Commentary
Cuba's Response to the HIV
Epidemic
Eliseo J. Perez-Stable, MD
Introduction
Cuba's response to the human immunodeficiency virus (HIV) epidemic has
been unique. Mass testing for HIV antibodies, for the most part compulsory, and
a mandatory relative quarantine of all persons testing positive is official policy." 2
Educational interventions using the electronic and printed media and school-based
programs were widely implemented in
1988 as a secondary component of HIV
transmission control. Cuba's policy highlights a historical and intriguing question
in public health practice: How much can
and should personal liberty and freedom
be curtailed for the public good?
As a Cuban American who has reported on health care in Cuba,3-5 I discuss
the topic of Cuba's response to the HIV
epidemic based on interviews in October
1988 with Dr. Hector Terry M6linert, the
Vice-Minister of Health for Hygiene, Epidemiology, and Health Education, who
has been in charge of coordinating policies
regarding control of the HIV epidemic;
interviews with clinicians involved in the
care of HIV infected persons; and on review of official documents.
Cuba 's Strategy
Cuba's strategy for HIV control is
based on testing the entire adult population and restricting all seropositives to facilities located in rural areas. Between
1986 and 1989, 5,117,250 persons had HIV
tests in Cuba, over 75 percent of the population 15 years of age and older. ',6 A total
of 434 persons, 315 men, and 119 women
had been identified as HIV positive for an
overall seroprevalence of 0.00009 percent
(all but one are HIV-1).
Government policy is to quarantine
all seropositive persons in controlled res-
idential parks, the first of which is located
in Santiago de Las Vegas in rural Havana
Province. The facility, popularly known
as "Finca Los Cocos," contains adequate
housing, better than average nutrition,
sports and exercise facilities, and medical
care. Quarantined persons are paid their
salary in full or given a stipend if they had
been unemployed. Five additional quarantine facilities in Central and Eastern
Cuba are currently in use.
Sexual contact with foreigners during
international travel or in Cuba was the
principal risk factor in 217 HIV positive
persons. According to the Cuban Ministry
of Public Health (MINSAP) authorities,
122 HIV infections were directly attributed to Cuba's military and political involvement in Africa. Of the 315 infected
men, 105 are gay or bisexual with an average of nine lifetime sexual partners. By
comparison, heterosexuals of either sex
infected with HIV reported an average of
3.7 lifetime partners.' Anal intercourse
with heterosexual men has been reported
as a common practice by 53 percent of the
119 infected women.'
The MINSAP categorically states
that illicit intravenous drug use does not
exist in Cuba and thus is not a risk factor
for HIV infection. Infected blood products, neonatal transmission, and occupational exposure account for only 11 HIV
positive persons. In 23 (5.3 percent) HIVinfected individuals, risk factors were unknown. '
Address reprint requests to Eliseo J. PerezStable, MD, Division of General Internal Medicine, Department of Medicine, University of
California, 400 Parnassus Avenue, Room
A-405, San Francisco, CA 94143-0320. This paper, submitted to the Journal January 23, 1990,
was revised and accepted for publication January 8, 1991.
American Journal of Public Health 563
P6rez-Stable
A total of 63 cases of acquired immunodeficiency syndrome (AIDS) was reported by Cuba to the World Health Organization (WHO) as of December 1989.7
Pneumonia due toPneumocystis cannii is
the most frequent index diagnosis for
AIDS in Cuba, and only two cases of Kaposi's Sarcoma have been reported.
Reliability, Validity of
Epidmiologic Data
Representatives from the WHO and
the Pan American Health Organization
(PAHO) have confirmed the reliability of
epidemiologic statistics on other diseases
made available by the MINSAP in several
reports.8-10 In a systematic review of
health care services in Cuba, Navarro"
praised the high priority placed by the
MINSAP in establishing a reliable system
for gathering morbidity and mortality statistics covering the entire Cuban population. Although the incomplete and unreliable nature of much of the reported
epidemiologic data from developing countries continues to be a problem, Cuba has
established a system capable of collecting
reliable and valid information. Numerous
independent reports about Cuba3,4-5s9,11-17
and the health profile of Cuban immigrants
entering the United States in 198018 support this contention.
Gordon19 has questioned the validity
of reports of low prevalence of HIV infection in Cuba. He based this on the presence of unequivocally positive tests for
HIV antibodies in four of 990 (0.4 percent)
Cuban immigrants who entered the US
during the 1980 Mariel boatlift.20 This estimate is not substantially different from
that reported by Cuba in the initial testing
of persons at highest risk. Considering that
the 1980 immigrants were predominantly
men of less privileged socioeconomic status, many of whom had been in prison and
institutions for the mentally ill, and a substantial number were homosexual or bisexual, Gordon's estimate of HIV infection may represent a selection bias.
