Monday, 17 February, 2003,
Cuba leads the way in HIV fight
By Molly Bentley
BBC News Online science writer in Denver
Few stories about HIV/Aids infection bring hope. But in the Caribbean, where communism takes its last gasp, there is encouragement in the fight against Aids. "Cuba has a lid on the HIV/Aids problem," said Dr. Byron Barksdale, the director of the American Cuban Aids Project, a non-profit organisation that provides humanitarian aid to the island. There has been no dramatic increase in HIV transmission in Cuba since the beginning of the epidemic, said Dr Barksdale at the at the annual meeting of the American Association for the Advancement of Science in Denver. Cuba's 0.03% infection rate is one of the lowest in the world. In addition, certain forms of HIV transmission that plague the rest of the globe are almost non-existent on the island. There is virtually no transmission of the virus through intravenous drug use, blood transfusion or to newborns at birth.
The country now produces enough anti-retroviral medicines to supply the country's patients. As a result, the 25% predicted mortality rates for patients with Aids in 2002 were instead 7%. While mother-child transmission is a huge problem in African countries, for example, in Cuba, the government ensures that all HIV-positive mothers are treated with prophylactic AZT therapy up to delivery and then the babies are delivered by caesarean section. No infants contract the virus through the birth canal, according to Dr Barksdale, who added that Cuba's prevention measures are not likely to be implemented in other countries. "It would be difficult to mandate Caesarean sections on all HIV-positive mothers in the United States," he said. Cuba's low HIV infection rate is due largely to the country's extraordinary response in early years of the epidemic.
Cuba established the National Commission on Aids in 1983 to provide education on the disease, a full two years before the first Cuban national contracted the virus, and at a time when the word "Aids" carried such stigma, US President Ronald Reagan refused to use it in public speeches. But in Cuba, said Dr Barksdale, people had lived under socialism long enough to have "an idea of classlessness," which made educating the public and providing medical attention fairly straightforward. Under Cuba's socialised health care system, all HIV/Aids patients receive medical care and drugs free of charge. But some requirements of the programme pinch personal liberties. In the late 1980s, Cuba implemented a classic public health measure and began quarantining patients. The quarantine system includes eight weeks of education and drug support, after which the patient is free to leave - although, many choose to stay, according to Dr Barksdale.
In addition, a national surveillance system tracks all infected people and
their partners. As a result, the government has an extensive database on all
HIV/Aids infections, including their source, whether from overseas or within
the country. While the authoritative response helped contain the spread of the
virus, Cuba's political isolation initially prevented access to life-saving
anti-retroviral drugs. Then Cuba got innovative. Unable to afford the expensive
anti-retroviral medicines produced in developed countries, Cuban chemists analysed
the drugs' chemical components and set about recreating their own. Cuba now
produces sufficient quantities of seven anti-viral medications for all its patients.
Because it is self-sufficient in drug production, said Dr Barksdale, the country's
next step is to export medication. He predicts that Cuba will soon offer to
sell the anti-retroviral drugs at cost to other countries. "I suspect there
will be countries in Latin America, the Caribbean basin, and in Africa that
will purchase these drugs directly from Cuba," he said. In this, Cuba has
set an example of political leadership in its response to the AIDS crisis, according
to Monica Ruiz, from the US National Institute of Allergy and Infectious Diseases.
"It's an example of what a country can do on it's own shores," she
said. "While each country will provide a different response, this shows
that political will has to be there." BBC News
Cuba's AIDS Policy Offers Lessons - UPI, Feb. 21, 2003
When it comes to trying to control the AIDS epidemic, America might find a few useful pointers from -- of all places -- Cuba.
The nation has combined political will, a well-coordinated healthcare system and an intensive, mandatory education program to achieve a rate of infection from the human immunodeficiency virus that is one of the world's lowest.
