Confronting AIDS Directions for Public Health, Health Care, and Research (1986) / Chapter Skim
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4. Opportunities for Altering the Course of the Epidemic
4. Opportunities for Altering the Course of the Epidemic
Pages 95-138
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From page 95... ...
In a few short years a remarkable amount has been learned about HIV and how it is transmitted. This solid evidence provides the basis for reasonable decisions about actions that must be taken to mitigate the devastating impact of HIV infection.
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From page 96... ...
PUBLIC EDUCATION For at least the next several years, the most effective measures for significantly reducing the spread of HIV infection are education of the public and voluntary changes in behavior. There are many social ills for which public education is prescribed as a cure, especially where there are few specific responses available.
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From page 97... ...
More needs to be known, however, about the practical efficacy of condoms in blocking sexually transmitted diseases spread by anal intercourse. Is anal intercourse more
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From page 98... ...
The increased availability of condoms probably will raise concerns about encouraging sexual activity by young people who are not sufficiently mature. Such concerns, while understandable, are overshadowed by the dire consequences of HIV infection.
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From page 99... ...
. by drug abusers sharing unclean needles or by homosexual relations" (September 3, 1985)
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What Are the Aims of Public Education? Because HIV infection is transmitted by means of only a few specific types of behavior, a prime goal of education about AIDS is to modify or eliminate such behavior.
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From page 101... ...
One-third believed that a person could contract the disease by merely "touching someone who has AIDS" or by "using a person's comb." Four in 10 students did not know that the use of a condom during sexual intercourse decreases the risk of transmitting HIV infection. The need for educating the nation's youth about sexually transmitted diseases is well known.
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From page 102... ...
Letters about the course were sent home to the parents of 2,800 students in one high school; the parents could request that their child be excused from the class only three did so (Rimer, 19861. Even if the dangers of HIV infection are not discussed in the context of sex, certainly these dangers can be discussed in school curricula dealing with the dangers of drug abuse.
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From page 103... ...
Health professionals doctors, nurses, health educators, public health officials are all important links in the educational process. They must be taught through professional associations, academic curricula, and continuing education so that they, in turn, can teach their patients and associates.
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From page 104... ...
For example, an individual may practice "safer sex" and greatly reduce his number of sexual partners as the result of exposure to an education program, but his likelihood of infection may nonetheless rise if the prevalence of the infection increases among his partners. This has been the case in San Francisco, where dramatic changes in sexual practices among homosexual men have been undermined by skyrocketing seropositivity rates (Centers for Disease Control, 1985b)
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From page 105... ...
For example, with the relatively recent advent of HIV antibody testing, little is known about how individuals who test positive will react to this knowledge (see section on "Voluntary Testing," below)
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From page 106... ...
Yet women represent 20 percent of all heterosexual intravenous drug users with AIDS. Heterosexual acquisition of HIV infection and the development of AIDS have also been reported among female sexual partners of men at risk.
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From page 107... ...
As a result of this sharing, the frequency of drug injection has been found to be a strong predictor of seropositivity in the New York City area. Another factor, which may be a critical determinant of the speed of viral spread, is sharing of injection equipment across friendship groups.
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From page 108... ...
This market has increased greatly since the AIDS epidemic began, and there has been some distribution of "free" sterile needles and syringes as a sales strategy by drug dealers. Drug Abuse Treatment Programs The ideal method of prevention of HIV infection among IV drug users would be to stop people from using IV drugs in the first place.
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From page 109... ...
In addition, methadone maintenance treatment, which tends to be the most acceptable treatment modality for large numbers of IV drug users, also tends to have the lowest degree of public acceptance, and is controversial even among health care professionals. Finally, using drug abuse treatment to reduce HIV transmission poses complex ethical and epidemiologic questions.
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From page 110... ...
Recommendations · For at least the next several years, the most effective measure for significantly reducing the spread of HIV infection is education of the public with respect to modes of transmission of the virus. The present effort is woefully inadequate.
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From page 111... ...
It can no longer be assumed that unprotected heterosexual intercourse is safe. It probably is safe only in such situations as a long-term exclusive relationship in which both partners have not engaged in risk-taking behavior or where both partners test negative for HIV infection after six months of refraining from risk-taking behavior.
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From page 112... ...
Mandatory screening programs in the strict sense have not yet been employed with free-living populations, nor have isolation or quarantine. The debate about the use of traditional public health measures with HIV infection must take note of certain factors that distinguish it from other diseases in degree, if not in kind.
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From page 113... ...
While blood-screening tests have provided an invaluable tool in the epidemiologic understanding of the course and transmission of AIDS, they present, at once, an essential tool in the successful limitation of the spread of HIV infection and a focus for divisive social forces that may inhibit the most expeditious realization of that goal. Only two years have passed since the discoveries that provided the basis for HIV screening tests, but the newly developed blood tests are employed more than 20 million times a year, or about 80,000 times per working day.
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From page 114... ...
