AIDS in Cuba: From Vigilant Quarantine to Vaccine Quest
Byron L. Barksdale, M.D. Updated December, 2009
“and when I shall die, take him and cut him out in little stars, And he will make the face of Heaven so fine that all the World will be in love with night, And pay no worship to the garish sun”
Subject: Assessment of HIV/AIDS Activities in Cuba with emphasis on durability
Purpose of travel: To continue to assess the HIV/AIDS activities
currentlsy being conducted in Cuba, identify gaps in service, and propose the
role(s) that the USA can play in increasing the capacity and delivery of key
strategies in the national plan of Cuba.
Summary: Members of the Cuba AIDS Project met key government
and non-government partners working in and around the AIDS epidemic in Cuba
as an annual followup on site visits from prior years. We found a great need
for funding and implementaion of needed services at virtually all levels. Cuba
is doing an excellent job in HIV/AIDS epidemiology, prevention, education and
care considering its limited resources. To have a durable program over many
years, we continue to propose three main axes around which to focus USA based
humanitarian efforts through Cuba AIDS Project: (1) assist Cuba with its HIV
surveillance and epidemiology (2) a comprehensive Maternal to Child Transmission
(MTCT) prevention program, (3) and delivery of needed informational items, medications,
nutritional supplements, including vitamins, as well as food and healthcare
supplies to HIV patients and their families.
History of HIV in Cuba
The native population of Cuba witnessed decimating epidemics introduced from Europe after Columbus arrived. Yellow Fever, due to a Flavivirus, caused epidemics devastating troops in the Spanish American War. Dengue fever epidemics also 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 USA. Cuba first diagnosed HIV/AIDS in a soldier returning from Mozambique in 1985...four years after HIV/AIDS was first diagnosed in the USA. Large scale testing of the Cuban population commenced in 1985. In 1986, Cuba, as many other nations in the World, was concerned about the possibility of HIV being a highly contagious virus (Ebola or Marburg virus) derived from Africa. Jorge Perez, M.D., an infectious disease expert who trained at McGill University in Montreal was very suspicious, despite international agency assurances, that blood products transmission of HIV was possible. Dr. Perez ordered the destruction of all foreign derived blood products in Cuba in 1986. This destruction of foreign origin blood products caused even more strain on the Cuban healthcare system because blood products had to be rapidly replenished from healthy people of Cuba. Dr. Perez’s “hunch” to destroy foreign derived blood products allowed Cuba to escape the ravages of HIV transmitted to hemophiliacs and others who electively receive blood. In 2002, blood product transmission of HIV is very uncommon in Cuba.
During 1985 and early 1986, a nationwide HIV screening program was initiated
at a cost of US $3.0 million dollars. In 1985, condoms as a preventive measure
for HIV/AIDS were introduced in Cuba. Condom use in Cuba has been problematic
due to the “machismo” attitude of many Cuban men. Over 20 million HIV tests
have been performed on the Cuban population since 1986. In 1987, 146 Cubans
were HIV positive. In 1989, 274 Cubans were HIV positive. Due to the restraints
of the Cuban economy and the USA Embargo restricting availability of modern
clinical laboratory testing and the concurrent lack of antibiotics and prescription
medications, Cuba, as it had done with other epidemics since 1900, instituted
classic public health measures in the late 1980s and early 1990s, including
a vigilant quarantine of HIV positive patients. The quarantine was used to educate
patients and their families about HIV, directly observe patient treatment outcomes
and to safeguard the general population of Cuba. Careful identification of every
HIV positive individual in Cuba allowed the tracking back to the “source” of
the patient’s HIV infection, whether in Africa or Cuba. Cuba has an extensive
confidential database of HIV positive individuals along with all their intimate
contacts who have contracted HIV or remained HIV negative.
Initially, there was only one HIV/AIDS sanitorium in Cuba in Santiago de las
Vegas, outside of Havana to quarantine HIV positive patients. Because many HIV
positive patients housed at the “Los Cocos” sanitorium were originally domiciled
in other regions of Cuba, Dr. Perez noticed family members moving to Havana
to be close to their HIV positive kin. This migration of families to the “Los
Cocos” vicinity placed additional strains on Cuba. Many of these family members
were jobless, lacked local housing or food and wanted to enroll their children
in local schools.
