This article describes Cuba's effort to develop a comprehensive program for control of its human immunodeficiency virus (HIV) epidemic. The program consists of multiple interventions, including blood donor screening, a ban on imported blood and blood products, widespread semicompulsory screening of defined and general populations, research and clinical trials on treatment and diagnostic methods, and health education in the press, radio, television, workplace, and schools. The most controversial of the program's measures has been the treatment of HIV antibody-positive persons (both asymptomatic and clinically ill) through what Cubans term a "sanatorial regimen," consisting of admission into an institutional setting where both preventive and curative treatment is offered, and where residents have limited contact with their families, neighborhoods, friends, and the rest of society. The Cuban HIV control program merits studying because of the comprehensiveness of the measures in a poor country; the special experience of screening large, mostly healthy populations; its potential contribution to understanding the natural history of the disease due to the early identification and follow-up of HIV antibody-positive individuals; and the cultural, political, and socioeconomic conditions that give rise to a different epidemiologic profile of the disease and to an apparent societal consensus on the controversial issue of institutional semiconfinement.
PIP: Cuba has a single, unified health system, locally administered, with professional oversight at the national level. The health care system is based upon the following operational principles, unchanged since 1961: health is the responsibility of the state and the right of the people; care must be comprehensive, integrating curative and preventive services; care must be free and accessible to all; social services, health care, and the socioeconomic development of the population are to be coordinated; and popular participation in the health system is fundamental. With the stated objective of controlling the spread of HIV and AIDS in the country, policymakers and administrators of Cuba require that HIV-seropositive individuals be committed to state-operated sanatoria. As of 1990, approximately 0.47 per 10,000 inhabitants of Cuba were infected with HIV, while the average annual incidence over the period 1986-90 is 0.102 per 10,000 population. 362 of the 497 seropositive individuals in Cuba are male, of whom 59% classify themselves as heterosexual and 41% as either bisexual or homosexual. The proportion of HIV-seropositive persons who classify themselves as bisexual or homosexual has been steadily, although slightly, increasing every year. HIV infection rates in Cuba are quite low, with Cuba not experiencing the exponential increase seen in other areas of the world, either in asymptomatic HIV infections or in AIDS cases. The authors reviewed available literature and conducted extensive interviews in Cuba on HIV/AIDS control in the Cuban health system for varying durations over the period 1986-90, making extreme efforts to assure the accuracy of information reported. They found a program which continues to evolve and the existence and provision of factual and nonhysterical educational materials. The educational component of the Cuban HIV control program is, indeed, of high quality and imaginative, yet somewhat disconnected and uncoordinated. Almost everyone in the country has at least heard a talk or radio program or seen information on the television, and understand that HIV can infect anyone, not only gay men. Many people do, however, believe that they can enjoy risk-free sexual intercourse because of the policy to commit HIV-seropositive individuals to sanatoria. Cuban health officials, however, acknowledge that ultimately only education affecting behavior will prevent infection. The sanatoria will therefore soon be functioning as back-up ambulatory facilities for receiving care and support instead of as permanent residences. It remains to be seen whether the program in Cuba will successfully lower or stabilize the rate of HIV transmission in the country.