The intensity with which Cuba has attacked the pandemic has ensured that it has one of the world's smallest epidemics.
Yudelsy García O'Connor, the first baby known to have been born with HIV in Cuba, is not merely still alive. She is vibrant, funny and, at age 25, recently divorced but hoping to remarry and have children.
Her father died of AIDS when she was 10, her mother when she was 23. She was near death herself in her youth.
“I'm not afraid of death,” she said. “I know it could knock on my door. It comes for everyone. But I take my medicine.”
Ms García is alive thanks partly to lucky genes, and partly to the intensity with which Cuba has attacked its AIDS epidemic. Whatever debate may linger about the government's harsh early tactics — until 1993, everyone who tested positive for HIV was forced into quarantine — there is no question that they succeeded.
Cuba now has one of the world's smallest epidemics, a mere 14,038 cases. Its infection rate is 0.1 per cent, on par with Finland, Singapore and Kazakhstan. That is one-sixth the rate of the United States, one-twentieth of nearby Haiti.
The population of Cuba is only slightly larger than that of New York City. In the three decades of the global AIDS epidemic, 78,763 New Yorkers have died of AIDS. Only 2,364 Cubans have.
Other elements have contributed to Cuba's success: It has free universal basic health care; it has stunningly high rates of HIV testing; it saturates its population with free condoms, concentrating on high-risk groups like prostitutes; it gives its teenagers graphic safe-sex education; it rigorously traces the sexual contacts of each person who tests positive.
By contrast, the response in the United States — which records 50,000 new infections every year — seems feeble. Millions of poor people never see a doctor.
Testing is voluntary, and many patients do not return for their results. Sex education is so politicised that many schools teach nothing about protected sex; condoms are expensive, and distribution of free ones is haphazard.
Cuba has succeeded even though it has the most genetically diverse epidemic outside Africa. Almost all American cases are of one strain, subtype B. Cuba has 21 different strains.
The genetic diversity is a legacy of its foreign aid. Since the 1960s, Cuba has sent abroad thousands of “internationalists” — soldiers, doctors, teachers and engineers. Stationed all over Africa, they brought back a wide array of strains. According to a study in 2002, 11 of Cuba's 21 strains are unknown elsewhere, formed when two others mixed.
And Cuba's success has come despite its being a sex tourism destination for Europeans and Canadians.
While the police enforce laws against overt streetwalking, bars and hotel lobbies in downtown Havana are filled with young women known as jineteras — slang for “jockeys” — who approach foreigners, asking if they would like to go for a drink, or perhaps dancing, with the unspoken assumption that it will lead to more. Even so, of the roughly 1,000 new infections diagnosed each year, 81 per cent are among men and very few among young unmarried women.
In a survey in 2009, 77 per cent of all sex workers said they regularly used condoms.
Heroin use, which drives epidemics in many countries, is virtually non-existent in Cuba, officials insist.
And since 1986, only 38 babies have been born with the virus. In Cuba's cradle-to-grave health care system, pregnant women get up to 12 free prenatal check-ups, during which they are tested for HIV at least twice.
Before antiretroviral drugs were available, HIV-infected women were offered abortions or, if they chose to deliver, Caesareans and free infant formula to discourage breast-feeding and reduce the risk of transmission. Now they get the drugs free.
As broken as it is economically, Cuba still points proudly to one legacy of its 1959 revolution: Basic health care is universal and free. Cuba has 535,000 health care workers (“We're all either doctors or baseball players,” one hospital microbiologist joked) and each citizen is officially registered with a family doctor nearby; if a patient skips a check-up, the doctor is expected to find out why.
“I was trained to expect my patients to come to me,” said Dr. Rafael Mazín, senior AIDS adviser for the Pan American Health Organization in Washington, who is Mexican. “In Cuba, the doctor comes to you.”
Cuba is tied with the United States in both life expectancy and infant mortality. Dr. Jorge Pérez Ávila is Cuba's Tony Fauci, its best-known AIDS doctor. He is grandfatherly now, and clearly much loved by former patients like Ms García, but he has memories of helping his bus driver father make gasoline bombs to throw at the police during the Batista government. As a teenager he dropped out of school to live in the mountains, teaching villagers to read under a literacy programme after Castro came to power.
He treated Ms García's parents on their deathbeds and heard her father beg, “Do whatever it takes to help my daughter live.” (Her father, who had been a soldier in Angola, was a truck driver. He had nine girlfriends in different towns, five of whom he infected.)
Many medical authorities agree that Cuba had an early and effective response to the epidemic. In his book, “AIDS: Confessions to a Doctor,” published only in Spanish, Dr. Pérez gave his account of the meeting that galvanised Cuba's response.