The Los Cocos facility, a rural Havana enclave having numerous acres of land,
was organized to allow HIV positive patients to have mobility, friendship among
fellow patients and to produce food for local consumption at the sanitorium.
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.
High level Cuban government officials decided to open sanitoriums throughout
Cuba. Although it was not his decision to authorize the sanitorium system, Dr.
Perez was enlisted to implement the sanitorium system for HIV/AIDS in 1986.
Between 1986-1989, Dr. Perez urged the Cuban government to relax the absolute
quarantine policy for HIV/AIDS patients in Cuba. Dr. Perez successfully lobbied
for the quarantine policy of Cuba to be discontinued in 1994. Long term residence
at HIV/AIDS sanitoriums in Cuba is voluntary.
The goal of the panCuban sanitorium system was to have HIV positive patients
live in the regions of Cuba of their original residences close to their families.
These sanitoriums were designed to provide proper nutrition, shelter, and medication
dispensation. There was to be no charge to the patients for their care at the
sanitoriums. These sanitoriums further evolved into being patient, local public
and international education resources. The sanitoriums in Cuba have been visited
by many international healthcare givers. Dr. Perez personally traveled throughout
Cuba and carefully selected the locations for these sanitoriums and annually
personally visits all the sanitoriums in Cuba. Sanitoriums existed in the USA
for many years for leprosy and tuberculosis. During the Kennedy Administration,
tuberculosis hospitals across the USA were closed and re-incarnated at mental
health facilities. Tuberculosis fell “off the radar” screen in the USA (and
has subsequently come back to haunt the USA and the World).
In addition to the establishment of the provincial sanitorium system, Dr. Perez
destigmatized HIV/AIDS in Cuba. Worries about HIV/AIDS being highly contagious
and a imminent threat to the public health of the general population of Cuba
lessened as Dr. Perez demonstrated 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.
Many HIV positive patients elect to voluntarily continue to live and work in
the sanitoriums to help Cuba prevent and control HIV nationwide.
The first HIV positive patient AIDS activist who continued to live at the Los
Cocos facility and help Cuba with its fight against HIV/AIDS was Raul Llano
Lima. Raul tested positive for HIV in 1986. Raul died at age 39. At his funeral,
Dr. Perez eulogized Raul as follows: “With us in the sanatorium, he worked in
the accounting department. Raul organized the inventories, help set up computerized
systems to keep track of medical supplies, and in fact he headed the sanatorium’s
accounting department for a period of time. Raul Llanos was known for the serious
quality of his work, for his dedication. That was Raul, the outstanding worker.
But at the same time, there was Raul, the HIV patient of the sanatorium since
1986: sharp, observant, revolutionary, who fought to see that the truth be known
about the sanatorium inside and outside of Cuba, defending the health care policies
of the Revolution and the Revolution itself. He spoke often to the foreign press
and visiting groups, and he always spoke to them with sincerity and firmness
of principles. In the United States—in San Francisco, New York, Philadelphia,
he spoke and told the truth about our system, defending the principles and the
fairness of the Cuban Revolution’s health policies.We have come here today together
with his friends and family, to bid our last farewell to a companero dearly
beloved by everyone. We have suffered a real loss. We join with his family,
friends, patients and workers of the sanatorium in saying: We will always remember
you, Raul. Rest in Peace.”
Another early activity of the sanitoriums was to assist Cuba in determining
local sources of HIV who had not been diagnosed, treated or educated about their
HIV status and the impact it had on HIV/AIDS spread in Cuba. In the 1990s, a
film, Vencer por la vida, documented the sanitorium system for HIV/AIDS care
in Cuba. The film was produced through the efforts of Javier Echevarria and
Eddie Leiva.
