Confronting AIDS Update 1988 (1988) / Chapter Skim
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. Jlscrlmlnatlon as a special case, 1, 29-30 worldwide cases, 22-23, 159 see also Cofactors in AIDS; HIV infection; Human immunodeficiency virus; Pediatric AIDS Africa AIDS cofactors in, 40 blood supply contamination, 40 heterosexual transmission of HIV in, 3, 40 parenteral transmission in, 40 seroprevalence in, 174 AIDS-associated retrovirus, see Human immunodeficiency virus AIDS Federal Policy Bill, 11, 81 AIDS patients costs of care for, 104-106 health care needs of specific populations, 13-14, 94-96, 106 life expectancy, 108 minorities, 15, 27, 98-99
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228 INDEX obligation of health care providers to treat, 8, 51, 52, 67-68 wage and productivity losses, 16, 106, 107 AIDS-related complex, 3, 37; see also Human immunodeficiency virus American Medical Association guidelines on physicians' duty to warn, 11, 80 policy statement on obligation to treat AIDS patients, 15, 99 recommendations on drug abuse treatment program enrollments, 85 American Nurses' Association, position on obligation to treat AIDS patients, 15, 99 Animal models/experiments baboons, 147 chimpanzees, 20, 21, 124, 142, 147-148, 191 development of, 147-149 facilities for, 149-150 genetically immunodeficient mice, 148 non-HIV-related retroviruses, 147 recommendations, 21, 145, 148, 149 rhesus macaques, 20, 21, 147, 148 simian, bovine, and feline lentiviruses, 18, 21, 124, 147 small animals, 21-22, 149 superinfection experiments, 142, 147 supplies of animals, 21, 148-149, 191 transgenic mouse, 149 vaccine development, 20-21, 142, 144, 145 Antibodies to HIV antienvelope, 134 neutralizing, 134, 142-143 Antibody tests for HIV availability of, 71 confidentiality of results, 10, 72-74, 79, 181 false results, 9, 35, 71 funding for, 88 home test kits, 10-11, 79-80 sensitivity and specificity, 9, 10, 71, 76, California 79 techniques, 71, 79, 190 Antiviral agents 2',3'-dideoxycytidine, 132, 137 ideal characteristics, 191 soluble CD4 preparation, 131 AZT, see Zidovudine Behavioral change B in IV drug abusers, 30 in prostitutes, 10, 79 ways for inducing, 9, 10, 30, 70, 74 see also Public education about AIDS Bisexual men, see Homosexual men Blacks AIDS prevalence among, 8, 51, 52, 67-68 education on AIDS, 8, 13, 68, 89 pediatric AIDS cases in, 95 seroprevalence among, 41, 47, 48, 52, 78, 84 Blood donations lack of risk in, 67 self-screening, 76, 180 Blood donors confidentiality of, 73 screening of, 34, 183 seroprevalence among, 39, 47-48 Blood products heat treatment of factor concentrate, 49 screening, 71, 75-76 World Health Organization safety initiative, 161 Blood transfusion recipients AIDS cases in U.S., 34, 51-52 incidence of new infections in, 4, 49 progression from HIV infection to AIDS, 36, 52 risk of infection, 3, 45, 76, 172 Blood transfusions, HIV transmission through, 34, 39, 42 Bovine immunodeficiency virus, 124 Brown University Center for Health Care Research, 110 Bubonic plague, 1, 27 C confidentiality of HIV test results in, 73 expenditures for AIDS prevention, 184 health care financing, 112 Prostitutes Education Program, 79 syphilis increases, 41 Candidiasis, oral, 36, 214, 215
