Confronting AIDS Update 1988 (1988) / Chapter Skim
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Appendix A: Summary and Recommendations from Confronting AIDS: Directions for Public Health, Health Care, and Research
Appendix A: Summary and Recommendations from Confronting AIDS: Directions for Public Health, Health Care, and Research
Pages 169-201
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Appendixes
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Much is known about the virus that causes it, about the ways in which the virus is transmitted, about the acute and chronic manifestations of infection, and about its impact on society. Although this knowledge is incomplete, it is extensive enough to permit projections of a likely 10-fold increase in AIDS cases over the next five years, to provide a basis for planning the provision of health care, to guide policy decisions on public health, and to envisage strategies for drug and vaccine development.
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The risk of infection with HIV is directly related to the frequency of exposure to the virus. Groups now at highest risk of infection are homosexual men, IV drug users, persons likely to have heterosexual intercourse with an infected person, and the fetuses or newborn infants of infected mothers.
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Cures for any one of the host of opportunistic infections associated with AIDS, with the possible exception of P carinii pneumonia, would not prolong survival much, because it is the HIV infection that causes the immune system damage and thus, ultimately, the death of AIDS patients.
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One drug has recently shown benefits in the treatment of AIDS, but agents that are acceptably safe for possible long-term treatment and that effectively halt or cure the disease may also not be available for at least five years. THE FUTURE COURSE OF THE EPIDEMIC Estimates of the future course of the epidemic are important to the planning of health care, public health measures, and research.
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Continuing spread of HIV in IV drug users throughout the United States is also expected. Infected bisexual men and IV drug users of both sexes can transmit the virus to the broader heterosexual population where it can continue to spread, particularly among the most sexually active individuals.
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This message is particularly important for IV drug users and their sexual partners. The most obvious targets for a campaign of education about AIDS are persons whose behavior puts them at special risk for example, male homosexuals who practice anal intercourse without a condom.
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However, the committee believes that governmental officials charged with protection of the public's health have a clear responsibility to provide leadership when the consequences of certain types of behavior have serious health outcomes. If government agencies continue to be unable or unwilling to use direct, explicit terms in the detailed content of educational programs, contractual arrangements should be established with private organizations that are not subject to the same inhibitions.
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Preventing HIV Infection Among IV Drug Users As a group, IV drug users have incurred the second-largest number of AIDS cases in the United States. IV drug users are also the primary source of heterosexual HIV transmission (via their sexual partners)
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However, if drugs are available and clean needles and syringes are not, IV drug users will probably use available unsterile equipment. The committee concludes that trials to provide easier access to sterile, disposable needles and syringes are warranted.
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Mandatory screening of selected subgroups of the population for example, homosexual males, IV drug users, prostitutes, prisoners, or pregnant women raises serious problems of ethics and feasibility. People whose private behavior is illegal are not likely to comply with a mandatory screening program, even one backed by assurances of confidentiality.
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Voluntary, confidential testing should be encouraged, because individual and aggregate antibody test results enable epidemiologists to assemble baseline data for longitudinal studies of the incidence, prevalence, and natural history of the disease. Such studies can be used to monitor the spread of the virus and to provide the data needed for changing control strategies.
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Resources are needed for education, serologic screening, surveillance, increased drug use treatment, and experiments designed to test the effects of greater availability of sterile needles and syringes to drug users. Present expenditures are inadequate.
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have occurred within small geographic areas where there are educated homosexuals. Programs for other groups, such as IV drug users, will face more difficult problems of access and motivation; they will therefore probably require more resources per capita.
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A major portion of this total should come from federal sources, because only national agencies are in position to launch coordinated efforts commensurate with the potential size of the problem. The process of designing and implementing educational interventions to reduce the risk of HIV transmission, followed by evaluations of their effectiveness, will enable policymakers to evaluate over the next year or two the magnitude of effort needed to bring about a drastic reduction in the spread of HIV infection.
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AIDS patients need an array of services that can prove difficult for hospitals to accommodate if they have not organized for the task. The committee recommends that, for provision of hospital inpatient care, AIDS units or teams should be established in high-incidence areas, with
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Also, representatives of existing agencies and health care providers should organize AIDS care groups to coordinate efforts toward community-based care. Special systems of care may be required to meet the particular needs of certain AIDS patients, such as IV drug users.