In 1983, Fidel Castro visited the Pedro Kourí Institute, Cuba's top tropical disease hospital, to hear a presentation on malaria and dengue fever.
As it ended, he suddenly asked the director, “Gustavo, what are you doing to keep AIDS from entering Cuba?”
Dr. Gustavo Kourí, son of the institute's founder, was caught off guard, Dr. Pérez said, and stammered: “AIDS, comandante? AIDS? It is a new disease. We don't even know whether it's produced by a bacteria, a virus or a fungus. There isn't much data on it, just what's been reported in the United States and a few cases in Europe. It will take time to know how big it is.”
Mr. Castro replied: “I think it will be the epidemic of this century. And it's your responsibility, Gustavo, to stop it becoming a major problem here.”
This was two years before any American President publicly uttered the word “AIDS.” Asked how Mr. Castro could have been so prescient, Dr. Pérez struggled to find the right word, then said: “Castro has luz larga” — “big lights,” the Cuban slang for automobile high beams. “He reads a lot. He sees far ahead.”
Dr. Pérez is simultaneously both a fan of the Castro government and a bit of a cynic; on December 1, he led a “Viva, Fidel!” cheer at his hospital's World AIDS Day. But he also mentioned that Mr. Castro once praised him by saying: “Jorge, I've been reading your mail. Your patients say very nice things about you.”
The medical establishment reacted quickly. The first step was to throw out all imported blood — 20,000 units. That avoided the devastation that the haemophiliac populations in the United States and France suffered.
Doctors were sent to Brazil and France to study cases.
All of the country's family doctors were ordered to watch for infections that indicate AIDS like Kaposi's sarcoma or Pneumocystis carinii pneumonia.
Because there was no HIV test yet, the first cases were found late in the disease, leading doctors to think most patients died within a year — an erroneous assumption that helped justify the quarantine policy.
In 1986, blocked by the embargo from buying American test kits, Cuba bought 750,000 French ones.
According to Dr. María Isela Lantero, AIDS chief at the Health Ministry's, Cuba's 11 million citizens have been tested 43 million times; last year, more than two million tests were done. That is the equivalent of testing the sexually active population every three years, though in reality the focus is on high-risk groups, who are tested more often.
Cubans returning from abroad are routinely tested, as are pregnant women, prisoners, soldiers, hospital patients, health workers and anyone treated for venereal disease.
Haydee Martínez Obregón, 33, who has lived in the AIDS sanitarium in Sancti Spíritus, in central Cuba, since she was 19, is an example of that. (She lives there by choice, she said, because she has no home outside.)
Asked how she learned she was infected, she said, “My family doctor thought it was a good idea to test me because I was so promiscuous.”
And how did he know that?
“My mother told him everything.”
Anonymous voluntary testing is also available at 700 clinics and hospitals.Anyone who tests positive gets an appointment with an epidemiology nurse, who asks for the names of everyone he or she has ever slept with.
By law, answering is voluntary.
“If they say no, nothing happens,” Dr. Pérez said.
But pressure is clearly applied. A patient who says no to the nurse gets an appointment with the doctor, then with a social worker and then sometimes with a psychologist. Then a team of HIV-positive educators will make a home visit. So might the local Committee for the Defence of the Revolution. Depending on whom one asks, those committees are the defenders of Cuban democracy, domestic spies or just state-sponsored Nosy Parkers.
Some still refuse. Arachu Castro, a professor of global health at Harvard Medical School who often works in Cuba, described one woman who absolutely insisted that she had never slept with anyone but her husband, who was virus-free.
“We called her the Immaculate Infection,” she said.
There are other subtle pressures, Dr. Castro said. Socialist education teaches Cubans to feel responsible for one another. Also, most Cubans subsist partly on government rations and the sick get extra food, and their lifesaving drugs, from the government.
Everyone who tests positive also must take a two-week course in “living responsibly with HIV.”
With mandatory quarantine long gone and the virus now mostly in gay and bisexual men, new infections are slowly but steadily rising. They now approach 1,000 a year, “and we're waiting for the plateau,” said Dr. José Joanes Fiol, the Health Ministry's chief epidemiologist.
Today, condoms and sex education are the chief weapons.
In theory, Cuba would be an ideal laboratory for “test and treat,” the new protocol in which patients who test positive go on drugs immediately to reduce by 95 per cent their chance of infecting anyone else.
However, it requires modern drugs and Cuba makes only the older, harsher ones. Only about 1,100 patients get new drugs, paid for by foreign donors.
“We know about test-and-treat,” Dr. Pérez said. “We would do it, if we could. But we need the funds.” — New York Times News Service