Monday, January 31, 2011

Why is HIV Prevalence So Low in Cuba? (Hint: Health Services)

Last October Esther Murugi, Kenyan minister for special programs, called for greater acceptance of gay people in society. Her call was met with predictable righteous indignation from most politicians and church leaders. And her call stirred up a bit of debate, a small amount of which may have been constructive.

In the last few days, Murugi called for isolation of HIV positive people as a means of eradicating the disease. Does she mean Kenya should isolate all 1.5 million HIV positive people for up to ten years and longer? Isolate them where? There are not enough schools for all the country's children nor hospitals for the country's sick people.

I'm inclined to give Murugi the benefit of the doubt. After all, she is willing to stand up for one of the most reviled groups in East Africa, gay people. And I don't think she can be held responsible for believing rubbish about HIV, given that global HIV policy is governed by a bunch of racist, sexist quacks.

Ok, she thinks that Cuba has one of the best controlled HIV epidemics in the world because they isolated HIV positive people. What she is probably not aware of is that Cuba has the highest number of doctors per head of population in the world. HIV positive people were actually treated, counseled and supported in Cuba, long before they were in most other countries.

Cuba, like many other countries (the US only recently dropped its travel ban on HIV positive people), panicked a bit at first. But they had one thing that most Western countries have and most African countries do not: good health services. And they took action to make sure that HIV transmission was reduced, both sexual and non-sexual transmission.

Murugi may also be confused because at one time Cuba didn't have access to antiretroviral drugs. That was because of US trade sanctions, not because those cruel Cuban leaders didn't care about HIV positive people. In fact, Cuba is probably one of the few countries in the world that acted decisively, quickly and effectively to limit the damage that HIV caused in most other countries, rich and poor.

Indeed, Cuba still manages to keep HIV transmission low, which is more than can be said for several Western, Eastern European, Asian, African and other countries. Cuba is fortunate in enjoying relative autonomy from UNAIDS and other institutions that seem to exert such a negative influence on HIV prevention and treatment policies around the world.

The minister is seriously misinformed, but misinformation about HIV is not uncommon, rather, it's the norm. And if any Kenyans happen to agree with Murugi, the answer is no, it's not going to happen. The country hasn't even tested the majority of HIV positive people yet or got the majority of people who need antiretroviral drugs on treatment. The country's health services do not have the capacity to even account for all HIV positive people, let alone isolate them, in any sense of the word.

If the minister wishes to make herself useful, she could raise the issue of gays again and perhaps take other measures to reduce HIV related stigma, rather than increase it. For instance, she could point to the evidence from WHO that a significant percentage of HIV comes from unsterile injections (and probably from other unsafe medical procedures).

The extremely low levels of HIV transmission in Cuba, from before HIV was identified, through the earliest days of the pandemic, right up to the present, probably have a lot more to do with the quality of their health services than with the amount of sex Cubans have or the types sexual practices most commonly found there. Levels of transmission in every country probably relates to quality of and access to health services and certainly doesn't relate to sexual behavior. But only Cuba seems to have noticed that.

And if Minister Murugi wants more Kenyan people to be tested, more HIV positive people to receive treatment and more HIV negative people to be protected, she needs to ensure than health services are cleaned up first. The last thing Kenya needs is for everyone to rush to their collapsing health services in the state they are in right now. That's only likely to increase transmission.


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