Cuba's HIV-infection rate is 0.03 percent of the population -- about 3,500 people. In the United States, the rate is 10 times higher. About 0.3 percent or about 1 million Americans are infected with HIV, the virus that causes AIDS. On other Caribbean islands, such as Haiti, infection rates are hundreds of times higher than on Cuba.
"The U.S. can learn a lot of things from Cuba about HIV/AIDS," said Dr. Byron Barksdale, a pathologist in North Platte, Neb., and director of the Cuba AIDS Project. It is a non-governmental organization that helps to provide drugs, diagnostic equipment and other humanitarian aid to the island, as well as licensed travel. The U.S. government permits the efforts despite its decades-long prohibitions against contact or trade with Cuba.
Speaking this week in Denver at the annual meeting of the American Association for the Advancement of Science, Barksdale said the key element that could be exported from Cuba to the United States is the concept of educating people intensively if they are newly diagnosed with HIV infection.
In Cuba, such individuals must spend six to eight weeks at a sanitarium where their infection is treated with anti-retroviral drugs manufactured in Cuba. There, he explained, patients are instructed about AIDS: what the disease is, how it affects the person who has been infected and how a person can prevent transmitting the disease to others, using safe sex practices that include proper use of condoms as well as abstinence.
"I don't know if six weeks or eight weeks are the magic numbers," Barksdale told United Press International, "but that is certainly a longer time than is given to people in the United States who received such a diagnosis. They may get about five minutes' worth of education."
Barksdale said the Cuban government has mandated the following:
-- Pregnant women must undergo an HIV test. If they are found to be HIV-positive,
they are given anti-retroviral drugs to prevent transmission to their newborn.
They also deliver via Caesarean section
-- a known method of reducing possible HIV transmission. Since 1985, only 12 HIV-positive babies have been born in Cuba.
-- HIV-infected people must provide the names of all sexual partners in the past six months, and those individuals must be tested for HIV.
-- People found to have sexually transmitted diseases must undergo an HIV test as well.
-- Voluntary HIV screening is encouraged.
"In the United States, the rights of the individual are foremost," Barksdale said, "but in Cuba the individual is expected to do what is necessary to protect the collective society." That is why people are willing to roll up their sleeves and not protest blood tests to determine their HIV status, he said.
From 1985 to 1994, the Cuban government quarantined all people found to be HIV-infected. Under the direction of Dr. Jorge Perez, a Cuban infectious disease expert, those infected were allowed to leave the sanitarium after completing the required education courses, Barksdale explained, adding that because food, housing, medication, social services, privacy and other services are provided in the sanitarium, about half the people decide to stay.
Dr. Monica Ruiz, a health scientist administrator at the National Institute of Allergy and Infectious Diseases in Bethesda, Md., said AIDS prevention projects seem to work in places such as Cuba and Uganda, where education and de-stigmatization of AIDS-infected people become goals of the government.
For example, she noted in Uganda, government officials always discuss AIDS in their speeches. Although AIDS continues to sweep across most of sub-Saharan Africa, Uganda's infection rates have plummeted in the past few years after the country's active prevention campaign.
"There are no vaccines that will be made available to treat or prevent HIV/AIDS any time soon," Ruiz said. "Prevention is the thing we have left, and that is driven by behavior."
In Cuba, Barksdale said, if patients who decide to leave the sanitarium engage in unsafe sex, they are likely to find themselves in permanent quarantine. He said the goal of his project is to help Cuban authorities keep HIV infection at bay. An ironic challenge might arise because thousands of American tourists might head for Cuba if the U.S. government lifts its trade embargo against the island nation.
"There are 21 different strains of HIV in Cuban patients," he said, "and all are of African origin." He suggested that if American tourists become infected with those strains -- which are uncommon in the United States -- it could cause a new explosion of infection and disease in North America. "We want to help Cuba keep a lid on this problem." he said.
"We can use prevention tactics to control HIV infection," said David Holtgrave, professor of behavioral science and health education at Emory University in Atlanta.