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INDEX 229 Casual contact, evidence against transmission by, 6, 29, 39, 67, 80, 96, 172 CD4 cells, 130, 133 Centers for Disease Control Costs, see Health care costs classification system for HIV infections, 38, 202-206 definition of AIDS, 2-3, 105, 203-205, 207-217 effectiveness of surveillance efforts, 167 HIV surveys and studies, 50 paid advertising for AIDS education, 7, 65 review of explicitness of educational materials, 66 universal precautions for health care Discrimination personnel, 10, 76, 98 Central nervous system, HIV detection in, 133-134 Children, see Infants and children Cofactors in AIDS in Africa, 40 chronically activated immune systems, 40 data needs on, 59 history of sexually transmitted diseases, 40 host immunoregulatory and infectious pathogens, 135 Colorado, HIV reporting requirements, 73 Condoms commercial advertising, 8, 69 education about, 8, 67, 69, 176 effectiveness, 68-69 prostitute use of, 78 regulation and quality control, 69 virucidal agents used with, 69 Confidentiality about cause of death, 73 exceptions to, 11, 73 health records and medical charts, 72-74 and physicians' duty to warn, 11, 80-81 recommended protections, 9, 72, 74, 101, 181 record of public health officials in preserving, 81 Consolidated Omnibus Budget Reconciliation Act, 114 Contact tracing and notification, 11, 43, 80-82, 179 D Deaths age and gender trends, 4-5, 29 of celebrities, 67 in New York City, 5, 52 projections, 57, 108, 162, 171 publication of cause of, 73 in San Francisco, 5, 52 Dementia care of AIDS patients with, 14, 96, 108 as part of Centers for Disease Control definition, 3, 36, 215 by health insurance companies, 113 protections against, 6, 62-63, 72, 113 public health responses complicated by, 6, 29, 63 range and scope, 63 Drug abuse education for adolescents, 13, 87 by former drug abusers, 13, 87 recommendations, 12, 13, 65, 87 Drug abuse treatment programs ADAPT, 87 counselors for, 12, 13, 85 coupon program, 86 expansion of slots in, 12, 84-85, 86 funding, 13, 84, 85, 88 importance in preventing AIDS, 5, 62 methadone maintenance, 84-85, 87 serologic testing in, 12-13, 87 third-party coverage for, 88 waiting lists for entry into, 12, 13, 84-85, 86, 88 Drugs AZT, see Zidovudine clinical trials, 19, 131, 132, 138-139, 192 development and testing, 18-20, 136-140 FDA approval process, 19, 137-140 HIV targets for design of, 131, 136 investigational new drug (IND) status, 17, 19, 117, 137, 139 liability issues, 139 "magic bullet," 28 Medicaid coverage for, 114-115 roundtable on, 146-147
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nnanclng Findings and recommendations access to health care, 16-17, 111, 117, 118 AIDS as a special case among diseases, 1, 29 AIDS-related complex, 3, 37 animal models/experiments, 21, 145, 148, 149 antidiscrimination measures, 6, 63, 64, 185 barriers to public health measures, 6, 62 biomedical research, 18, 135-136 budget for research, 22, 151 cause of AIDS, 2, 33 clinical trials, 19-20, 140, 145 condom use, 8, 69 confidentiality protections, 9, 72, 74, 101, 181 contact notification programs, 11, 82 counseling and psychiatric/psychosocial support, 9, 10, 12-13, 16, 74, 87, 103-104 drug abuse treatment programs, 12, 13, 84, 85, 87, 178 drug development and testing, 19, 20, 117, 139, 140, 146-147 education of seropositive children, 182 educational programs, 7, 8, 13, 65-69, 87, 175-178, 199
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INDEX 23 1 epidemiological research, 5, 53 facilities for research, 22, 150 funding, 13, 88, 135-136, 184 health care facilities, 14, 95, 96, 185-186, 188 health care financing, 16-17, 111, 117, 118, 188 health care personnel, 15-16, 79, 101-103 international research, 164, 197 models and modeling, 5, 60, 174-175 National Commission on AIDS/HIV infection, 25-26, 167, 198, 199 needle distribution to drug abusers, 86, Health care 179 occupational risks of HIV infection, 15, 100 paid advertising by Centers for Disease Control, 7, 65 precautions by health care workers, 10, 76-77 prevention and control measures, 5, 11-12, 82-87, 174-175, 184 reagents for research, 22, 151 reporting of test results, 11, 82, 180 restrictive