In addition to government programs regarding HIV/AIDS in Cuba, Alberto Montano,
after discussing his plans with Dr. Perez and Father Fernando de la Vega, founded
the Cuba AIDS Project in 1995. The Cuba AIDS Project was originally based in
Miami, Florida. In 1997, Alberto sought the help of Byron L. Barksdale, M.D.,
a Nebraska pathologist who had an interest in Cuba and HIV/AIDS in Cuba. Alberto
lacked healthcare credentials and needed a physician in the USA to help add
credibility to the efforts of his Non-Governmental Organization efforts. Alberto
remained the director of the Cuba AIDS Project until his untimely death in 1999.
In compliance with all USA laws, rules and regulations regarding Cuba, the Cuba
AIDS Project works with Father Fernando de la Vega at Monseratte Church in Central
Habana and his HIV/AIDS patient support group.
Cuba’s policy on the importance of Non-Governmental Organizations
(NGOs) is as follows:
“Grassroots NGOs have the ability to develop a regional solution to an issue-specific
aspect of the HIV/AIDS pandemic. The Republic of Cuba believes that acknowledging
the importance of NGOs in the fight against HIV/AIDS is a crucial factor in
creating an effective global campaign to prevent the spread of the pandemic.
However, Cuba recognizes that many NGOs face some problems such as lack of resources
and poor networking. Therefore, Cuba suggests that governmental institutions
running activities to prevent the spread of HIV/AIDS should come together with
their programs for networking and select the best strategies to avoid unnecessary
duplication of some activities and thus help save resources. Cuba also supports
AIDS service NGOs to develop follow-up activities to the Declaration on HIV/AIDS
and to share experiences and lessons learned. Cuba appeals to all nations to
support NGOs, and to work together with them to sensitize and create awareness
initiations to slow down the HIV/AIDS epidemic in the world, to render a long
term workplace HIV/AIDS intervention program as HIV/AIDS would be a development
problem for the coming many years. The most important role for the government
in the fight against AIDS is to ensure an open and supportive environment for
effective programs. Accordingly, Cuba firmly holds the viewpoint that it is
crucial that governments integrate and accept findings and strategies recommended
by various NGOs rather than refusing them.”
Cuba now produces anti-viral medications (AZT, d4T, ddI, ddC, saquinavir, and
nelfinavir) domestically for use in its patients and will export these medications
to other countries once the national requirements within Cuba are attained.
Longer than most nations, including the USA, Cuba has realized the importance
of 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, sexually transmitted
diseases (syphilis, herpes, gonorrhea) as well the HIV infection itself with
anti-retroviral medications.
Surveillance and Epidemiology: (1) Expand a population-based
HIV sero-prevalence survey to be representative of the entire country (2) Expand
a sentinel antenatal surveillance system (3) Evaluate the potential for additional
sentinel screening and educational programs (4) Assist health officials with
the timely collection, analysis, interpretation, and dissemination of surveillance
data facilitated by state of the art software provided to Cuba for epidemiology
and management of infectious diseases (5) Assist health officials in identifying
ways of publicizing surveillance data to policy makers, health care providers,
and researchers (6) Provide computers and train key staff in computer applications
such as data management, data presentation, and use of data for decision making
(7) Provide training and build capacity for laboratory studies to help maintain
the infrastructure of surveillance system.
A comprehensive Maternal To Child Transmission (MTCT) prevention program that
includes: (1) Nutritional supplementation and prophylaxis against opportunistic
infections for patients found to be HIV-infected (2) Use of AZT or Neverapine,
in conjunction with Voluntary Counseling and Testing (VCT) among pregnant women,
to reduce MTCT of HIV (3) Voluntary testing and counseling (VCT) primarily for
pregnant women and their primary sex partners (4) Rapid testing for rural sites
(5) Ante-natal RPR testing and treatment for syphilis if indicated (6) TB screening
for HIV+ women, as well as preventive prophylaxis (7) Treatment of certain opportunistic
infections (i.e., INH for TB and cotrimoxazole for certain infections) (8) Nutritional
supplementation to alleviate anemia or wasting syndrome (9) Couples’ counseling
(encourage husbands of HIV+ women to seek testing) (10) Provide milk for at
least a minimum of the first six months after birth of infants whose mothers
are HIV positive (11) Monitoring and evaluation of programs and all HIV/AIDS
related activities in Cuba.
