New Day for AIDS Policy in Cuba

For years, Cuba has been notorious for its draconian treatment of people infected with the virus that causes AIDS: The government has rounded up everyone infected with the human immunodeficiency virus and locked them in sanitariums until they developed AIDS and died.

But now the Cuban government is quietly taking a less oppressive approach to preventing the disease.

The most striking indication of that change is the government’s decision to allow Doctors Without Borders, an international medical aid organization, to design and put in place a public health campaign to prevent the spread of AIDS on this island 90 miles off the Florida coast.

After a year spent diagnosing the problem, a Dutch-Cuban team this year began conducting seminars and distributing AIDS information brochures and condoms outside rock concerts and in homes. Cuban musical icon Pablo Milanes even gave a concert dedicated to AIDS awareness.

The regime of dictator Fidel Castro apparently did an about-face in dealing with AIDS, analysts say, less because of international criticism than pragmatism: Cuba--which lost its main trading partner and source of foreign aid with the 1991 collapse of the Soviet Union--cannot afford to quarantine everyone infected with HIV, health care workers said.

Increasing international tourism encouraged by the government as a way to earn foreign exchange--combined with promiscuity here--also has raised concern that Cuba might be vulnerable to an outbreak of sexually transmitted diseases, including AIDS.

Cuba’s much-vaunted but financially pressed health care system is not up to that challenge, and therefore has accepted international help to prevent an epidemic. “Cuba cannot afford to carry out a public health campaign of this magnitude,” said Isabel Duque, a Cuban specialist in education about sexually transmitted diseases and one of the project leaders.

In January 1996, when Doctors Without Borders set up shop here, the country did not even have enough foreign exchange to import condoms.

Since then, the Cuban government has worked out a deal with Chinese manufacturers, though distribution problems remain. While some pharmacies and nightclubs report they have a plentiful supply of prophylactics, others in the same neighborhoods ran out weeks ago.

Still, distribution is only part of the problem.

First, Cubans must be persuaded that they need to use condoms.

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To attract attention, the Doctors Without Borders project has appealed to the Cuban penchant for risque puns. The 60 Cuban medical students--called promoters--who work with the program wear T-shirts with a randy and profane slogan that roughly translates, “Without a Condom? No . . . Way!”

“AIDS awareness is extremely low,” Duque said. “People believe that everyone who is infected is in sanitariums, and that is not true.”

Until four years ago, the Cuban government isolated those infected with HIV, which causes AIDS, allowing them to leave sanitariums only with escorts.

Cubans argue that their approach has worked: Officially, 659 cases of HIV infection have been detected in Havana since 1986. Health care workers said that across the island, 1,615 of Cuba’s 11 million people are infected. That is the lowest HIV infection rate in the Caribbean, according to the World Health Organization.

But as the number of people infected has grown and the island’s economic crisis has deepened, Cuba can no longer afford to keep patients in sanitariums until they die, health care workers said. Now, people with AIDS are brought to sanitariums for several months of intensive counseling, with an emphasis on their responsibility not to infect others. At the end of that period, patients, in consultation with psychologists, decide whether to remain in the sanitarium or to return to the community, health care workers said.

In Cuba itself, little information is available about the change in AIDS policy. Nor are most Cubans aware that the main source of HIV infection has changed in recent years, health care workers said.

They said the first cases of AIDS in Cuba were detected among Cuban soldiers who had been stationed the African nation of Angola.

But now, most HIV infections have been traced to Northern European tourists, according to Cuban scientists who have studied genetic evidence.

Cuban authorities acknowledge that they are concerned that AIDS will spread because of the casual attitude young people have toward sex, combined with the rise in recent years of international tourism--their euphemistic reference to the reappearance of prostitution in Cuba.

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Outlawed after the 1959 Marxist revolution, prostitution has once again become common as Cubans look for new ways to earn dollars that they can use to buy valued goods that are not for sale in pesos--everything from cheese to tennis shoes.

Prostitutes are among those now at highest risk for AIDS in Cuba. They also have been the most difficult group to reach with AIDS prevention information, said Go Bruens, the Dutch administrative assistant for the Doctors Without Borders project.

Project leaders organized a seminar for the women, first in a classroom and later at the home of one young prostitute. But “they left us waiting,” said Bruens, noting that because prostitution is illegal, “they are afraid of being identified.”

To address the difficulties in getting through to this high-risk population, the Doctors Without Borders team is developing a new program to get AIDS information to prostitutes.

In the meantime, a visit to the waterfront Vedado district shows the scope of Cuba’s potential problems with sexually transmitted diseases, especially AIDS.

At Sherezada, a singles bar snuggled among the hotels, paired shadows sway on the dance floor to the romantic strains that Cubans call “feeling.”

Regulars, some of whom are as young as 15-year-old Liselca Rodriguez, say they party there two or three nights a week. They leave it to have sex with different partners, often foreign tourists.

Recognizing the risks that their customers run, the management at the government-owned bar recently added a new item for sale: condoms, priced at 20 Cuban cents (about 1 U.S. penny), which are cheap even for workers who earn the minimum wage of $100 a month. Offering condoms--until recently available only in pharmacies--for sale in bars popular among young people is a key part of the Doctors Without Borders effort.

And the young people said in interviews at various Havana nightclubs that AIDS awareness is increasing.

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“Condoms are fundamental to avoiding disease,” said Yeni Ricardo, 24, as Rodriguez nodded in agreement. “I tell guys, ‘If there’s no condom, there’s nothing’ “--their partners will not have sex with them.

That attitude is common among young Cuban women, said Raul Acosta, 25, who bought a condom at the Sherezada bar. “A lot of my [male] friends think that sex loses its beauty with a condom,” he said. “But the girls worry about [disease] a lot. They themselves carry condoms in their purses.”

Ariel Quesada Alvarez said that Karachi, the nightclub he manages, has sold 400 of the 2,600 condoms supplied two months ago, a level of sales he said is “not great, but not bad.” One customer, Eduardo Trevino, 30, a department store employee, said he appreciates the convenience. “It’s good for an emergency,” he said. “Imagine, you meet a woman here and you have to tell her, ‘Wait for me while I run down to the pharmacy.’ ”