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AIDS in Cuba On Site Report
Byron L. Barksdale, M.D. Updated November 26, 2002

"and when he shall die, take him and cut him out in little stars, And he will make the face of Heaven so fine that all the World will be in love with night, And pay no worship to the garish sun" Romeo and Juliet, William Shakespeare

Cuba AIDS Project

Subject: Assessment of HIV/AIDS Activities in Cuba with emphasis on durability

Purpose of travel: To continue to assess the HIV/AIDS activities currently being conducted in Cuba, identify gaps in service, and propose the role(s) that the USA can play in increasing the capacity and delivery of key strategies in the national plan. Additionally, propose the type of longer-term healthcare personnel that would work in this country in conjunction with Cuban health professionals.

Summary: Members of the Cuba AIDS Project met key government and non-government partners working in and around the AIDS epidemic in Cuba as an annual followup on site visits from prior years. We found a great need for funding and implementaion of needed services at virtually all levels. To have a durable program over many years, we continue to propose three main axes around which to focus humanitarian efforts through Cuba AIDS Project: (1) surveillance and epidemiology (2) a comprehensive Maternal to Child Transmission (MTCT) prevention program, (3) and delivery of needed medications, nutritional supplements, including vitamins, as well as food and healthcare supplies.

Cuba now produces seven (7) anti-viral medications domestically for use in its patients and will export these medications to other countries once the national requirements within Cuba are attained. Longer than most nations, including the USA, Cuba has realized the importance of support infrastructure (as seen in the sanitoriums established in the 1980s) for HIV patients and their families. Support facilities, education, prevention and caring partnered with preventive or interventional therapeutics is the best way to offer hope to people with HIV/AIDS and to control HIV/AIDS prevalence, morbidity and mortality in any country. Cuba has understood and implemented these concepts for many years.HIV/AIDS in Cuba is essentially a sexually transmitted disease. Preventive therapeutics includes prevention of opportunistic infections. Interventional therapeutics includes treatment of opportunistic infections, malignancies, other sexually transmitted diseases (syphilis, herpes, gonorrhea) as well the HIV infection itself with anti-retroviral medications.

The Cuban produced anti-HIV medications already have caused a significant decrease in morbidity and mortality among HIV/AIDS patients in Cuba. During the first 10 months of 2002, 66 people in Cuba died from AIDS-related causes. Cuban authorities anticipated a death rate of 25 percent for people with AIDS this year, but through October 31, 2002 there has been a death rate of only 7 percent. In November, 2002, 743 Cubans with AIDS were currently receiving Cuban produced anti-HIV treatments. Cuba first diagnosed HIV/AIDS in a soldier returning from Mozambique in 1986...five years after HIV/AIDS was first diagnosed in the USA. Since 1986, 4,390 people have been diagnosed HIV positive in Cuba and @1,000 of them have died from AIDS or its associated complications..

Surveillance and Epidemiology: (1) Expand a population-based HIV sero-prevalence survey to be representative of the entire country (2) Expand a sentinel antenatal surveillance system (3) Evaluate the potential for additional sentinel screening and educational programs (4) Assist health officials with the timely collection, analysis, interpretation, and dissemination of surveillance data facilitated by state of the art software provided to Cuba for epidemiology and management of infectious diseases (5) Assist health officials in identifying ways of publicizing surveillance data to policy makers, health care providers, and researchers (6) Provide computers and train key staff in computer applications such as data management, data presentation, and use of data for decision making (7) Provide training and build capacity for laboratory studies to help maintain the infrastructure of surveillance system.

A comprehensive Maternal To Child Transmission (MTCT) prevention program that includes: (1) Nutritional supplementation and prophylaxis against opportunistic infections for patients found to be HIV-infected (2) Use of AZT or Neverapine, in conjunction with Voluntary Counseling and Testing (VCT) among pregnant women, to reduce MTCT of HIV (3) Voluntary testing and counseling (VCT) primarily for pregnant women and their primary sex partners (4) Rapid testing for rural sites (5) RPR testing perinatally and treatment for syphilis if indicated (6) TB screening for HIV+ women, as well as preventive prophylaxis (7) Treatment of certain opportunistic infections (i.e., INH for TB and cotrimoxazole for certain infections) (8) Nutritional supplementation to alleviate anemia or wasting syndrome (9) Couples' counseling (encourage husbands of HIV+ women to seek testing) (10) Provide milk for at least a minimum of the first six months after birth of infants. (11) Monitoring and evaluation of program

Training of counselors

FINDINGS:

PRIMARY PREVENTION: Voluntary Counseling and Testing (VCT) VCT should be expanded aggressively nationally as an integral part of HIV/AIDS program in Cuba. UNICEF should agree to train counselors for every district. Expand VCT to non-traditional sites to target HIV positive individuals.

Mother To Child Transmission (MCTC): (1) Women are quite amenable to testing (2) Expand TB testing as part of HIV+ follow-up (3) Expand treatment of opportunistic infections and provide total care for HIV-infected persons (prophylaxis, nutritional supplementation, palliative care) (4) Assure milk and vitamins are available (at least six months) for infants post delivery by HIV+ women (5) Assure RPR testing is done routinely.

Blood Banks Blood product transmission of infectious diseases is not a significant problem in Cuba. There are multiple testing sites and all blood is tested (HIV, HVB, syphilis). Non-acceptable blood is destroyed and patients harboring infectious diseases are evaluated and treated.

