The way Cuba went about containing its HIV/AIDS epidemic has been both praised and criticised. Should other countries follow its example?
Cuba's comprehensive approach to controlling the spread of HIV/AIDS has provided a rare success story in the battle against the global epidemic, but lingering controversy over past human rights violations mars its achievements.
Cuba has seen no dramatic increase in HIV transmission since the first case was diagnosed in 1986, and the country's HIV infection rate – 0.05 per cent – is one of the lowest in the world and exceptional in a region with some of the highest infection rates in the world.
"Cuba was one of the first countries to take AIDS seriously as a problem, and provide a comprehensive response combining both prevention and care," Peter Piot, executive director of UNAIDS, the umbrella AIDS organisation and a strong critic of Cuba's heavy-handed response of the 1980s, told a regional HIV/AIDS conference in Havana in April 2003.
When the first cases emerged, the government treated HIV/AIDS as a public health emergency: HIV patients were quarantined indefinitely and their sexual partners traced and tested; Cubans who had visited Africa were tested, as were pregnant women; HIV positive women were given drugs to prevent transmission to their unborn children, their babies were delivered by caesarian section.
No anti-retroviral drugs were available on the island because of a US trade embargo. But in 2001 Cuban laboratories began manufacturing generic versions of six different drugs. Now it is one of a handful of developing countries that offer all its HIV/AIDS patients a comprehensive supply.
Cuba set up a National Commission on AIDS to educate its 11 million people about HIV/AIDS in 1983 – three years before the island's first case was diagnosed. Today, Cuban health officials argue that their early response to AIDS was no different to that of South-East Asian governments who quarantined suspected cases of the respiratory virus SARS as recently as in 2003.
Some aspects of Cuba's broad development model, such as its emphasis on health and education, are held up by UN experts to other developing countries, including those in the Caribbean region, whose infection rate of 2.3 per cent is the second highest in the world after sub-Saharan Africa (9 per cent). Cuba's neighbour Haiti has an infection rate of 6.1 per cent.
Dr Rigoberto Torres, director of the Health Ministry's HIV/AIDS programme told Panos Features: "Cuba was one of the first countries to establish control and educational programmes. Our good educational system makes it easy. TV information ads teach people about AIDS and promote safe sex. We also have a sex education programme in schools."
These days the government maintains a comprehensive database of those infected and their chain of sexual partners; and although patients are still required to attend an eight-week course in a sanatorium, HIV testing is no longer compulsory – though it is strongly recommended for pregnant women and those in high-risk groups.
Dr Byron Barksdale, director of the Cuban AIDS Project, an American charity, says "The US can learn a lot of things from Cuba about HIV/AIDS." He told the annual meeting of the American Association for the Advancement of Science this year that the US too should educate people intensively if they are newly diagnosed with HIV infection.
"I don't know if six weeks or eight weeks are the magic numbers," he said referring to the education programme, "but that is certainly a longer time than is given to people in the US who receive such a diagnosis. They may get about five minutes' worth of education."
But he also admits to cultural differences between the two countries that would make it difficult to implement the Cuban model. "In the US, the rights of the individual are foremost, but in Cuba the individual is expected to do what is necessary to protect the collective society."
That is why people in high risk categories are willing to roll up their sleeves and not protest HIV tests, he adds.
In Havana the law is clear on both the rights and duties of HIV-carriers, and those suspected of being infected. Anyone who is HIV positive, who does not use a condom and does not tell their sexual partner, commits a crime.
At the same time, says independent Cuban filmmaker Belkis Vegas, who is making a documentary on AIDS, "Cuban law also prohibits discrimination – nobody can be fired from their job. Their salaries are still paid – even for the AIDS patients in a sanatorium."
One such sanatorium, Les Cocos, is set amidst leafy parkland on the outskirts of Havana. The atmosphere was relaxed as doctors mingled with both patients and visiting relatives recently.
Manuel Acosta and his wife Mayalin, both HIV positive, choose to stay in Les Cocos rather than go home. Acosta told Panos Features: "I'm comfortable here. Since I became HIV positive, I have received training and now work as an x-ray technician. Food is free; it is much better than going home." Since contracting HIV Mayalin has retrained as a nurse.
Dr Rivero Wong, who founded Les Cocos, still smarts from the old accusation that the sanatoriums forcibly detained AIDS patients and deprived them of their rights: "It was never like a prison here and since 1993 all patients have been free to come and go as they please."
The sanatorium is part of a nationwide AIDS awareness prevention campaign (APG), whose activists include 25 Les Cocos patients. One of them, Maria Elena Becquerm, a national coordinator of APG, says: "We go into high schools and test them on what they know about AIDS; the need for condoms. Latin people don't like to use condoms but we try to change their habits."
With 47 per cent of HIV patients choosing to stay on in sanatoriums once their education course is over, the APG also runs a confidential AIDS hotline for those outside.
"Cuba has a lot of potential and lots to offer" others grappling with the AIDS epidemic, says Nina Ferencic, UNAIDS programme development advisor for the Americas. But, she adds, it is largely up to individual countries to decide how they want to apply the model.
For its part, Cuba has offered to produce anti-retroviral drugs for poor countries if another country agrees to finance production at cost price. Two developed countries – Britain and France – are reported to have shown some interest in collaborating with the proposed project.
But Torres is unimpressed. "In coping with the global AIDS crisis, the most serious problem is the lack of political will," he says. "I think it has been a very poor response from rich nations on Cuba's offer to combat AIDS in other countries."
Tom Fawthrop is a British freelance journalist based in South East Asia who writes for the Economist, BBC Online and London Sunday Times.