PRIMARY PREVENTION: Voluntary Counseling and Testing (VCT)
VCT should be expanded aggressively on a national basis as an integral part
of HIV/AIDS program in Cuba. UNICEF should agree to train more counselors for
every district. Expand VCT to non-traditional sites to target HIV positive individuals.
Mother To Child Transmission (MCTC): (1) Women are quite amenable to testing
(2) Expand TB testing as part of HIV+ follow-up (3) Expand treatment of opportunistic
infections and provide total care for HIV-infected persons: prophylaxis, nutritional
supplementation, palliative care, (4) Assure milk and vitamins are available
(at least for six months) for infants whose mothers are HIV+ positive (5) Assure
RPR testing is done routinely.
Blood Banks Blood product transmission of infectious diseases is not a significant
problem in Cuba. There are multiple testing sites and all blood is tested (HIV,
HVB, syphilis). Non-acceptable blood is destroyed and patients harboring infectious
diseases are evaluated and treated.
Strengthening Sexually Transmitted Infections (STI) management:
(1) Expand routine screening, (2) Improve STI surveillance data (3) Expand drug
sensitivity testing for STI (4) Aggressively evaluate and treat all patients
and their sexual contacts. HIV/AIDS in Cuba is essentially a sexually transmitted
disease. Vertical transmission of HIV, blood product transmission of HIV and
IV drug abuse transmission of HIV in Cuba are all very uncommon.
Building Public and Private Partnerships: A majority of the
population is agriculturally based. There is a national program on HIV/AIDS,
directed by the Ministry of Health, to set the course for national policy
Increasing Prevention Programs for Youth: (1) An increasing
percentage of the population is < 35 years of age (2) Youth should be more
aggressively targeted for screening (3) In the absence of prophylactic measures
(such as limited supplies of condoms due to the USA embargo’s prevention of
selling raw materials to make condoms in a Las Tunas factory), youth should
be aggressively advised to abstain from risky sexual behavior by clergy and
adults or enter into monogamous relationships.
Supporting and strengthening national education and mobilization efforts:
(1) Expand the use of radio and television in getting people to participate
in VCT (2) Increase visual motivation (posters, theater, etc.) to participate
in VCT. There are very few billboards and other visual reminders in urban areas.
(3) Expand teaching of sexually transmitted diseases in schools.
Improving community and home-based care and treatment: (1)
Expanding tuberculosis (TB) prevention and care (2) Increase active surveillance
of TB (3) Expand medical evaluation for TB to all “at-risk” individuals (4)
Develop comprehensive measures to prevent nosocomial transmission of Mycobacterium
tuberculosis (5) Expand surveillance for drug-resistant Mycobacteria.
Enhancing Care and treatment of HIV/AIDS and opportunistic infections (1) Expand
the ability of patients to access and receive anti-retroviral triple therapy
(2) Expand the diagnosis and treatment of opportunistic infections (3) Develop
“state of the art” feasible guidelines for managing HIV-related conditions (4)
Expand capacity for home-based care (5) Monitor and improve the quality of palliative
care (6) Optimize coordination of services at all health care levels, (7) offer
hope to HIV patients and their families of turning HIV into a chronic disease
which can be managed and allows people to return to useful work and a wholesome
life.
Development of capacity and infrastructure for surveillance:
(1) Expanding and strengthen HIV/STI/TB surveillance programs (2) Current accepted
level of sero-positivity in the general population is about 0.03% which is significantly
lower than sero-positivity in the USA (0.4%) and (3) Assure adequate capacity
to analyze and interpret data
.
Expanding and Strengthening HIV/STI/TB surveillance programs
(1) Laboratory staff should receive comprehensive training (2) Expand tuberculosis
surveillance – program should implement screening of all HIV+ pregnant women
(consider more widespread screening as capacity develops) (3) Expand the capacity
for antimicrobial sensitivity testing, particularly among M. tuberculosis and
N. gonorrhea isolates.
Vaccine Development and Clinical Trials:
Cuba is working on a vaccine to combat HIV/AIDS. The clinical trials are being
coordinated between the C.I.G.B. and the IPK Tropical Medicine Institute. The
country is being divided into several regions for clinical trials. When data
is available, the outcome of these clinical trials will be given here.