Strengthening Sexually Transmitted Infections (STI) management: (1) Expand routine screening, (2) Improve STI surveillance data (3) Expand drug sensitivity testing for STI (4) Aggressively evaluate and treat all patients and their sexual contacts.

Building Public and Private Partnerships: A majority of the population is agriculturally based. There is a national program on HIV/AIDS, directed by the Ministry of Health, to set the course for national policy

Increasing Prevention Programs for Youth: (1) An increasing percentage of the population is < 35 years of age (2) Youth should be more aggressively targeted for screening (3) In the absence of prophylactic measures (such as limited supplies of condoms due to the USA embargo's prevention of selling raw materials to make condoms in a Las Tunas factory), youth should be aggressively advised to abstain from risky sexual behavior by clergy and adults or enter into monogamous relationships.

Supporting and strengthening national education and mobilization efforts: (1) Expand the use of radio in getting people to participate in VCT (2) Increase visual motivation (posters, theater, etc.) to participate in VCT. There are very few billboards and other visual reminders in urban areas. (3) Expand teaching of sexually transmitted diseases in schools.

IMPROVING COMMUNITY and HOME-BASED CARE and TREATMENT (1) Expanding TB prevention and care (2) Increase active surveillance of TB (3) Expand medical evaluation for TB to all "at-risk" individuals (4) Develop comprehensive measures to prevent nosocomial transmission of Mycobacterium tuberculosis (5) Expand surveillance for drug-resistant M. tuberculosis

Enhancing Care and treatment of HIV/AIDS and opportunistic infections (1) Expand the ability of patients to receive triple therapy (2) Expand the diagnosis and treatment of opportunistic infections (3) Develop "state of the art" feasible guidelines for managing HIV-related conditions (4) Expand capacity for home-based care (5) Monitor and improve the quality of palliative care (6) Optimize coordination of services at all health care levels, (7) offer hope to HIV patients and their families of turning HIV into a chronic disease which can be managed and allows people to return to useful work and a wholesome life.

DEVELOPMENT OF CAPACITY and INFRASTRUCTURE FOR SURVEILLANCE (1) Expanding and strengthen HIV/STI/TB surveillance programs (2) Current accepted level of sero-positivity in the general population is about 0.03% which is significantly lower than sero-positivity in the USA (0.4%-0.6%) and (3) Assure adequate capacity to analyze and interpret data

Expanding and Strengthening HIV/STI/TB surveillance programs (1) Laboratory staff should receive comprehensive training (2) Expand tuberculosis surveillance – program should implement screening of all HIV+ pregnant women (consider more widespread screening as capacity develops) (3) Expand the capacity for antimicrobial sensitivity testing, particularly among M. tuberculosis and N. gonorrhea isolates.

Vaccine Development and Clinical Trials:

Cuba is working on a vaccine to combat HIV/AIDS. The clinical trials are being coordinated between the C.I.G.B. and the IPK Tropical Medicine Institute. The country is being divided into several regions for clinical trials. When data is available, the outcome of these clinical trials will be given here.

Recommendations:

There is a continuing need for facilitation of major activities (surveillance, epidemiology, laboratory support, vertical transmission of HIV, voluntary counseling and testing, prevention, social support, treatment, etc). Health officials in Cuba are dedicated individuals who have already established a national system to combat HIV/AIDS under the guidance of Dr. Jorge Perez at the IPK Tropical Medicine Institute. Behavioral changes (monogamous relationships, abstinence, etc.), increased counseling and voluntary testing for HIV, the delivery of medications, food and nutritional supplements, including vitamins, condoms, and informational materials to the people of Cuba must be increased to assure adequate control of HIV/AIDS in the population (hunger is a potent driving force for people to enter the sex business fueling HIV spread) as well as optimal management of any patient’s disease and/or complications. Educational materials in Spanish regarding HIV/AIDS should be provided more extensively to NGOs and the HIV/AIDS support group at the Monserrate Church in Central Habana.

The efforts of Father Fernando de la Vega at Monserrate Church should not be underestimated as an effective mechanism to restore a sense of community among homeless, hungry, despairing, sick HIV/AIDS patients in Havana. Local community Non-Governmental Organizations (NGOs) for HIV/AIDS patients should be established in all major cities in Cuba (Cuba AIDS Project is planning to help start these support groups in Santiago de Cuba and Cienfuegos). The Church offers a renewal in faith, love, patience, hope for the future while simultaneously the Church ameliorates the persecution, suffering and the disenfrachisement HIV/AIDS patients and their families often experience in many countries, including Cuba. The people of the USA, through Cuba AIDS Project, have an opportunity to present, through their care, donations, and support, the "greatness and compassion of the people of the USA" directly to the people of Cuba.

Public campaigns for prevention of HIV need high priority because any funds spent are cost-effective. Preventive and interventional therapeutics must be partnered with overall prevention programs. Treatment offers hope for the future to HIV patients and their families of transforming HIV into a chronic disease (such as diabetes) which can be managed permitting people to return to school, work or enjoy a wholesome life.

The enormous increase in tourism to Cuba from many countries (Europe, Canada, USA, etc.) mandates Cuba maintain and continuously improves its HIV/AIDS program for obvious reasons. After the USA Embargo against Cuba is lifted, there will be millions of USA citizens visiting Cuba. The USA does not need to have HIV/AIDS endemic and highly prevalent in its neighbor country, Cuba, with millions of USA citizens visiting in the post-Embargo era.

Healthcare professionals may travel legally to Cuba through Cuba AIDS Project. For more information, visit the CAP website at www.cubaaids.com

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