"It is a matter of will. We know what kind of interventions that work.
We know what needs to be done. We know what it will cost."
Copyright 2003 by United Press International.
All rights reserved.
Transcript of Cuba Aids Project Interview:
Nebraska Public Television, 3/26/2003)
[Bill Kelly, Reporting] The Monserette Church does not stand out in Central Havana. Mass on weekday evenings draws a modest sized group of the faithful...mostly women...mostly older. No sooner has mass ended then the cooking begins. Twice a week the Church ministers to a younger group. Many are not Catholic. All are HIV positive, or accompany a family member who is.
[Luis Ernesto, HIV+ Cuban] Every week I look forward to Wednesdays like they are a gift. Luis Ernesto, 35, married, finds support, and understanding and laughter at least once a week here at the Monserette Church.
[Luis] Here I can get away from the reality, and talk to people suffering the same way I do. Luis found a safe harbor in a country which… like the United States… struggles to understand this disease and the people it attacks.
[Bill Kelly] Father Fernando de la Vega has become the unlikely host to Havana's only support group for Cubans facing life with AIDS. This aging cleric still marvels at the calling God has provided his church.
[Fr. Fernando de la Vega, Cuban AIDS Project] I'm not so much surprised as I am gratified.
[Bill Kelly] The phone calls never end from those seeking advice and comfort. It is a Catholic ministry that serves all denominations for anyone facing AIDS, often fearful and hopeless.
[Fr. Fernando] There are those who are ill and dying who choose suicide. Others seek redemption. When the final time is coming, my personal experience is, a lot of them choose Christ.
[Dr. Byron Barksdale, Cuban AIDS Project] What Father Fernando does there is provide a sense of community to the out patient HIV/AIDS patients in Havana.
[Bill Kelly] The Father's unlikely partner is known only as Dr. Byron. He lives a place most Cubans would be hard pressed to find on a map: North Platte, Nebraska. From here he serves as director of the Cuban AIDS Project.
[Barksdale] Well it wasn't by choice initially. I was just on the advisory council and the founding member unfortunately passed away and so it fell into my lap. I don't think people in the Midwest are fearful of a difficult task. If the Project was easy, it probably wouldn't be quite as challenging.
[Bill Kelly] Sixteen hundred miles from Havana, Dr. Byron Barksdale manages western Nebraska's biggest pathology lab. He grew up in Florida, fascinated with Cuba, just across the water. His work with The Cuban AIDS project started as a favor and evolved into a second job once he'd met Father Fernando.
[Barksdale] Father Fernando has brought in people who are homeless, hungry, sick and suffering from despair and given them an opportunity to relate to one another. He feeds them and provides them with educational materials and support.
[Bill Kelly] Dr. Barksdale provided an American connection that the cleric in Havana knew was invaluable.
[Fr. Fernando] Four years after the group started we received a visit from Dr. Byron. He explained he could help with setting up a web site in the United States to promote us. Soon every time people came to Cuba they would bring a small bag of medicine or personal items for our group.
[Bill Kelly] It is against the law for Americans to travel to Cuba as tourists. They can get permission from the U.S. government if they are on a humanitarian mission. The AIDS Project makes sure the proper forms and permits were filed. The night we visited a diamond wholesaler from Fort Myers, Florida who stopped by Monserette Church with a delivery of supplies.
[Hogan] Everybody needs Santa Claus and without Santa Claus there is no hope. And in this day and time when Americans are looked down on, it could be Cuba it could be anywhere, I'm just doing my part. Because everyone needs a little help now and then.
[Bill Kelly] At the same time, the second support group of the week gathers. These gay men of Havana struggle with a disease and a lifestyle not always accepted or understood in a macho, Latin culture.
[Fr. Fernando] The congregation of the Church did not understand the people with AIDS and did not want them. Neither did the people in the neighborhood. There is a horrible lack of understanding about AIDS in Cuba.