Nevertheless, validation of Cuba's reports of HIV/AIDS is difficult, given the
economic and information blockade that
hinders scientific exchange.
Cuban scientists developed a domestic version of the enzyme-linked immunosorbent assay (ELISA) and Western blot
tests for detecting HIV antibodies. Collaboration with US-based scientists was
prohibited by the 30-year-old economic
embargo imposed by the US Government.
Validation of the Cuban tests with an in-
564 American Journal of Public Health
ternational standard has been conducted
in collaboration with the Oswaldo Cruz
Foundation in Brazil and Sweden's
Health Ministry and, according to MINSAP authorities, Cuba's domestically developed tests are comparable. Concerns
have been raised regarding both sensitivity and specificity of the Cuban testing
procedures.2 Currently, there are 45 laboratories capable of performing HIV tests
with one acting as the national reference.
Each positive ELISA assay is confirmed
two additional times, and the Western blot
assay is routinely repeated at least once.'
Possible Advantages of Cuba's
HIVPolicy
Cuban health officials expect to have
HIV test results on most of the adult population by the end of 1990, and will thus
have the most complete population-based
country-wide serologic study in the world.
Identification of seropositive individuals
before HIV transmission has become
widespread and may allow for an effective
infection control strategy to be implemented.21 As a result of widespread serotesting, the risk of HIV transmission by
infected blood products has been minimized, and women found to be positive at
prenatal screening are offered a therapeutic abortion. Testing of sexual contacts of
HIV-positive individuals has led to the implementation of focused education and
counseling in order to promote changes in
sexual practices of those found to be negative and prevent the potential for explosive transmission of HIV.
The fact that Cuba reports a low
prevalence of HIV infection and incidence
of AIDS implies that there is a window of
opportunity to prevent widespread transmission. Efforts at educating the population have been implemented after mandatory testing and quarantine were
established as policy. However, while education is essential, other voluntary efforts to stop transmission of HIV,22 such
as contact tracing, have also been emphasized. The relativelyyoung age ofthe population and the marked increase in syphilis
rates during the past decade would indicate that prevention of ulcerative sexually
transmitted diseases should be a priority
for the MINSAP. The policy of compulsory testing may be more acceptable if the
goal in identifying HIV-infected individuals was to be able to offer them secondary
prevention with zidovudine23 or primary
prevention of Pneumocystis carinii pneumonia without any associated social
stigma.
The MINSAP contends that mandatory lifetime quarantine is the only
method of guaranteeing that HIV-infected persons will behave in a sexually
responsible way. MINSAP's greatest
fear is that of irresponsible sexual behavior among men characterized by the machismo cultural trait who are likely to
seek extramarital sexual partners. In the
view of Dr. Terry Molinert, lifetime quarantine will radically alter the threat of the
HIV epidemic in Cuba by restricting the
personal liberty of these individuals. He
credits Cuba's policy with the prevention
of up to 4,000 new HIV infections, but no
data are available to support this statement. If Dr. Terry Molinert is correct,
Cuba's policy may be justified.
Possibl Di&advanges of
Cuba's Poly
Although the goal of compulsory
testing may seem justifiable for public
health reasons, little can be said in defense
of lifelong guarantine. HIV-infected individuals have been confined without,any
legal basis or precedent in the Cuban Constitution. If there was a strong public
health justification for this restriction of
human rights in a selected group of individuals guilty of no illegal act, then quarantine should be critically evaluated. Unfortunately, there is little basis on which to
justify this drastic measure, and in contrast, several factors emphasize its defi
ciencies.
Historical precedents for this type of
public health measure include the establishment of colonies for persons with leprosy which may have contributed (along
with the ravages of the bubonic plague) to
the virtual elimination of leprosy in Europe during the Middle Ages.24 Cuba's
policy of lifelong quarantine for HIV-infected persons is the first effort in the 20th
century at isolating large populations for a
public health reason. More recently, quarantine has been used in individual patients
with a focused goal such as enforcing
treatment of a noncompliant patient infected with tuberculosis or to segregate a
patient with a highly communicable disease (e.g., typhoid fever).2' Quarantine
rarely has been used for patients with a
sexually transmitted disease.
Data on the test characteristics of the
ELISA and Western blot tests for detecting HIV antibodies in populations with a
May 1991, Vol. 81, No. 5
Commentwy
pretest likelihood of infection of at least 1
percent show that the sensitivity and specificity approach 100 percent.25 However,
when the population prevalence is as low
as it has been observed in Cuba (0.00009
percent), the proportion of false positive
results are likely to be higher.25 Based on
the known test characteristics, Bayer and
Healton2 estimated that between 21 and 53
persons may have been inaccurately designated HIV positive and, as a consequence, quarantined. This is probably an
overestimate of the number of false positive HIV tests because repeated tests are
conducted after the person has been confined. However, the fact remains that
some persons may be inappropriately
quarantined because of an inaccurate test
result. Cuban authorities expressed concern regarding false positives and have
limited confinement to persons with three
positive ELISA tests and an unequivocal
Western blot.
