Fear of mother-to-child transmission of HIV and other infectious diseases has been used as an excuse to deny women health care around the world. Some women living with HIV have even been sterilized without their knowledge. But with proper treatment, the chances of transmission to an unborn child are very low in many cases. The World Health Organization (WHO), in fact, just declared Cuba the first country to eliminate mother-to-child transmission of HIV and syphilis.
The news has generated disparate reactions. Some are celebratory, others more dubious. Few have expressed much shock or surprise, however. There are a couple of reasons for this. First, while not perfect, the Cuban national health care system produces significant positive health outcomes. Second, other countries have met the same standards for eliminating transmission; they just haven’t been recognized by the WHO.
“Elimination,” in this case, does not equate to zero transmission. According to the WHO, “elimination of transmission is defined as a reduction of transmission to such a low level that it no longer constitutes a public health problem.” In Cuba, a low-level mother-to-child transmission rate means that “less than two percent of children whose mothers have HIV are born with the virus.”
How Did Cuba Do It?
Many public health experts attribute Cuba’s success to its universal health care and system of “consultorios” and “policlinicos,” which are essentially well-resourced clinics integrated into local communities. Consultorios provide primary care, and policlinicos provide secondary care.
Melissa Marzán, a Puerto Rican epidemiologist, was impressed by her visit to a maternity home in the Matanzas province of Cuba. In an interview with the Maternal Health Initiative, Marzán described the home as “a link between communities and the hospital,” with the capacity to serve around 5,000 at-risk pregnant mothers each year. The home uses an “ecological model,” meaning that it accounts for many of the factors that affect maternal health, from placenta previa to exercise. It offers a wide array of programs on the changing needs of mothers at different stages of pregnancy, including educational trainings on nutrition and breastfeeding as well as more targeted programs, such as those for adolescent mothers. Due to Cuba’s nationalized system, all these programs are free.
While the maternal home in Matanzas is just one example, it represents what makes the consultorios and policlinicos so successful. They deliver accessible, free health services directly to communities rather than forcing people to travel several miles to the closest hospital, and they apply a comprehensive, woman-centered approach that addresses both individual and social determinants of health.
In what seems like a push for additional countries to go through the validation process, the WHO acknowledges that others have achieved similar reductions in transmission. These countries include: Anguilla, Barbados, Canada, Montserrat, Moldova, Puerto Rico, Thailand, and the United States. Many, like the United States, have simply not sought validation.
Given this, not everyone is placing Cuba on a pedestal. Puerto Rico is using the increased regional attention to highlight its own gains. “Without wanting to detract from what our brothers in Cuba celebrate today, we celebrate that in Puerto Rico we have eliminated HIV transmission from mothers to infants since 2011; and in the [Center for Mother and Child Studies], we did since 2003,” Dr. Carmen Zorrilla, director of the Center for Mother and Child Studies at the University of Puerto Rico, told El Nuevo Día.
Few people know better about the state of mother-to-child transmission in Puerto Rico than Zorrilla. She started the first longitudinal clinic in the country for women living with HIV and is the director of the Center for Mother and Child Studies, which offers extensive prenatal care and treatment options for HIV-positive pregnant women, including antiviral treatment for mothers and infants, Caesarean sections, and formula instead of breastmilk. The center’s open door policy has allowed it to prevent HIV transmission to more than 500 infants in the past 12 years.
Puerto Rico presents an interesting comparison to Cuba due to differences in health care systems and regional roles. Since Puerto Rico is an American territory, one might expect the health system to benefit from a close relationship with the United States. However, on top of a mounting $73 billion debt, the country is suffering from a crisis caused in part by differential Medicaid and Medicare reimbursements.
What’s Next for the Caribbean?
As of 2011, 79 percent of HIV-positive pregnant women in the Caribbean received antiretroviral treatment. While this level of coverage is impressive, the region still has the second-highest HIV transmission rate after sub-Saharan Africa and a long way to go before reaching the WHO validation requirement of more than 95 percent coverage.
Cuba’s example, and the recognition it has received, may encourage other countries to seek WHO validation. Cuba and Puerto Rico have demonstrated different ways to reduce mother-to-child transmission. However, a universal need, according to Marzán, is comprehensive, community-accessible health facilities and consistent and widespread data collection.
Sources: AVERT, The Daily Beast, El Nuevo Día, Joint United Nations Program on HIV/AIDS, Journal of the American Board of Family Medicine, New Vision, Noticias 24/7, Washington Post, The Well Project, World Health Organization.
“Moncada Health Clinic” © 2010 PBS NewsHour, used under a Creative Commons Attribution license: https://creativecommons.org/licenses/by-nc/2.0/
This post originally appeared on The New Security Beat, blog of the Environmental Change and Security Program at the Wilson Center