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Pinned to a wall in central Havana, where several dozen local people of all ages have gathered to dance the salsa, listen to speakers and wander between stalls offering information on health, a poster shows a young man holding out a condom in front of him, beneath the words: “Your future is in your hands.”
It is part of a prevention programme in Cuba that official data suggests has helped keep HIV prevalence at 0.1 per cent of the adult population: one of the lowest levels not only in the Caribbean, but around the world.
Prof Jorge Perez, deputy director of the Pedro Kourie Institute, Cuba’s tropical medicine agency, remembers the start of the HIV epidemic in Cuba. In 1985, he diagnosed the first known patient in the country: a heterosexual Cuban man returning from work in Mozambique, suffering from conditions including anaemia and an enlarged spleen.
That case, and others which followed, soon led to the imposition by Cuba of a move adopted by other countries including the US: the requirement for an HIV test for visitors. Those already in the country who tested positive were allowed to finish their studies before being sent home.
But Prof Perez went further, arguing along with colleagues for an initiative that sparked greater controversy, but which he still defends today. He proposed that all patients with HIV should be quarantined in a state sanatorium.
“We were at the beginning of a new disease,” he says, speaking in his large office, dominated by a vast wooden meeting table. “No one knew much about Aids, we had no treatment and this would allow us to learn the natural history of the disease, try to avoid its spread, and offer the best medical attention.”
Over almost a decade, Cuba looked after nearly 2,000 patients in a network of a dozen such centres across the country. They were treated well, and offered medical assistance, rooms with air-conditioning and television, and high-protein diets.
That was no trivial provision, especially during the economically troubled “special period” of the early 1990s. Even today, some 200 patients remain.
But Prof Perez stresses that the policy ended once the disease was better understood and treatment became available: “Life is not food and colour TV but freedom, family and social activities,” he says.
Those patients also became advocates and educators, returning to the community to advise others, helping distribute condoms and reinforcing Cuba’s already strong emphasis on preventive care. Widespread testing and treatment was also launched, although the US embargo means that Prof Perez has had to use a network of contacts and sometimes even purchase drugs himself while abroad to bring back for his patients.
One measure applied more assertively in Cuba than many other countries has been “contact tracing”, to actively identify sexual and drug-sharing contacts and offer them tests. “It works for syphilis, TB and gonorrhoea,” he says. “Why not for HIV?”
Financial support from the Global Fund to Fight Aids, TB and Malaria, and domestic production of anti-retroviral therapy, has helped strengthen Cuba’s response in recent years, and Prof Perez’s institute is also researching new approaches to treatment.
But in spite of Cuba’s distinctive approach, it shares many of the challenges other countries face. There are some signs that infection is increasing, and it is having to extend and refresh policies continually in order to encourage a reduction in risky behaviours.