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Large numbers of infected IV drug users in certain cities will seriously encumber their municipal hospital facilities. In New York City, AIDS patients who are IV drug
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The Financing of Health Care for HIV-Related Conditions The financing of care for patients with AIDS and other HIV-related illness now depends on the same variety of public and private plans that apply to patients with other diseases. Most of the public funds for care of AIDS patients come through the Medicaid program, which is estimated to cover about 40 percent of such patients.
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The Natural History of HIV Infection Much remains to be learned about the natural history of HIV infection how the virus establishes and maintains infection and how it leads to the immunologic deficits and pathologic consequences associated with ARC and AIDS. For instance, it is not known what factors activate the provirus; what influences the ability to isolate the virus from an infected
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In addition, active surveillance is needed of groups of particular epidemiologic importance, such as heterosexuals and non-IV drug users in high-incidence areas, IV drug users and homosexual men in low-incidence cities, spouses of infected individuals, pregnant women, newborn children of infected mothers, prostitutes throughout the country, and recipients of blood products. Better information is also needed to quantify the number of persons infected with HIV.
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Thus, mechanisms should be developed to ensure that AIDS-related experiments with chimpanzees proceed only if there is a broad consensus among the interested scientific community that the proposed experiment is critically important to the development of vaccines or antiviral agents and cannot be conducted in any other species or by any other means. Antiviral Agents The development of acceptably safe and effective antiviral agents for the treatment of HIV infection is likely to be a long, hard job with no certainty of success.
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Shortly before the publication of this report, data were released by the National Institutes of Health and the Burroughs Wellcome Company from a study of azidothymidine (AZT) administered for 20 weeks to a group of approximately 140 AIDS patients while a similar group received a placebo.
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Social Science Research Needs Social science research can help develop effective education programs to encourage changes in behavior that will break the chain of HIV transmission. It can contribute to the design of policies that reduce the public's fear of AIDS and that help eliminate discriminatory practices toward AIDS patients.
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These funds must be new appropriations, not a reallocation of existing Public Health Service funds. Areas of clear need include high-containment facilities for primate research, better containment facilities for universities and research institutes, training funds, construction and renovation funds, equipment funds, social science and behavioral research funding, vaccine and drug development efforts, international studies, basic research efforts, and epidemiologic studies.
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Such personnel may be at risk of infection or need appropriate care. Risks of Infection Outside the United States Sexual transmission probably accounts for the largest proportion of transmission of HIV outside of the United States.
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The committee concludes that simpler serologic tests that give sensitive and specific results rapidly and reliably are essential before widespread efforts to control HIV transmission via the blood supply in developing countries will be practicable. Transmission of HIV through the sharing of needles and syringes used to inject IV drugs is well documented in countries where IV drug use is common.
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federal agencies, private voluntary groups, and foundations interested in international efforts on AIDS and HIV. GUIDANCE FOR THE NATION'S EFFORTS No single approach whether education and other public health measures, vaccination, or therapy is likely to be wholly successful in combating all the problems posed by HIV infection.
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The commission would monitor the course of the epidemic; evaluate research, health care, and public health needs; encourage federal, state, philanthropic, industrial, and other entities to participate; stimulate the strongest possible involvement of the academic scientific community; encourage greater U.S. contribution to international efforts by relevant government agencies and other organizations; make recommendations for altering the directions or intensity of health care, public health, and research efforts as the problem evolves; monitor and advise on related legal and ethical issues; and report to the American public.
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· The committee recommends that the President take a strong leadership role in the effort against AIDS and HIV, designating control of AIDS as a major national goal and ensuring that the financial, human, and institutional resources needed to combat HIV infection and to care for AIDS patients are provided. · The committee urges all cabinet secretaries and other ranking executive branch officials to determine how AIDS and HIV relate to their responsibilities and to encourage the units within their purview to work collaboratively toward responding to the epidemic on a national and international level.
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· Improve understanding of the natural history and pathogenesis of AIDS, and trace the spread of HIV infection by means of epidemiologic and clinical research. · Study sexual behavior and IV drug use to find ways to reduce the risk of infection.
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· United States involvement should include both support of World Health Organization programs and bilateral efforts.
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