MSJAMA. Human immunodeficiency virus and quarantine in Cuba.

Abstract

IN 1986, 1 YEAR AFTER DOCUMENTING ITS FIRST CASE OF AIDS, Cuba instituted the world’s only mandatory quarantine policy for people with human immunodeficiency virus (HIV) infection. The Cuban Ministry of Health began widespread HIV testing, focused on but not limited to members of groups considered to be at high risk due to their travel or sexual histories. In 1986 alone, the ministry invested $3 million in testing equipment. By 1993, 12 million tests had been conducted in a country with 11 million citizens. Cubans with HIV infection were confined in newly constructed sanatoriums across the island and were questioned by health workers about past sexual partners for contact tracing and testing. Critics of Cuba’s quarantine policy charged that it violated human rights, while supporters applauded Cuba’s commitment to HIV control. In 1994, the quarantine was officially lifted. However, by 2003, half of all HIVpositive Cubans still lived in the sanatoriums. Cuba’s early response to HIV was unique in the world, but so were the circumstances of its quarantine. First, as an island and a Communist country, Cuba was geographically, politically, and socially isolated from North American and Western European countries that reported high HIV infection rates. Second, Cuba’s Communist political culture did not recognize individual rights as an impediment to its public health measures. Third, compared with other resource-poor nations, Cuba had a well-developed health care system that assigned a primary care physician to all citizens and conducted routine surveillance for infectious disease, and in which universal HIV testing and contact tracing was theoretically feasible. In addition, the Cuban government prioritized HIV care and by the 1990s devoted $15 million to $20 million annually to providing antiretroviral drug therapy, intensive medical care, high-quality food, and housing to quarantined patients. In 2002, the Cuban government reported an HIV prevalence of 0.03%, nearly 11 times lower than that in the United States. International health organizations have reported confidence in Cuba’s HIV reporting system. While Cuban government officials have stated that HIV screening and quarantine were both necessary to maintain the low HIV prevalence on the island, at least 3 other factors could explain the epidemiology of HIV in Cuba. First, since Cuba has been politically and socially isolated from countries with a high prevalence of HIV, social-sexual exchange with regions with high HIV prevalence in the 1980s was limited. Second, Farmer has argued that because of guaranteed minimum levels of income and access to education, housing, and health care, Cubans were less susceptible to important risk factors of HIV transmission such as poverty and social inequality. Third, aggressive HIV screening and subsequent contact tracing and counseling of infected individuals may have slowed the rate of HIV transmission independent of quarantine. No systematic epidemiological studies of HIV infection in Cuba have been published that would clarify the relative effects of quarantine, social/political isolation, living standards, or testing and tracing on HIV infection rates. Although residence in HIV sanatoriums is no longer mandatory for HIV-positive Cubans, Cuba continues to rely on the sanatorium system as transitional counseling and care facilities. In 1997, the Cuban health ministry announced that Cuba’s HIV infection rate was rising. Since Cuba’s economic crisis in the early 1990s, tourism has generated 43% of Cuba’s balance of payments. No longer socially isolated, Cuba is home to what the international press describes as a prominent sex trade in Havana centered on tourists. Cuba’s prohibition of unofficial community-based health activism may have impeded grassroots HIV prevention efforts, especially among groups contributing to the majority of new infections, such as men who have sex with men. Meanwhile, sexually active Cubans in Havana have reported feeling less susceptible to HIV infection via sexual transmission because of Cuba’s rigorous and successful public health measures in controlling infection rates.