measures for HIV carriers, 11-12, 83, 182 screening, 10, 75-79, 101, 196 social science research, 9, 67, 75, 79, 104 test standards and quality assurance, 9, 71 Florida testing, 9, 10-11, 12-13, 15, 74-75, 79, 87, 101, 196 training of health care providers, 15, 102 U.S. international responsibilities, 23, 163, 197 vaccine development and testing, 20, 21, 145, 146-147, 193 mandatory screening for HIV infection, 78-79 pediatric AIDS cases, 95 syphilis increases, 41 Funding animal models, 148 biomedical research, 18, 135-136, 194 diversion from other research and treatment strategies, 6, 30, 62, 194 drug abuse treatment programs, 84, 85 educational programs, 7, 13, 88, 177, 181-185 facilities for research, 150, 194 health care cost research, 110 primate research, 149-150, 194 see also Health care financing G Genital ulcers, 40 H access to, 16-17, 19, 63, 98-99, 110-111, 117, 118, 139-140 basic approach, 93 community-based, 14, 95, 96, 105, 109, 110, 186 day care, 95 decline in high-prevalence areas, 29 deficiencies, 13, 30 demonstration projects, 110, 183 discharge planning, 13-14, 94 ethical issues in, 1, 11, 15, 27, 80-81, 97-101 foster care, 14, 96 geographic burdens, 29, 111, 117 home hospice care, 14, 95, 105 hospital, 29, 105, 106, 185, 187-188 incentive payments for, 14 infection control precautions, 10, 14-15, 76, 97, 98 long-term, 95 nursing homes, 14, 95, 96, 115 recommendations, 16-17, 95, 96, 99-102, 103-104, 111, 117, 118, 185-186 residential care, 14, 95, 96 respite care, 95 sexually transmitted disease clinics,47, 62 special-patient needs, 13-14, 94-96, 186 specialized AIDS clinics, 93, 96 see also Psychiatric/psychosocial support Health care costs average lifetime cost per AIDS case, 16, 104, 178 direct, for AIDS patients, 104-106, 187 estimation, 105 geographic variations in, 105-107, 109
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232 INDEX hospital, 105, 106, 109 indirect, of HIV-related conditions, 16, 106-107, 186-187 for long-term care, 96 Medicaid, 111 national expenditures, 107-108 projections, 16, 108 reimbursement for, 96, 109, 114-115 research on, 16, 109-110, 188 type-of-patient factor in, 106, 109 zivoduvine (AZT) treatments, 108 Health care financing deficiencies, 16, 30, 94, 110-111, 113 eligibility for, 111-112, 114-115, 116 Employee Retirement Income Security Act and, 115 for experimental therapies, 17, 114, 117-118 federalgrant program, 17, 116-117 Medicaid, 17, 111-112, 114-115, 188 Medi-Cal, 112 Medicare, 112, 109, 116, 188 recommendations, 117-118, 188-189, 200 sources, 111-113 strategies, 17, 113-118 waiting period, 17, 112, 116 see also Health insurance Health care personnel AIDS units/teams, 13-14, 93-94 collaborative surveillance study, 44 education and training, 15, 101-102, 186 emergency care personnel and surgeons, 15, 98 funding for, 88 HIV exposure through accidental needle sticks, 39, 44 private physicians, 62 psychological stress in, 15-16, 103-104, 185, 187-188 right to know serologic status of patients, 73 risks to, 14, 97-98 screening for HIV infection, 15, 76-77, 100-101 seropositivity in, 15, 100-101 universal precautions, 10, 14-15, 76, Hispanics 97, 98 volunteers, 105, 186 Health care planning data needs for, 70 problems, 30 Health insurance antidiscrimination laws governing, 113 drug abuse treatment coverage, 88 early-stage coverage, 38 ethical issues, 113 extension of coverage period, 114 inadequate coverage, 17, 111, 188 incentives and subsidies for AIDS patient coverage, 17, 113-114, 116 limitations on coverage, 17, 112-113 state risk pools, 17, 115-116 Health Resources and Services Administration, 102, 110 Helper/inducer cells, see CD4 cells Hemophiliacs AIDS cases in U.S., 51 incidence of new infections