HIV in Cuba:
Prevention of Mother-to-Child Transmission
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Mariela Castro, MS
Director, National Center for Sex Education

Jorge Pérez, MD, MS
Director, IPK Hospital, Havana



Mariela Castro, MS
Director, National Center for Sex Education

Mariela Castro with Cuban HIV poster: 
“How do I show you I love you?”

By  Gail A. Reed

Cuba’s National Center for Sex Education (CENESEX) brings together a multitude of professionals for academic courses through master’s level degrees, research, community work, social communication, counseling and sexual therapy.  More broadly stated by its Director Mariela Castro, CENESEX’s mission is to contribute to “the development of a culture of sexuality that is full, pleasurable and responsible, as well as to promote the full exercise of sexual rights.” This is a tall order for any society, especially one with a history of machismo and prejudice against all but heterosexual orientation.  MEDICC Review spoke with Mariela Castro about the experience of women and HIV infection in Cuba.

MR:  Who are the women most at risk today in Cuba for HIV infection and why?

MC:  First of course, women who have both vaginal and anal sex are more vulnerable as a whole than men because of these tissues’ greater absorbency. Interestingly, however, we are not finding that women in casual relationships or even prostitutes are the ones accounting for the most significant numbers among new cases.  Rather, these are among women in stable relationships whose husbands have had extramarital relations, either with other women or with men. This means we have to do more research on the model of partnership such couples adopt for their lives. 

MR:  That in itself raises a number of questions about sexuality and gender roles in Cuba…

MC:  Yes, it does.  And it’s also another indication of why education for safe sex must have a gender component, a gender approach. 

Historically speaking, changing mentality is one of the most difficult things to do, one of the slowest processes in society.  And, as in all societies, we have inherited gender stereotypes that bear serious critical analysis in order to change them.  Even though we’ve made substantial political and legislative strides, we’re still bound by aspects of roles defined long ago.  This subjectivity begins early, in the way children are raised, in how they’re taught to play. We have to learn to recognize which elements of the traditional masculinity or femininity are actually doing us damage.  What parts of the picture actually take away from our freedom, fulfillment and dignity.  We have to take a hard look at these things, or else we’ll keep passing them down from generation to generation.

MR:  How are these manifested?

MC:  In the family, for example, women are still the main ones responsible for domestic life and work, while men “own the street.”   So when a child is born, we have women quite happy to take their maternity leave, but very few fathers taking advantage of their legal right to paternity leave.  Women will stop working to take care of a sick relative - even though they might feel frustrated, they’ll do it.  But very few men do.

There is still a tendency within families to teach boys how to become “machos,” not men.  They grow up thinking they have to “have many women,” rather than pursue equitable, respectful relationships.  The prism for the macho universe is the penis; while for a man, sexual relations are part of a human relationship. These are completely different viewpoints: the first is based on maintaining power over women, while the second shows the way towards an alternative construct of masculinity.

MR:  And so how does this come into play in promoting practices of safe sex?

MC:  We have to include a gender perspective - promotion of new constructs of masculinity and femininity - and not just take an epidemiological approach.  For example, an epidemiologist might simply say:  prevent HIV, use a condom.  But we have to take into consideration how condoms are viewed in the “macho” framework - as a barrier to full sexual enjoyment, to which the “macho” is entitled at all costs, in a relation in which he’s exerting his power.  So, for him to use a condom, he has to begin to construct and define his masculinity in a different way, that doesn’t put a premium only on his own pleasure.  In the end, this stereotype is very dangerous to his own health as well as his partner’s - and this can be true for homosexual as well as heterosexual couples, whenever a relationship defines that one partner has hegemony over the other. 

So, you need to combine both an epidemiological and a gender approach to these very intimate issues. This is why, for example, our posters and other materials emphasize that protection of your partner against HIV and STIs in general is a sign of caring, and that means it’s a responsibility of both partners in a relationship.

MR:  How does CENESEX work with health promoters?  And who are these promoters?

MC: We work with groups who promote safe sex among their peers: men who have sex with men, transvestites, and transsexuals; adolescents and young people in general; and then more broadly with medical students.  In each medical school, there’s a department of Sexology and Education for Sexuality.

MR:  Since you have raised the issue of men having sex with men (MSM), that leads me to ask about respect for sexual orientation in Cuba today.  How does this influence, for example, women’s vulnerability to HIV and other STIs? 

MC:  We see cases of men who have had a stable relationship over the years with a woman or with another man - and then he’ll have an affair perhaps with a younger man, for which the tendency is not to use protection. And so in that single moment, he’s exposed himself to the risk of infection, and of course, also exposed his stable partner. Regarding attitudes towards MSM and bisexuals as well, there have been positive changes - I say that empirically, since we are still studying this.  But at our conferences and workshops that we hold with people from the whole country, it’s clear that participants are more able now than ten years ago to understand and respect another sexual orientation.  I think the work thats been done over the decade in health and by the Cuban Women’s Federation has helped bring about that change, and we’ve done it reaching out to people’s sensitivity as human beings. 

In essence, our view is that any kind of prejudice or discrimination is damaging to health.

We need to do everything possible in Cuba to legitimize and ensure respect for sexual orientation because we’re confronting a traditional culture, like in many societies, with ingrained prejudice. How can we do this?

First, I think we have to work more and better in the schools.  We’ve worked with the Ministry of Education, but I’m still not satisfied we’ve made enough progress, and so we need to deepen understanding among teachers and other school staff; we need to carry more on educational TV, and so on.  And this also has to do with a gender focus, of course.  In the 70s and 80s, we found a lot of fear and resistance to a national program for sex education with such a gender focus.  The program was finally accepted in 1996, and now it’s taught throughout the country; since then it has reduced school dropouts from early marriages and childbirth by one half.

The country now has policies that legitimize sexual orientations and also has brought laws in line with a gender perspective.  But on the legislative front, there is still a lot to be done.  For example, homosexuals now live within the law in consensual relationships, but gay marriage is not recognized, so you have many issues such as inheritance that aren’t fully resolved.  We need changes in the family code itself related to these and other questions, including domestic violence.  CENESEX has now presented two bills in Parliament before the education and children’s commissions that have to do with gender, and these have been well received.

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