CU HIV AIDS strategy
28 October 2003

Chicago Tribune - PINAR DEL RIO, Cuba - Niurka Rojas was diagnosed with HIV 13 years ago and confined to a sanitarium on the outskirts of this provincial town. Since then, the government has given Rojas all the medication she needs to fight the illness, ample food and a tidy three-room home that would be the envy of most Cubans. In exchange, Rojas and 45 other patients living here have forfeited some of their independence. Using a strategy that critics have called excessive but that some health experts praise as effective, Cuba has managed to control the spread of the AIDS virus more successfully than most nations. But the approach is grounded in the kind of coercion that only a one-party state can wield.

While the HIV infection rate in the Caribbean region is exploding and now is second only to sub-Saharan Africa, officials in Cuba say that only .05 percent of the country's population has been infected, by far the lowest rate in the area. Cuba's aggressive campaign against AIDS involves universal treatment for those who are HIV positive. There also is an extensive outreach program that uses television advertisements and volunteers distributing educational materials and condoms to encourage safe sex and limit transmission. But the government also closely monitors the lives of those infected with the AIDS virus. Most Cubans who test positive are required to stay in a sanitarium for at least three months. Once there, they can leave only with the permission of the staff. Those who are considered at high risk to spread the infection could stay much longer. Some, like Rojas, choose to make it a permanent home.

"It's good in comparison to how people live on the outside," said Rojas, 32, who has developed AIDS. "I've adapted to this world. I don't know if I will ever leave." Cuba's campaign against AIDS shows how government officials here often use the absolute power of the state to advance what they define as the collective good--in this case slowing the spread of HIV--even if it means limiting the civil liberties of individuals. Peggy McEvoy, a former top United Nations AIDS official in the Caribbean, said Cuban President Fidel Castro responded quickly to the initial outbreak and has continued two decades later to pour staff and resources into the fight against AIDS. "I have enormous praise for what they've done," she said. "It provides an object lesson in what a socialist government can do when they want to do it."

The story is much different in the rest of the Caribbean, where the stigma of the virus is so pronounced that those infected often lose their jobs and are denied admission to hospitals. Poverty, sex tourism, deep prejudice against homosexuals and poor health-care systems have contributed to the rapid spread of AIDS in the region, McEvoy said. "It remains a low priority, and there is a lack of political will," she said. "Being HIV positive in the rest of the Caribbean is becoming the kiss of death."

But critics say Cuba's success in fighting HIV is tempered by the tough measures used in its campaign. Berta Gomez, an AIDS expert with the Pan American Health Organization, said Cuba's approach to fighting AIDS has not been a model for other nations because its policy of isolating carriers violates human rights. "This model is impossible to replicate in other countries because it's a model that separates a person from their family," Gomez said. In a country where family ties are strong, many Cubans infected with the virus said they were devastated after being pressured to enter a sanitarium. "The moment you are diagnosed, you are very vulnerable and feel a lot of fear," said Jorge Brito, a psychiatric nurse who was sent to a sanitarium outside Havana last year and now works there. "The separation from your family is very traumatic. "When you enter, you lose your privacy," he added. "You feel like a prisoner."

While the government's public service campaign has helped curb discrimination against those infected with the AIDS virus, many HIV-positive Cubans living outside the sanitariums said they still fear rejection from society. Rev. Fernando de la Vega, a Catholic priest who runs one of the few non-governmental support groups for Cubans with HIV/AIDS, said he had to shutter the church's balcony windows after neighbors shouted obscenities at participants. "There is a lot of ignorance in Cuba about how you get infected by HIV," he said. "A month ago a neighbor told me that I should stop helping them because AIDS was a punishment from God." Some with HIV/AIDS refuse to participate in a government program that provides them with increased food rations because they fear neighbors may find out that they are infected.

"If the person in the local store knows about my illness, then everyone will know," said a 33-year-old Cuban who is HIV positive and asked not to be identified. "The society is not yet ready to receive people who are HIV positive."

It was in the early 1980s that Cuban officials began noticing that soldiers returning from the war in Angola were suffering from a then-mysterious illness. The government tracked down all Cubans who served in Africa--including soldiers, doctors and teachers--as far back as the mid-1970s and administered more than 100,000 tests for HIV. They also checked all blood donations. By 1986, Cuban health officials had identified 99 people with HIV and quarantined them in a sprawling estate shaded by tropical fruit trees about 10 miles west of Havana. The hospice, known as the Sanitarium Santiago de las Vegas, was the nation's first facility devoted to curbing HIV/AIDS. The policy drew international condemnation. Cuban health officials said the first patients were kept in almost total isolation because little was known about the illness. The common wisdom was that HIV was a death sentence. Several years later, Cuban officials began allowing patients deemed responsible to leave the sanitariums on weekends. In 1993, HIV-positive men and women were allowed to leave permanently if they were considered to be at low risk of infecting others.

Today, about 800 of the 3,892 Cubans diagnosed with HIV/AIDS live at the island's 14 sanitariums, including one that houses only convicted criminals. Any Cuban infected with HIV is required take a course in the fundamentals of the illness and how to prevent its spread through condom use and other means. Those in the sanitariums remain for three to six months and are taught how to identify skin sarcoma, pneumonia and other AIDS-related illnesses and how to safely handle a cut or nosebleed. The government also provides anti-retroviral drugs, though many Cubans say that vitamins, antibiotics and other needed drugs are prohibitively expensive and in short supply. Still, while the overall rate of HIV infection remains low in Cuba, there has been an increase in recent years, and officials are concerned about the spread of the virus among bisexual men.