in, 4, 49 progression from HIV infection to AIDS, 36 risk of transmission for sexual partners of, 43 seroprevalence among, 4, 47 Hepatitis B virus occupational risks to health care personnel, 97 similarities between HIV spread and, 33, 97 Heterosexual contacts AIDS cases in U.S., 51 seroprevalence among, 39, 41, 42, 47 Heterosexual transmission in Africa, 3, 40, 196 chain of, 12, 41, 78, 84 efficiency of, 39, 43 from men to women, 39, 41-42 study design, 39 from women to men, 39, 41-42 Heterosexuals, prevalence of HIV infection in, 39, 41, 42 High-risk groups case distribution, 51-52 contact tracing among, 82 disease trends by, 46-47, 51-52, 160 education of adolescents in, 87 social stigma and prejudice toward, 6, 61 AIDS prevalence among, 8, 51, 52, 68 educational programs on AIDS, 8, 13, 68, 89 pediatric AIDS cases in, 95 seroprevalence among, 41, 47, 48, 78, 84
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detection, 124 genome structure, 127 prevalence, 18, 123 regulatory genes, 130 taxonomic assignment, 124 transmission and pathogenesis, 123
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contribution to, 30 Intravenous (IV) drug abusers AIDS cases in U.S., 51 bleach distribution to, 12, 86-87 care needs of, 14, 94-95, 106 costs of treating, 106, 109 counseling for HIV infection, 12-13, 87 data needs on, 59 distribution of sterile needles and syringes to, 12, 86-87, 179, 200 efficiency of HIV transmission among, 3, 42-43, 45 former, as counselors, 12, 85, 87 heterosexual transmission of HIV infection through, 12, 41, 8 high-risk behaviors, 41, 42-43, 196 incidence of new infections in, 49 presenting diagnosis for AIDS patients, 106 seroprevalence among, 4, 34, 41, 46-47, 84, 87 testing of, 12, 87 women, 84 see also Drug abuse treatment programs J Job Corps entrants, seroprevalence among, 48 K Kaposi's sarcoma, 106, 205, 214, 216 L Legal issues confidentiality of test results, 9, 72, 81 criminal penalties or civil liability for intentional transmission, 83 discrimination, 63-64, 72, 81 distribution of sterile needles and syringes, 86 education about AIDS, 66 informed consent for testing, 71-72 new drug/vaccine therapies, 139-140, 145 personal liberty restrictions, 12, 83-84 reporting of HIV infection, 180 third-party warnings, 11, 80-81 Lentiviruses disorders caused by, 124 similarity to HIV-1, 124, 133 Life insurance, distinction among applicants, 64 Louisiana, mandatory screening for HIV infection, 77 Lymphadenopathy, see Persistent generalized lymphadenopathy M Macrophages, role in HIV infection, 18, 133, 143, 145
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INDEX 235 Massachusetts confidentiality of HIV test results in, 73 HIV prevalence among women giving birth, 48-49 Maternal-infant transmission IV drug abuse and, 95 risk, 3, 35, 42, 45 Miami, seroprevalence among prostitutes, 78 Military personnel, seroprevalence among, 39, 48 Minnesota, insurance risk pools, 116 Models/modeling data needs for, 5, 58-60 difficulties, 58, 174-175 IOM/NAS workshops on, 60 prevalence and incidence of AIDS/HIV infection, 5, 36 of progression from seropositivity to AIDS, 2, 36 research recommendations, 5, 60 transmission dynamics of HIV infection, 58 types, 58 uses, 57, 60 Monitoring, see Epidemiological surveillance N National Cancer Institute, drug screening program, 136-137 National Center for Health Services Research and Health Care Technology Assessment, 109 National Center for Health Statistics, HIV surveys and studies, 50-51 National Commission on HIV Infection and AIDS, 14-26, 165-167, 198-199 National Institute of Allergy and Infectious Diseases AIDS clinical trial units, 20, 140 AIDS Research and Reference Reagent Program, 22, 150-151 National Cooperative