[Bill Kelly] Some of the regulars were given recently donated asthma inhalers. Magazines were given out as door prizes. A questionnaire helped sort out self-esteem issues.
[Bill Kelly] More than anything, it was just nice to be in a place where no one judged you or feared your disease.
[Fr. Fernando] They have understood that they are in the same boat. The HIV positive diagnosis is not the last of life. They must make the most of their lives.
[Bill Kelly] The Cuba AIDS support groups put a revealing face on the nature of the disease on the island.
[Barksdale] The majority of HIV/AIDS in Cuba is homosexual or heterosexual transmitted. It's a sexual disease in Cuba. It is not an IV drug abuse disease or a blood products’ disease as HIV/AIDS is in other parts of the world.
[Bill Kelly] This is a passionate and sexually open culture. If the gay community has been driven underground by Castro's regime, heterosexuals are open, flirtatious, even boastful. Luis spoke openly about how both his wife and his girlfriends deal with his diagnosis.
[Luis Ernesto] My wife, she is healthy. She helps me and supports me with how I am now. After I got out of the sanitarium, all of the girls I hooked up with were healthy. These girls ask you: Do you have condoms?, and if you do, they go to bed with you. That depends on the personal attitudes of the person.
[Bill Kelly] Condoms are readily available and government campaigns urge couple to use them. They are even made available by Father Fernando.
[Barksdale] Father Fernando recognizes the importance of sexual transmission of AIDS in Cuba so he allows the group to have access to condoms, which, in general, the Catholic Church frowns upon.
[Fr. Fernando] We need more Spanish language literature about the need to use condoms, but also the message must be that sex needs to be something that happens for love and not just for pleasure.
[Bill Kelly] The Cuban government also gets good marks for the health care it provides those with AIDS, even if the approach seems radical in America. The health officials established Sanitariums---isolation wards for those who have AIDS. The medications that are available are free and the treatment mostly compassionate.
[Barksdale] I think Cuba recognized earlier than the United States that there was more to controlling HIV/AIDS than prevention. Cuba actively intervened therapeutically as well as Cuba could. Cuba understood the social support structures better than the United States. Cuba provided people with food, housing, and clothing. Cuba basically gave its HIV/AIDS patients hope sooner and showed people cared.
[Bill Kelly] Still, those diagnosed with AIDS discover that the stigma of this disease is strong. The same government that provided Luis with decent medical care also will turn him away for a job.
[Luis Ernesto] I eliminate myself from the job when they ask me for medical tests. I say I won't pass the test anyway, so I don't try.
[Bill Kelly] The government won't hire you if you have HIV?
[Luis] Yes, it does, but you must be tricky.
[Bill Kelly] At the Monserette Church, a virus in the blood stream is no reason to turn you away.
[Fr. Fernando] The only difference between them and us is that they are in a searching calculation of the meaning of the last years of their lives. And the rest of us are not.
[Bill Kelly] The strangers who arrive at the Church's back door to help bolster Father Fernando's faith. He remembers the first... the one he calls the wingless angel.
[Fr. Fernando] When I was alone in the Church one evening I came down here to this place in the dark. I say to Him "you are the owner of this business and I am only your employee. If you don't place your hand on this business there is no way to pay the electric bill." Then a wingless angel appears at the door. She says here is 20 American Dollars for you. So we can pay the electricity. I am a very faithful man.
[Barksdale] I've learned there are people better than myself in this World and that Father Fernando is someone whom I can aspire to emulate as far as altruism towards Mankind.
[Bill Kelly] So a soft-spoken doctor from Nebraska says he learned about the very essence of compassion and decency on an island considered to be a political enemy of the United States.
Reporting from Havana, Cuba, I'm Bill Kelly for STATEWIDE on NETV
(Nebraska Public Television).
