Confronting AIDS Update 1988 (1988) / Chapter Skim
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4. Altering the Course of the Epidemic
4. Altering the Course of the Epidemic
Pages 61-92
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From page 61... ...
It also highlights the needs of IV drug abusers and several problem areas that will require more attention, such as the impact of AIDS on minorities. FEATURES OF PUBLIC HEALTH PROGRAMS Certain properties of the HIV epidemic distinguish it from other dread diseases and prompt special concerns in fashioning a public health response.
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From page 62... ...
, hospitals, and other health care clinics are all appropriate places for HIV education, counseling, and testing. In fact, many of the programs designed to combat gonorrhea, syphilis, chlamydia, chancroid, and other sexually transmitted diseases will themselves have a direct bearing on the AIDS epidemic, as will efforts to combat drug abuse.
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From page 63... ...
The commute believes that the fear of do nation is a major constraint to the wide acceptance of many potentially effective public health measures. Public health programs will be most effective if they are accompanied by clear and strict sanctions to prevent unwarranted discrimination against those who are infected with HIV or who are at risk of infection.
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From page 64... ...
This statement is no less true today than it was in 1986 when Confronting AIDS was published. At that time, IOM/NAS lamented the failure of the United States to mount an aggressive, effective AIDS education campaign, calling such efforts woefully inadequate.
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From page 65... ...
The linking of HIV transmission to sexual behavior and IV drug abuse raises concerns about the propriety of the educational message, concerns that have not abated since the publication of Confronting AIDS. Those who view homosexual relations, heterosexual relations outside of marriage, or IV drug abuse as immoral may believe that frank, straightforward educational or public health programs encourage such activities.
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From page 66... ...
Many states have initiated some kind of AIDS education program. At the time of publication of Confronting AIDS, nine states had statutes that specifically allowed or mandated public school classroom teaching about sexually transmitted diseases.
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From page 67... ...
Nevertheless, many may be infected (Hein, 19871. Recent reviews of college-level activities have identified the college campus as a particular gap in AIDS education efforts (Biemiller, 1987; Caruso and Haig, 19871.
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From page 68... ...
AIDS and Condoms Condoms are a generally effective means of preventing the spread of HIV infection and a number of other sexually transmitted diseases.
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From page 69... ...
Health care professionals need to advise their patients in detail about how to use condoms. CDC has issued a detailed review of the role of condoms in the prevention of sexually transmitted diseases including detailed guidelines for their use (CDC, 1988a)
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From page 70... ...
trials in asymptomatic individuals is one additional reason asymptomatic persons at risk might wish to know their status. In patients with new symptoms that suggest HIV infection, HIV antibody testing should be part of a diagnostic workup.
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From page 71... ...
, and reproducibility of test results. The accuracy of currently marketed HIV antibody tests compares quite favorably with other medical diagnostic tests and has been borne out by experience in the nation's two largest screening programs: blood banks and the military.
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From page 72... ...
A few states have clarified the law by requiring specific consent for HIV antibody testing. Still, in the past year, there have been a number of accounts of patients who were tested without their knowledge or consent (Henry et al., 1988a,b)
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From page 73... ...
AIDS has been a catalyst in some states for a new look at the entire range of protection afforded various types of medical records. Other states have considered the confidentiality of HIV antibody test results specifically.
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From page 74... ...
The differences in behavioral responses on learning of a positive or negative test result, as well as the determinants of individual variations, should be the subjects of continued study. (Apart from the possible behavioral impact of knowledge of antibody test results,
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From page 75... ...
Nevertheless, screening programs that cast the net more widely among low-risk groups have garnered political as well as popular support, regardless of whether they are likely to reduce the spread of HIV (Hento~, 19871. To examine the merits of some of the plethora of mandatory testing and screening program proposals, what follows are highlights of experiences with programs and data that have come to light since the publication of Confronting AIDS.
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From page 76... ...
FDA and CDC, in concert with the American Fertility Society, the American Association of Blood Banks, and the American College of Obstetrics and Gynecology, have recently issued more detailed recommendations on HIV antibody screening for semen banking and organ and tissue transplantation (CDC, 1988b)
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From page 77... ...