Perhaps as a concession to some individual liberties, Cuba's current policy
allows for weekend passes in the company
of a health care technician, medical students, or spouses. In the words of Dr.
Terry M6linert, "the technicians do not
accompany them into the bedroom," and
at least one woman has been documented
to seroconvert following weekend visits
by her quarantined husband. Thus, Cuba's policy is one of relative quarantine
and, although new HIV transmission may
be decreased, it is unlikely to be completely eliminated.
The success of quarantine will also
depend on restricting new sources of HIV
infections. Being an island with an authoritarian socialist government, travel in and
out of Cuba is somewhat limited. As part
of the current policy, Cuban citizens traveling or working abroad will be periodically tested for HIV antibodies. As the
Cuban economy struggles to establish
sources ofhard currency other than sugar,
policy makers expect the tourist industry
to expand and assume a much more prominent role in the economy. Although the
success of the tourist industry will depend
in part on normalization of economic relations with the United States, and this
seems unlikely to occur in the near future,
Dr. Terry M6linert stated that tourists will
not be tested for HIV antibodies under
any circumstances. This means that the
potential for new transmission of HIV
would continue despite the quarantine
policy.
Guarantees of confidentiality for
HIV positive persons with a policy of relative quarantine seem at best difficult to
May 1991, Vol. 81, No. 5
conceive. The disappearance and transient reappearance of individuals from
their homes will not go unnoticed by the
officially instituted Committees for the
Defense of the Revolution (CDR). Although originally conceived in 1960 to increase surveillance of political activity
against the Cuban Revolution, the CDRs
have an important role in many aspects of
Cuban life (e.g., immunization and hygiene campaigns, prevention of crime by
establishing neighborhood watch, and settling disputes between neighbors).5,13,17
Many of the older supporters of the revolution are active participants in the CDR
and thrive on the verbal communication of
unpublished news. Thus, although Dr.
Terry Molinert emphasized the importance of avoiding stigmatizing seropositive individuals by identifying them in
public, I doubt that this information will
remain confidential.
Dr. Thrry M6linert stated that Cuba's
current HIV policy is under constant revision and subject to change as conditions
evolve. The fact that an effective vaccine
against or a pharmacologic cure of HIV is
unlikely in the near future has led to reconsideration of the quarantine policy.
MINSAP authorities tentatively plan to
reintroduce selected HIV-infected individuals to their communities after a defined period of quarantine. As of this writing, a final decision on revision of the
quarantine policy has not been made.
Economic Costs
The decision to develop HIV-testing
capacity and to initiate a campaign to test
every potentially sexually active person in
Cuba has been an expensive policy. Compared to other countries in Latin America,
Cuba invests a substantially higher proportion of national resources in health
care. In 1983, the Minister ofHealth stated
that 7.8 percent of the government budget
was spent on health care,26 and in 1989
nearly 12 percent of the government budget was spent on health.
Dr. T&rry M61inert estimates that the
cost of developing a domestic ELISA,
Western blot assay, and antigen tests and
establishing the facilities for testing was
approximately $3 million. Mass HIV testing and the consequences of identifying
seropositive persons was estimated by Dr.
TUrry M6linert to cost about $2 million per
year since 1986. Since HIV tests are unlikely to end with complete testing of the
population, maintenance of the HIV surveillance program will continue to require
financial resources.
The public health strategy of tracing
sexual contacts of all HIV-positive individuals requires the full-time deployment
of 450 nurses and 200 epidemiologists by
the Cuban Ministry of Health.1 During the
course of our conversation, Dr. Terry Molinert stated in a frustrated and tired voice
that 90 percent of his time was now consumed by the HIV program. Although
these efforts are admirable and reflect the
high priority placed on HIV control, in a
nation with limited resources and with
public health problems with greater consequences on morbidity and mortality,
other aspects of health care may suffer.
Missed Oppoz1unities
In 1987, Cuba published an annotated
compendium of the English literature on
AIDS for distribution to health professionals at a nominal cost.27 However, efforts
to educate the general population were delayed. In manyways, Cuba seems to be an
ideal place to test the implementation of a
community-wide educational campaign
on HIV, its cause, methods of transmission and consequences, with the goal of
preventing new transmissions. The population is literate, has few concerns about
the basic necessities of life, and electronic
and printed media are widely available at
a reasonable cost.