Recommendations:
There is a continuing need for facilitation of major activities (surveillance,
epidemiology, laboratory support, vertical transmission of HIV, voluntary counseling
and testing, prevention, social support, treatment, etc). Health officials in
Cuba are dedicated individuals who have already established a national system
to combat HIV/AIDS under the guidance of Dr. Jorge Perez at the IPK Tropical
Medicine Institute. 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), condoms, and
informational materials to the people of Cuba must be increased to assure adequate
control of HIV/AIDS in the population as well as optimal management of any patient’s
disease. Educational materials in Spanish regarding HIV/AIDS should be provided
extensively to Non-Governmental Organizations (NGOs) including the HIV/AIDS
support group at the Monserrate Church in Central Habana.
The efforts of Father Fernando de la Vega at Monserrate Church should not be
underestimated as an effective mechanism to restore a sense of community among
homeless, hungry, despairing, sick HIV/AIDS patients in Havana. Local community
Non-Governmental Organizations (NGOs) for HIV/AIDS patients should be established
in all major cities in Cuba (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 simultaneously the Church
ameliorates the persecution, suffering and the disenfranchisement HIV/AIDS patients
and their families often experience in many countries, including Cuba. The people
of the USA, through 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 for the future
to HIV patients and their families of transforming HIV into a chronic disease
(such as diabetes) which can be managed permitting people to return to school,
work or enjoy a wholesome life.
The enormous increase in tourism to Cuba from many countries (Europe, Canada,
USA, etc.) mandates Cuba maintain and continuously improve its HIV/AIDS program
for obvious reasons. Currently, it is estimated 170,000 USA citizens travel
to Cuba annually. After the USA Embargo against Cuba is lifted, there may be
millions of USA citizens visiting Cuba each year. The USA does not need to have
HIV/AIDS endemic and highly prevalent in its neighbor country, Cuba, with millions
of USA citizens visiting in the post-Embargo era, contracting the virus, and
then returning to the USA infected with new genetic strains of HIV-1 to be further
disseminated within the USA.
The Cuba AIDS Project continues its efforts to bring USA awareness to the uniqueness
of HIV/AIDS in Cuba. An example is recent data discovered about the genetic
variation of HIV-1 in Cuba.
Unparalleled Genetic Diversity Found in HIV-1 Isolates from Cuba
The genetic diversity of HIV-1 isolates obtained in Cuba is "extraordinarily
high," investigators report in the August 16th 2002 issue of AIDS.
Dr. Rafael Nájera, of the Instituto de Salud Carlos III in Madrid, Spain,
and associates, under the auspice of UNAIDS, conducted sequence analysis of
pol and env segments of virus isolated from 105 individuals resident in Cuba.
Fifty of the isolates were subtype B while 55 sequences were of non-B subtypes.
Only 12 non-subtype-B isolates were non-recombinant and included subtypes D,
G, C, F1, H and J. The recombinant viruses included 14 different forms, most
frequently D(pol)/A(env).
Altogether, the investigators identified 21 genetic forms. This degree of diversity
has only been reported from countries in Central Africa, the authors note. However,
"considering that the estimated number of infections is only approximately
2000, the HIV genetic diversity found in Cuba, in relative terms, has no parallel
in any other country," they add.
The authors ascribe the source of the genetic diversity to the many individuals
stationed in Angola in the 1970s and 1980s, as well as Cuban aid workers who
worked in several sub-Saharan African countries. The finding that more than
half of isolates were of non-B subtype, but only 10 infections were acquired
in Africa, indicates that viruses introduced from Africa are now circulating
in Cuba.
Dr. Nájera and his colleagues also suggest that prolonged quarantine
of HIV-infected individuals in sanatoria and low availability of condoms led
to a high rate of co-infections, which in turn facilitated the generation of
recombinants.
The authors caution that the expansion of tourism in Cuba and economic pressures
that increase the likelihood of casual sexual contacts could lead to the export
of multiple genetic forms of HIV-1.