With help, Cuba copes with AIDS
by Mary Murray, NBC NEWS, June 28, 2002
U.S. charity comes to the rescue of Havana mission HAVANA, June 27, 2002 — Seven years ago, a young Cuban runaway named Regino found out he had AIDS. Regino lived in Havana, broke and alone, searching for work after having left the family farm. His timing could not have been worse — Cuba’s economy was in tatters and Havana overcrowded with many others like Regino fleeing the poverty of the provinces. He ended up working Cuba’s black market, selling cigars and sex to foreign tourists.
ONE MORNING, after spending the night on a park bench, Regino felt desperate. Even though not religious, he found himself knocking at the rectory door of Havana’s Nuestra Señora de Montserrat Church. The priest who answered his knock, Father Fernando de la Vega, would be his temporary salvation until Regino’s death several years later.
“We talked for hours. Regino told me about others living alone with AIDS. Then and there, I decided to open the church to them,” de la Vega said.
Regino came back for supper with a friend, another homeless person infected with the HIV virus. The meal they shared that night was a preview of what would become the city’s first soup kitchen and community support group for people living with AIDS.
Every Thursday night since then, about 100 people gather in a makeshift dining room in the back of the church to share what for many is their only hot meal of the day.
De la Vega’s volunteers serve up rice, beans, chicken and salad at a cost of about $1 per person — a bargain price by U.S. standards but a fortune in cash-strapped Cuba, where neither the Catholic Church nor the government funds such grass-roots operations.
When asked how he has kept the soup kitchen running all these years, de la Vega answers, “with a miracle” — albeit an earthly one. Donations come mainly from the Boston Archdiocese and a tiny non-profit called the Cuba Aids Project that operates with a U.S. Treasury Department license allowing humanitarian aid to circumvent the economic embargo on the island.
Father Fernando de la Vega opened his door to AIDS sufferers.
FOCUSING ON THE VULNERABLE
At Nuestra Señora de Montserrat, there is no money to spare — not to replace a collapsing roof or a ramshackle car for the parish priest. Built in 1843, the stone church throws off an impressive shadow at dusk, but the glare of the tropical sun reveals an aged façade literally falling to pieces. The church blends in with the rest of the neighborhood, a seedy commercial zone with empty storefronts outnumbering the few businesses whose doors remain open. De la Vega shrugs that off — focusing instead on helping the most vulnerable in his community. He is also unusual in that he refuses to convert the Thursday evening AIDS support group into a forum to proselytize. “I worry about their souls, but I worry more about their food, their housing and their state of health.” De la Vega’s more traditional flock at first rebelled at the idea of making their church a sanctuary for people sick with the HIV virus. At the start, people simply assumed the priest must be a homosexual to welcome the AIDS community into the church.
About 70 percent of Thursday night’s participants are gay men, reflecting Cuba’s national AIDS statistics. After that speculation died out, his parishioners still balked at sharing the church with HIV carriers. “The congregation was hysterical. They thought I was deranged. Little by little, they came around.” Regular church members now serve up the Thursday night dinners on chipped china donated by the congregation. On a recent Thursday night, a delegation from the Cuba AIDS Project delivered several dozen care packages to de la Vega’s support group. “These are simple things but make all the difference,” said Orlando, a 26-year-old Cuban physician living with AIDS, as he opened a shopping bag containing aspirin, a toothbrush, flu medicine, appetite stimulants, calamine lotion and a bottle of vitamins.