Today, such tests are viewed as an inefficient and costly means of discovering too few prospective spouses with sexually transmitted diseases (Cleary et al., 19871. The trend away from premarital screening also reflects the fact that marriage is not the precursor to sexual activity, or even to childbearing, that it once was.
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From page 78... ...
The prevalence of HIV infection is highest in the northern New Jersey and Miami areas and lowest in Nevada, where the Nevada Board of Health requires prostitutes in county-licensed brothels to test negative for HIV antibodies as a condition of employment. Although female prostitutes historically have experienced higher levels of sexually transmitted diseases than the public at large, with HIV the primary risk factor seems to be IV drug abuse.
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From page 79... ...
Encouraging behavioral change among prostitutes demands especially vigorous counseling and voluntary testing programs. Testing should be offered in conjunction with counseling about condom use, opportunities for drug abuse treatment and vocational rehabilitation, and medical care referral.
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From page 80... ...
Rather, it is specific drug abuse and sexual practices (unprotected vaginal or anal intercourse) that endanger third parties.
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From page 81... ...
The AIDS Federal Policy Bill of 1987 was drafted to provide for the confidentiality of HIV antibody test results and to prohibit discrimination against persons with AIDS or those at risk. Provisions of the bill allow physicians to use their discretion in warning third parties at risk.
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From page 82... ...
Contact notification programs provide for the notification of sexual or drug abuse partners of infected individuals who are afraid, embarrassed, or unwilling to notify partners themselves. The health department can notify the contact without revealing the identity of the index case.
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From page 83... ...
that distinguish AIDS from other sexually transmitted diseases. Indeed, such laws may be ineffective, protecting neither the public health nor civil liberties.
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From page 84... ...
AIDS AND IV DRUG ABUSE Confronting AIDS highlighted the needs of IV drug abusers and noted that this group had not received as much media attention as other risk groups. This situation is changing with recognition of the looming danger that IV drug abuse poses for the user, his or her needle-sharing or sexual partner, and his or her offspring (Des Jarlais et al., 1988~.
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From page 85... ...
Intervention Innovations The committee supports the increased use of former IV drug abusers as community health workers to provide "one-on-one" risk reduction counseling and materials to drug abusers who are not in treatment, including instruction in the use of bleach to sterilize injection equipment. This program points up one important requirement of effective intervention programs they must reach beyond treatment centers, as no more than 20 percent of IV drug abusers attend treatment programs in any given year.
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From page 86... ...
Reports indicate that 84 percent of the distributed coupons were redeemed in the first 3 months of the program (Jackson and Rotkiewicz, 1987~. Distribution of Sterile Needles and Syringes Confronting AIDS concluded that, because not all IV drug abusers will be able to abandon drug abuse or switch to safer, noninjectable drugs, "tilt is time to begin experimenting with public policies to encourage the use of sterile needles and syringes by removing legal and administrative barriers to their possession and use." Some tentative results from needle exchange programs in other countries support this recommendation, and the committee continues to believe that evaluation of the effectiveness of providing sterile needles and injection equipment to drug abusers in certain circumstances is an essential part of planning a prevention strategy.
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From page 87... ...
There are a number of other short- and long-term approaches to the problems of IV drug abuse that deserve attention, both on their own merits and because the stakes are now higher as a result of the HIV epidemic. In particular, the widespread variations in seroprevalence among even needle-sharing drug abusers highlight the opportunity for interrupting the spread of infection in this group (see Chapter 21.
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From page 88... ...
Perhaps the single greatest concern is the lack of availability of treatment facilities for IV drug abusers and the lack of support for programs to eliminate or reduce drug abuse or to mitigate the danger of shared injection equipment. The committee believes that a substantial sum of money will have to be spent for these purposes, well beyond the $1 billion originally proposed for AIDS public health and education measures.
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From page 89... ...
Educational efforts to foster changes in sexual behavior are critical for minority communities. Sexually transmitted disease programs, family planning clinics, and maternal and child health centers that cater to minority clients are all critical vehicles for this effort and are in dire need of greater federal support.
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From page 90... ...
1988b. Semen banking, organ and tissue transplantation, and HIV antibody testing.
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From page 91... ...
1988. Geographic distribution of human immunodeficiency virus markers in parenteral drug abusers.
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From page 92... ...
1988. Transmission of human immunodeficiency virus by blood transfusions screened as negative for HIV antibody.
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