The brand new Cuba-USA lovefest took another step forward this week with the loud trumpeting of Cuba’s first-in-class achievement, “eradication” of mother-to-child transmission of HIV and syphilis.
The WHO announced it had certified that Cuba as the world’s first country to officially have ridded itself of what is referred to as vertical (mom-to-infant) spread of the virus that causes AIDS. The news quickly hit every headline and newscast, the latest entry in the feel-good moment connecting the two countries.
Not to be a spoilsport, and not to diminish in any way all that Cuba has achieved, but there is a small problem for those who are celebrating. Cuba didn’t actually eradicate HIV—if by eradicate, we mean a concept described by the English word, eradicate. It did “eradicate” the disease in a bureaucratic sense, meaning it fulfilled certain criteria spelled out in the fine print that define the eradication “validation indicators.”
For those who read to the bottom of the page of the WHO’s self-congratulatory press release, the definition of eradicate is defined as follows: at least one year of mother-to-child HIV transmission occurring in less than 50 per 100,000 live births. Since Cuba has about 125,000 births a year, this could be as many as 65 infants with HIV born a year—though surely the actual count is much lower. Here’s why.
The WHO also defines “eradication” as a rate of HIV transmission between infected mother to infant of less than 5 percent in breast-feeding populations and less than 2 percent among babies not breast-feeding (read all about it here in the footnotes).
That’s a lot of potential transmission. So yes, things are impressive—very, very impressive—but no, the HIV risk for infants in Cuba has not been removed.
Plus there are facts about Cuba and HIV that are relevant to consider before we use Cuba as a blueprint for other countries. Cuba has about 11.5 million people of whom 14,000 are infected with HIV; their rate of HIV among adults is 0.2 percent. But HIV in Cuba is a disease of gay and bisexual men—women constitute only 20 percent of cases, which translates to about 2,800 cases among females, most of whom are of childbearing age. This puts the rate of HIV among adult women well below 0.1 percent, or less than one in a thousand.
In fact, one study from 2005 found that 16 of 137,000 pregnant Cuban women were infected with HIV. Eradicating—and surely “eradicating”—HIV in Cuba then means that 16 cases must be prevented a year with treatment of Mom and newborn baby, not an impossible task
To put these many numbers in perspective, New York City has almost 9 million people, including around 100,000 living with HIV, of whom 30,000 are women.
Though the number of pregnancies among the 30,000 is not known, overall in the U.S., almost 9,000 HIV-infected women give birth annually. Figure 1,000 or two HIV-infected pregnant women live in New York City among the 100,000-plus who are uninfected and give birth each year. Yet right here in NYC, only a small handful of babies annually are born with HIV. Using the WHO Criteria, it seems as if the People’s Republic of New York City should be certified to have eradicated transmission as well.
The difference is this: Cuba is starting from an incredibly low rate of infected moms, an achievement not from their approach to pregnancy, but of their exemplary adult screening and treatment program. Cuba has applied the most basic principle of public health: systematic diagnosis and treatment of infected persons. Of course, the fact that HIV (and syphilis) is sexually transmitted adds endless sermonizing and finger shaking to the discussion, often grounding prevention programs before they ever really get going—at least in the U.S., where sexual abstinence remains a non-risible public health intervention.
However, Cuba’s admirable accomplishment in adult and pediatric HIV control never will be greeted by a full-throated cheer from public health officials, at least for those who recall Cuba’s HIV control efforts in the 1980s and early 1990s. Then, the local approach was to quarantine infected persons in sanatoria, where they would live out their lives away from the uninfected. By the mid-1990s, the sanatoria began to be changed over to outpatient centers, where antiviral pills were given and other medical conditions attended to. But for many, the brutally inhumane approach to the sick and dying remains unconscionable.
Plus there is this very somber note. As the U.S. and Cuba become BFFs, tourism to the island surely will flourish and with it, commercial sex, drugs, and sexually transmitted diseases, including HIV. Already this year, before the current political embrace, a particularly virulent strain of HIV was reported from Cuba.
Cuba should therefore celebrate their achievement, however oddly defined, on the public health public stage. I suspect that all too soon, this era of calm and control will be referred to as the good old days, the golden moment when the government still could look after the health of its citizens.