Drug Discovery Groups, 18-19, 136 National Institutes of Health grants for health care training, 102 Office of AIDS Research, 166 National Research Council Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences, 59, 67 Needle sticks, accidental, HIV transmission through, 4, 44, 45, 97-98, 196 Needles and other unsterile implements, HIV infection from, 40 Neurologic complications care needs of patients with, 14, 96 prevalence and severity, 135 types, 205 Nevada mandatory testing of prostitutes for HIV, 78 seroprevalence among prostitutes, 78 New Jersey burden on health care system in, 111 drug abuse treatment programs, 86 mandatory testing for HIV, 79 pediatric AIDS cases, 95 posthospital residential care program, 95 seroprevalence among IV drug abusers, 4, 47 seroprevalence among prostitutes, 78 New York City burden on health care system in, 107-108, 111, 187-188 Covenant House, 79 deaths from AIDS, 5, 52 drug abuse treatment programs, 84-85 educational programs in, 8, 68 pediatric AIDS cases, 77, 95, 109 seroprevalence among homosexuals in, 34 seroprevalence among infants, 86 seroprevalence among IV drug abusers in, 4, 34, 42, 47, 49, 109 seroprevalence among women delivering babies, 49, 52 syphilis increases, 41 o Opportunistic infections in AIDS, 205 Oregon, insurance risk pools, 116 p Palo Alto Medical Foundation Research Institute, 109-110 Parenteral transmission accidental needle sticks, 4, 44, 45
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236 INDEX in Africa, 40 blood transfusions, 34-35, 36; see also Blood transfusions; Hemophiliacs through needles and other unsterile implements, 88 see also Intravenous (IV) drug abusers Pediatric AIDS care needs for patients, 14, 95-96, 109 cases in U.S., 51-52, 77, 95 family disruption, 95, 14 transmission routes, 35, 51 Perinatal transmission, see Maternal-infant transmission Persistent generalized lymphadenopathy, 36, 37, 204 Pneumocystis carinii pneumonia, 106, 138, 173, 205, 214, 216 Polio epidemics, 28 Presidential Commission on the Human Immunodeficiency Virus Epidemic, 24, 165-166 Prevention strategies for blood products, 49, 88 budget for, 88, 183 contact tracing and notification, 70 criminal penalties or civil liability for intentional transmission, 83 importance of, 60 isolation and quarantine, 11-12, 28, 83 for IV drug abusers, 30, 62, 85-87, 178-179; see also Drug abuse treatment programs from programs for other sexually transmitted diseases, 62 resources for, 13, 87-89 see also Behavioral change; Condoms; Public education about AIDS; Public health measures; Vaccines against HIV Projections accuracy, 108 AIDS cases and deaths, 57, 108, 162, 171 data needs for, 5, 58-60 economic costs of AIDS, 16, 108 progression from HIV infection to AIDS, 36, 57 see also Models/modeling Prostitutes case-control studies in Africa, 40 IV drug abuse by, 10, 41, 78 mandatory screening of, 10, 78 - 79 prevention strategies, 10, 79 seroprevalence among, 40, 41, 47, 78 Psychiatric/psychosocial support for AIDS patients, 186 with antibody testing, 9, 70, 72, 74, 78, 79, 88-89, 101 for health care workers, 15-16, 103-104 recommendations, 9, 10, 12-13, 16, 74, 87, 103-104 Public education about AIDS for adolescents, 66-67, 68, 87 all-household mailing, 24, 167 at colleges, 7, 66-67, 88 content of, 7, 65-66, 176 culturally specific programs, 8, 68 "dirty words" issue, 66 funding for, 7, 13, 88, 177, 181-185 gaps in, 67 historical parallels to syphilis epidemic, 28 moral issues, 7, 65 obstacles, 7, 64, 65, 69 paid advertising, 7, 64-65, 69 public service announcements, 65 recommendations, 7, 8, 65-69, 87, 175-178, 199 resources for, 13, 87-89 school-based, 7, 66-67, 88, 177 statutes allowing or mandating, 66 success of, 67-68 Public health measures classification of programs, 61-62 complication by discrimination, 2, 29, 63 contact tracing and notification, 11, 80-82 criminal penalties, 83 historical parallels to syphilis epidemic, 28 isolation or quarantine, 11-12, 28, 83 recommendations, 5, 11-12, 82-87, 174-175, 184 Q Quarantine, 11-12, 28, 83 R Recommendations, see Findings and recommendations