The main thrust of the educational
campaign as ofJune 1990 has been 33 television and several hundred radio programs about HIV. The programs have
varied from innovative pilot projects to
Spanish translations of inappropriate European film clips. Nationally televised
two-hour programs have featured bland
panel formats with experts from the MINSAP and depend heavily on the importance of the authoritative expert to communicate information about HIV.
Physicians and public health experts
wearing their white coats responded to
questions using predominantly technical
terminology and few graphics to illustrate
concepts. The program I viewed included
discussions of the epidemiology of HIV in
Cuba, the sanatorium in Havana province, methods of transmission, methods of
preventing transmission, use of zidovudine, treatment of opportunistic infections, and a description of the international consequences of the HIV epidemic.
The information was presented in a rational manner with emphasis on the facts.
The educational campaign is actively promoting the importance of responsible individual behavior and the inherent limitations of the MINSAP to protect the
American Journal of Public Health 565
P6rez-Stable
population from HIV. The programs are
prerecorded, and thus potentially controversial issues are not discussed or are edited out. Production of more sophisticated
and creative educational programs taking
advantage of Cuba's established film industry were not mentioned by Dr. Terry
M61inert in future plans. At the start of the
1988 school year, an HIV educational
campaign directed at fifth graders was
launched with school teachers as the principal source of information. School-based
education offers promise to equip the population with accurate information and to
dispel misbeliefs regarding the epidemic.
Promotion of the sale and use of condoms by Cubans presents a particularly
difficult challenge to MINSAP. Condoms
are readily available at any pharmacy, but
there are no vending machines in discreet
locations. Thus, in order to purchase a
condom, an individual must personally request it of the pharmacist, as in the case of
many prescription medications. The logistical barrier of asking for a condom is compounded by the social stigma that has been
traditionally associated with condom use
in Latin America.28 In addition, the machismo culture may further inhibit the use
of condoms by both men and women
when participating in high-risk sexual
practices.29
Promotion of Behavioral
Change
Prior to the past decade efforts to educate the public about preventable causes of
morbidity and mortality have received relatively few resources compared to high tech
curative technologies.5,12,30 Forexample, an
anti-smoking educational campaign was
launched in Cuba in 1983,30 even though
cigarette consumption has been a widespread epidemic in Cuba foryears. In 1982,
Cuba ranked third in the world in the per
capita adult consumption of cigarettes per
year with 2587,31 and the inevitable lung
cancer epidemic has followed.6 Related to
HVtransmission, the rate of reported cases
of syphilis have increased dranatically from
7.2/100,000 in 1970 to 84.3/100,000 in 1987,
and during the 1980s the number of reported
cases has doubled.6 Clearly, promotion of
condom use may potentially result in ben-
efits beyond the prevention of HIV transmission. One must ask the question of what
are the appropriate priorities in health care
expenditures?
In a report on health education in
Cuba, Tesh30 found that health promotion
campaigns (anti-smoking, accident pre566 American Journal of Public Health
vention, and occupational safety) were
dominated by the element of personal responsibility. Tesh argues that the socialist
perspective would hold that change in behavior results from economic change in
the society. Focusing on personal responsibility implies a "your-fault" assumption
and contradicts the premises of a socialist
society. Examples of structural changes,
not implemented in Cuba, that may lead to
modification of individual behavior include the level of tobacco production and
enforcement of laws requiring seat belts.
Although individual behavior change is
perceived by MINSAP to be essential to
reduce nicotine dependence, HIV control
policies are primarily based on government imposed factors. In Cuba there exists the intangible public perception that
the MINSAP is "responsible for taking
care of our health," and thus the issue of
personal responsibility for behavior
change remains unanswered.
Although I discussed the HIV quarantine policy with other health authorities,
family members, friends, and many regular working citizens, I detected not a hint
of disagreement. I found this attitude impressive given the spectrum of public
opinion on many issues voiced by the Cuban people. The quarantine policy, if
effective, eliminates the presence of freeliving seropositives in Cuban society and,
in a subtle way, removes the responsibility
of behavioral change from the individual.
Although the threat of quarantine may
serve as a coercive force to alter high-risk
sexual behaviors among certain individuals, the quarantine policy may paradoxically permit most Cubans to feel they are
personally invulnerable to the HIV epidemic. This may be the greatest challenge
facing the MINSAP in implementing educational campaigns about HIV. El
Acknowledgments
This paper would not have been possible without the cooperation of Dr. Terry M6linert and
others at the MINSAP. Drs. Barbara Marin and
Thomas Coates made critical comments on an
earlier draft. Dr. Perez-Stable is a Henry J. Kaiser Family Foundation Faculty Scholar in general internal medicine.
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