as well as abstinence. ‘‘I don't know if six weeks or eight weeks are the magic numbers,’’ Dr. Barksdale said ‘‘but that is certainly a longer time than is given to people in the United States who received such a diagnosis. They may get about five minutes worth of education’'.

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Testing required

In Cuba, he said, the government also mandates: (i) all pregnant women undergo an HIV test, and if they are found to be infected with the disease they are given antiretroviral drugs to prevent transmission to the newborn, and are delivered by Cesarean section—another known method of reducing possible HIV transmission. Since 1985, only 12 babies have been born with HIV infection in Cuba; (ii) all persons found to be HIV infected are required to provide the names of their sexual partners in the past 6 months, and those individuals have to undergo an HIV test; (iii) all persons who are found to have sexually transmitted diseases must undergo an HIV test as well; (iv) voluntary HIV screening is encouraged.

`‘In the United States, the rights of the individual is foremost,’’ Barksdale said, ‘‘but in Cuba the individual is expected to do what is necessary to protect the collective society’'. That's why people are willing to roll up their sleeves and not protest blood tests to determine HIV status, he said.

The Cuban government actions have kept the HIV-infection prevalence at 0.03 percent of the population—about 4000 people. In the USA, the rate is 10 times higher—about 0.3 percent of the population is infected with HIV, nearly 1 million people. In other Caribbean states – such as Haiti – the rates are hundreds of time higher than on Cuba. Dr. Barksdale said the government quarantined all people found to be HIV infected from 1985 to 1994. However, under the direction of Dr. Jorge Perez, MD, a Cuban infectious disease expert, people infected with the disease – who complete the required education course – may leave the sanatorium. Because food, housing, medication, social services, privacy and other services are provided in the sanatorium about half the people decide to stay, he said.

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Prevention works

`‘We can use prevention tactics to control HIV infection,’’ said David Holtgrave, Ph.D., professor of behavioral science and health education, at Emory University, Atlanta, Georgia. ‘‘It is a matter of will. We know what kind of interventions will work. We know what needs to be done. We know what it will cost,’’ he said. Dr Monica Ruiz, a health scientist administrator at the National Institute of Allergy and Infectious Diseases, said governments such as those of Cuba and Uganda where education and de-stigmatization of person infected with AIDS are goals of the government, prevention projects appear to work. She noted that in Uganda, the government officials always discuss AIDS in their speeches. ‘‘There are no vaccines that will be made available to treat or prevent HIV/AIDS any time soon,’’ Ruiz said ‘‘Prevention is the thing we have left. And that is driven by behavior.’'

Ed Susman

© 2003 Lippincott Williams & Wilkins, Inc.