Since 1995, the Cuba Aids Project has shuttled tons of medicines to HIV/AIDS sufferers on the island. Several times a year small groups of average Americans travel to de la Vega’s church to hand over the aid and meet with Cuban health care providers. The only requirement stipulated by the U.S. Treasury Department license authorizing the mission: Travelers are forbidden from engaging in tourist activities during their stay. The man heading the humanitarian effort couldn’t be a more unlikely candidate for the job: Dr. Byron Barksdale, a red-blooded Republican who traces his American ancestors to two Barksdale brothers who settled in the Carolinas in the 1600s. Francis Marion, another Barksdale ancestor, was a patriot leader in the American Revolution. Byron, a scion of a military family, proudly points to his great-grandfather who fought in the Civil War, his father who took part in World War II, and his brother once stationed at the U.S. Naval Base in Guantánamo, Cuba. There’s also a Louisiana Air Force base and a Texas Army camp named after the family. Byron Barksdale became involved in the AIDS Project when he learned how medicine scarcities on the island were killing AIDS patients. The pathologist now living in Nebraska blames the U.S. embargo on Cuba as one factor causing the shortages.
“Cuba has a first-class AIDS surveillance system and prevention program.… Many of the AIDS treatment modalities are available. They’re producing their own anti-retroviral drugs. Their problem is cranking up the supply to satisfy the increasing need in Cuba,” he said “People with AIDS die of common infections, and they lack common anti-fungal or anti-microbial agents to combat this. They don’t have proper anti-cancer therapy to combat tumors. This is their problem — having access to the powerful weapons to control the disease.” Barksdale is also spurred into helping Cuba by the fact that the AIDS virus respects no borders.
“Eventually the embargo will be lifted and we’ll have 1 or 2 million U.S. citizens coming down here. The last thing you want is a high prevalence of AIDS. Imagine if Cuba gets to be a hot spot during spring break. Our sons and daughters will be coming down here, contracting HIV and taking it back to the United States. You can’t cure AIDS in the U.S. but not wipe it out in Cuba. It’s just like polio. You have to eradicate it globally.”
PERILS OF THE CARIBBEAN
As of November 2001, Cuba’s rate of HIV infection was 17 times lower than the rest of Latin America, where an estimated 1.8 million adults and children are living with HIV. According to the United Nations, the Caribbean is in danger of becoming the second most-affected region in the world. Nearly 700,000 people in the Caribbean are HIV-positive. In the Bahamas, adult HIV prevalence has risen to about 4 percent and in Haiti to nearly 6 percent. Cuba retains the lowest AIDS rate in the Americas and one of the lowest in the world with an adult prevalence rate of 0.3 percent. Testing of all pregnant women has resulted in a zero mother-child transmission rate since 1997. At the start of the global AIDS outbreak, Cuba succeeded in keeping down the numbers through harsh measures — running from mandatory testing to forcibly isolated HIV carriers in sanatoriums. While these institutions still exist, most patients are now free to return to their communities.Since Cuban doctors diagnosed the first AIDS case in 1986, a total of 3,750 people have been found infected with the HIV virus. Of these, 2,923, or 78 percent, are male, and 827, or 22 percent, female.
According to Cuba’s foremost expert on AIDS, Dr. Jorge Perez, the greatest challenge to caring for his patients is securing an adequate supply of the right medicines. In 1997, soon after the anti-retroviral medicines hit the world market, Cuba could only afford to buy enough of the “cocktail” for HIV/AIDS children and the most seriously ill adults.
By the summer of 2001, Cuban chemists successfully duplicated the anti-retrovirals and began producing enough for local use to make a difference.
Previously, Perez had routinely hospitalized 90 patients a month in Havana’s sophisticated Tropical Medicine Institute. By November, that rate had been slashed to a dozen. Still, there is not enough of the medicines to go around.
Under Cuba’s socialized health care system, complete medical attention for HIV/AIDS sufferers, including the anti-retroviral treatment, is free of charge. Underscoring the emphasis on health and education, the Cuban government allocated 65 percent of its national budget this year to funding social programs.
Perez, a frequent lecturer at de la Vega’s AIDS support group, often counsels on prevention strategies. But the same economic hard times that lured people like Regino to Havana and into the sex trade, hamper the cash-starved island from importing sufficient quantities of condoms.
U.N. money this year should help ease this shortage along with a national task force that aims to integrate prevention strategies by involving educators, health care providers, government agencies and non-government organizations.