Cuba, although hosting over 2 million tourists per year has the lowest hiv/aids infection rate in the world.

Some details.

LESSONS LEARNED

What has been understood and misunderstood about the Cuban HIV/AIDS program? And what are the lessons from Cuba regarding HIV/AIDS? Some others have attempted to address these questions.

A group of Cuban and French researchers and health professionals surmised that the policy of extensive testing and contact tracing "may be an important factor," as well as education through the public media and schools. However, the rising infections were "worrying," especially among homosexual and bisexual men (39). A detailed report by Gorry stressed the integrated nature of all elements of the Cuban program, suggesting this was a clear "rights-based approach" in terms of privacy, health promotion, peer education, and participation, as well as guaranteed treatment and counseling (40). Gorry considers the major challenges for Cuba to be the impact of the US economic blockade on the health care system, underreporting of infections, the steadily rise in HIV infections among gay and bisexual men, and the persistent cultural stigma toward sexual diversity and the disease (40). With regard to underreporting, however, if the estimates of one Cuban study in 2003 (4) are accurate, this would seem to be less of a problem than elsewhere.

During the past decade, the main developments in Cuba's program have been the rise of the day care program, the Living with HIV courses, the increased role of peer educators, and, since 2001, an ARVT coverage rate of 100%. No neighboring country has this level of treatment. The Cuban infection rate among sexually-active adults has risen gradually in recent years, from 0.1% to nearly 0.15%. Nevertheless, this rate is still well below that of any of its neighbors. The reasons for Cuba's relative success, this paper suggests, are not well understood outside Cuba. During its two-decade experience with HIV/AIDS, Cuba's methods have been alternately ignored or misunderstood. Misunderstandings appear to be most prevalent in the US literature.

Outside views of the testing regime have been criticized through anecdotal material centering on complaints over privacy. Yet the formal practice of targeted testing, patient consent, and legal privacy protection are not so different in Cuba than in many developed countries. Nevertheless, the Cuban emphasis on social responsibility and its related moral pressures do create a distinct climate for testing and thorough contact tracing. It is likely that Cuban health professionals see such moral pressures as a plus, not a problem.

Isolation of patients has played little part in Cuba's program or its success. There has been no quarantine for the past 20 years, a period corresponding to most of the epidemic in Cuba. The 1986-1989 quarantine period was excessive, however it was not aimed at homosexual men, who at that time constituted about 20% of infected persons in the late 1980s. The sanatoria continue to play a lesser, but probably important, role in the HIV program of respite and treatment. However, extended voluntary residence in the sanatoria has led to a new challenge for social inclusion, a concentration of a minority group with high levels of psychological, social, and family support problems.

Cuba's approach to HIV education programs evolved over the 1980s and 1990s by incorporating some important outside influences. "Health promotion" began to supersede "prevention," particularly through peer educator-led activities. Since the 1990s, some international agencies have been directly engaged with HIV education in Cuba.

Finally, one uniquely Cuban feature of the overall HIV/AIDS program has been its strong intersectoral cooperation; that is, the coordinated work of Cuban government agencies, schools, media, and community. HIV education is thus not treated as an isolated program, but is supported by sex education in schools, television programs, and broader "sexual diversity" campaigns.

In spite of the serious effects of the US economic blockade, which limits access to foreign medicine and impedes scientific and professional exchange, Cuba's HIV/AIDS program has drawn on its intersectoral cooperation to help link community education, epidemiological surveillance, targeted testing, and thorough contact tracing. These elements are in turn backed up by a free public health system and a strong commitment to social solidarity. Cuba's experience deserves serious study by those concerned with effective and inclusive approaches to HIV/AIDS.