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INDEX 237 Research basic biomedical, importance of, 18, 135-136 budget, 22, 151 HIV "starter kit," 22, 151 international opportunities, 196-197 see also Epidemiological research; Social science research Research needs diversion of resources from other important conditions, 6, 30 on educational campaigns, 8 epidemiological studies, 5, 52-53 facilities, 22, 149-150 international data base on activities, 24, 164 reagent distribution center, 22, 150-151 see also specific subject areas Reverse transcriptase, inhibition of, 18, 131-132, 137 Robert Wood Johnson Foundation AIDS Health Services Program, 110 Roundtable on Development of Drugs and Vaccines Against AIDS, 146-147 S San Francisco AIDS case trends, 34, 107 burden of AIDS patients on health care system in, 107-108 community care resources, 105 contact tracing program in, 82 deaths from AIDS, 5, 52 educational programs, 8, 68 Men's Health Study, 34 seroprevalence among homosexual men in, 34, 46 seroprevalence among IV drug abusers in, 4, 49 Screening for HIV of blood and blood products, 34-35, 71, 75-76, 179 of blood and plasma donors, 49 at drug abuse treatment centers, 47 health care workers, 76-77, 100-101 historical parallels to syphilis epidemic, 28 hospital patients, 10, 48, 70, 77 institutionalized populations, 70 mandatory, 10, 75-79, 180-181 newborns, 50 organs and tissues for transplantation, 76 premarital, 10, 77-78 prenatal, 77 of prostitutes, 10, 78-79 public health objectives achieved through, 8-9, 70 recommendations, 10, 75-79, 101, 196 semen for banking, 76 sites for, 47, 50, 89, 183 Serologic testing, see Antibody tests for HIV; Screening for HIV; Testing/tests for HIV Seropositive individuals age trends, 48 asymptomatic, 64, 70 discrimination against, 63-64 employment of, 6, 63-64, 100-101 health care workers, 76-77, 100-101 insurability, 113 progression to AIDS, 35-36 reporting of, 11, 80 students and teachers, 6, 63-64 Seroprevalence in Africa, 174 age and, 48 among blacks, 41, 47, 48, 52, 84 among blood donors, 39, 47-48 data needs on, 59 among hemophiliacs, 4, 47 among heterosexual partners, 39, 41, 42, 47 among Hispanics, 41, 47, 48, 52, 84 among homosexual men, 4, 34, 35-36, 39, 46, 52, 68 among hospital patients, 48-49 among infants, 48, 52, 86 among IV drug abusers, 4, 34, 41, 46-47, 49, 52, 84, 87 among Job Corps entrants, 48 among military inductees and personnel, 39, 48 modeling, 5, 58 national estimates, 4, 49-50 among prostitutes, 40, 41, 47 studies for determining, 82 among women, 40, 47, 48-49, 52 Sexual behavior data needs on, 59 see also Behavioral change
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23, 162-164, 196-197 economic costs of AIDS, 104-105; see also Health care costs patterns of disease spread in, 3, 40 payments to World Health Organization, 163 rationale for international involvement, 161-162 U.S. Department of Health and Human Services joint infection control guidelines with U.S.
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action, 132 approval process, 138 in combination with biological response modifier, 19, 137 comparison of other drugs with, 139 effectiveness, 37, 108, 132 Medicaid coverage for treatment, 114 side effects, 132 treatment costs, 108 trials in asymptomatic individuals, 70,
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