Cuba is Far Ahead of America in HIV/AIDS Control and Prevention
Juan Carlos Miranda, an AIDS patient, with Dr. Victor Maracha at an AIDS treatment sanitarium near Havana.
By DONALD G. McNEIL Jr.
Fidel Castro Foretold the Pandemic before any American President even uttered the word AIDS.
Fidel Castro reads a lot. That is why he sees far ahead of others.
HAVANA — Yudelsy García O’Connor, the first baby known to have been born with H.I.V. in Cuba, is not merely still alive. She is vibrant, funny and, at age 25, recently divorced but hoping to remarry and have children.
Her father died of AIDS when she was 10, her mother when she was 23. She was near death herself in her youth.
“I’m not afraid of death,” she said. “I know it could knock on my door. It comes for everyone. But I take my medicine.”
Ms. García is alive thanks partly to lucky genes, and partly to the intensity with which Cuba has attacked its AIDS epidemic. Whatever debate may linger about the government’s harsh early tactics — until 1993, everyone who tested positive for H.I.V. was forced into quarantine — there is no question that they succeeded.
Cuba now has one of the world’s smallest epidemics, a mere 14,038 cases. Its infection rate is 0.1 percent, on par with Finland, Singapore and Kazakhstan. That is one-sixth the rate of the United States, one-twentieth of nearby Haiti.
The population of Cuba is only slightly larger than that of New York City. In the three decades of the global AIDS epidemic, 78,763 New Yorkers have died of AIDS. Only 2,364 Cubans have.
Other elements have contributed to Cuba’s success: It has free universal basic health care; it has stunningly high rates of H.I.V. testing; it saturates its population with free condoms, concentrating on high-risk groups like prostitutes; it gives its teenagers graphic safe-sex education; it rigorously traces the sexual contacts of each person who tests positive.
By contrast, the response in the United States — which records 50,000 new infections every year — seems feeble. Millions of poor people never see a doctor. Testing is voluntary, and many patients do not return for their results. Sex education is so politicized that many schools teach nothing about protected sex; condoms are expensive, and distribution of free ones is haphazard.
Cuba has succeeded even though it has the most genetically diverse epidemic outside Africa. Almost all American cases are of one strain, subtype B. Cuba has 21 different strains.
The genetic diversity is a legacy of its foreign aid. Since the 1960s, Cuba has sent abroad thousands of “internationalists” — soldiers, doctors, teachers and engineers. Stationed all over Africa, they brought back a wide array of strains. According to a study in 2002, 11 of Cuba’s 21 strains are unknown elsewhere, formed when two others mixed.
And Cuba’s success has come despite its being a sex tourism destination for Europeans and Canadians.
While the police enforce laws against overt streetwalking, bars and hotel lobbies in downtown Havana are filled with young women known as jineteras — slang for “jockeys” — who approach foreigners, asking if they would like to go for a drink, or perhaps dancing, with the unspoken assumption that it will lead to more. Even so, of the roughly 1,000 new infections diagnosed each year, 81 percent are among men and very few among young unmarried women.
“Most of those who sleep with tourists know to use condoms,” said Dr. Ribero Wong, an AIDS specialist here.
In a survey in 2009, 77 percent of all sex workers said they regularly used condoms.
There are male jineteras for gay tourists too, of course, “but we believe the main vector is within the people,” said Dr. Luis Estruch Rancaño, deputy minister for public health. “Mainly, the very promiscuous group in the homosexual community who have many partners and don’t take precautions.”
One example is Carlos Emilio García, 50, a registered nurse who lives and works at a former quarantine sanitarium outside Havana. He had negative H.I.V. tests at his job every six months from 1990 to 1996, but became infected in 1997.
He admits to having had many partners; as he put it, “No, I don’t know who my assassin is.”
Asked why a well-educated nurse would risk sex without a condom, he waved his hands in the air and replied, “You know — because we all do crazy things sometimes.”
The few Cuban women who are infected usually get the virus from partners who are secretly bisexual, experts said.
“Homo-bisexual transmission” is its own category in Cuba; socially, a man who occasionally has sex with other men is not considered gay if he is a “top” — the penetrative partner, explained Ramón Arango García, a fashion designer and educator at the National AIDS and Sexually Transmitted Disease Prevention Center.
Heroin use, which drives epidemics in many countries, is virtually nonexistent in Cuba, officials insist.
And since 1986, only 38 babies have been born with the virus. In Cuba’s cradle-to-grave health care system, pregnant women get up to 12 free prenatal checkups, during which they are tested for H.I.V. at least twice.
Before antiretroviral drugs were available, H.I.V.-infected women were offered abortions or, if they chose to deliver, Caesareans and free infant formula to discourage breast-feeding and reduce the risk of transmission. Now they get the drugs free.
Universal Coverage
As broken as it is economically, Cuba still points proudly to one legacy of its 1959 revolution: Basic health care is universal and free. Cuba has 535,000 health care workers (“We’re all either doctors or baseball players,” one hospital microbiologist joked) and each citizen is officially registered with a family doctor nearby;
Click here to read the rest of the report on the New York Times.
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