In blood banks, where those at risk of HIV infection have already been asked to refrain from donating blood for transfusion, the uninfected greatly outnumber the infected. This group of uninfected persons produces the largest number of positive test reactions, because even a small fraction of false-positive results outnumbers the positive reactions of the few individuals who actually are infected with HIV.
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From page 115... ...
Since that time, the practice of transfusion medicine and the use of the HIV blood-screening tests have become one of the most complex and emotional aspects in the AIDS epidemic (Goldsmith, 19851. Yet remarkable progress has been made in ensuring the safety of the nation's blood supply (National Institutes of Health, 1986)
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From page 116... ...
These were established in public health departments, hospitals, sexually transmitted disease clinics, and health service organizations for homosexuals. Typically, people who desire to be tested at an alternative site are counseled privately, and if they wish to be tested they are given an identifying number (such as date of birth)
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From page 117... ...
Data on HIV infection and related diseases are critical to all aspects of coping with the epidemic. In all states, AIDS cases must be reported promptly to local and state health authorities.
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From page 118... ...
Statistical and research techniques well known to epidemiologists are such that it is possible to gauge trends in the spread of diseases that have well-understood epidemiologic patterns without the reporting of each and every case. With HIV infection, however, it is desirable to have reporting that is complete or nearly so in order that more can be learned about the epidemiology of the disease e.g., its spread in the heterosexual population.
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From page 119... ...
Contact Tracing and Notification Closely related to reporting requirements are efforts by public health authorities to trace the contacts of infected persons. Such programs of contact notification or tracing are a traditional part of controlling sexually transmitted diseases.
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From page 120... ...
For example, some homosexual males have only one sexual partner or are not sexually active, whereas some heterosexuals have numerous sexual partners. Members of the latter heterosexual group are more likely to transmit HIV infection than members of the former homosexual group.
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From page 121... ...
Mandatory premarital screening for HIV infection is one program that has been debated and rejected by groups such as the American Medical Association. The committee believes that including HIV antibody testing as part of a mandatory premarital examination is inadvisable.
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Voluntary Testing In a therapeutic context the HIV antibody test allows physicians to determine whether their patients have been infected with HIV. Individual and aggregate data concerning antibody test results also enable epidemiologists to assemble baseline data for longitudinal studies monitoring the natural history of the disease.
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With HIV infection, risk perception may depend
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From page 124... ...
The benefits that could accrue to the individual from such a system include the following: (1) a heightened alertness to the possibility of clinical manifestations of HIV infection, leading to more rapid diagnosis and the early institution of treatment; (2)
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From page 125... ...
This would include IV drug users, prostitutes, women who have had many sexual contacts in areas where HIV infection is prevalent, women with a history of multiple sexually transmitted diseases, or women who have had sexual contacts with men in high-risk groups. These women should have the opportunity to seek testing and counseling.
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From page 126... ...
Such proposals must, however, be viewed in the light of knowledge about the predominant modes of HIV transmission, which generally involve voluntary behaviors (with the exception of perinatal transmission, rape, and blood and blood product transmission)
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From page 127... ...
In many states the definitions and lists of venereal diseases are decades old and do not reflect current concerns about such diseases as herpes and chlamydia. Most of the states have not, at least as of yet, designated AIDS or HIV infection as a sexually transmitted disease.
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From page 128... ...
Only a few such closings have taken place, and they have perhaps been largely symbolic, to aid in general campaigns meant to discourage the use of such places for sexual activities known to spread HIV infection and other sexually transmitted diseases. Attempts to close the bathhouses resulted in pitched battles over what is for some a symbol of homosexual liberation, and for others, commercial establishments allowed to foster casual, anonymous sexual activity putting participants at the greatest risk of transmitting HIV infection.
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From page 129... ...
Although high-risk sexual relations with many anonymous partners admittedly puts one at the greatest risk of HIV infection, opponents of bathhouse closure have argued that it is the type of behavior, not its locus, that presents the greatest danger. Closing such establishments might discourage such behavior.
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From page 130... ...
The CDC guidelines are recommended for further reference in this area. FUNDING FOR EDUCATION AND OTHER PUBLIC HEALTH MEASURES Although the committee did not attempt to budget in detail the cost of the education and other public health measures needed to stem the spread of HIV infection, it recognizes that some estimate of the likely magnitude of resources is needed.
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From page 131... ...
Of this $117.3 million, $5.2 million has come from redirection or reallocation of existing resources within state health departments usually from communicable or sexually transmitted disease programs. The states of California and New York together account for approximately 55 percent of all reported AIDS cases, with the New York and San Francisco SMSAs alone accounting for 40 percent of cases (as of August 1, 19861.
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From page 132... ...
One page of advertising in a major newspaper can cost around $25,000 per day, and a minute of national television time can cost between $60,000 and $400,000. Consequently, to influence the behaviors affecting HIV transmission, policymakers must begin to contemplate expenditures similar to those made by private sector companies to influence behavior" for instance, $30 million to introduce a new camera, or $50 million to $60 million to advertise a new detergent.
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From page 133... ...
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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From page 134... ...
In several jurisdictions, the state antidiscrimination commission or agency has designated AIDS and HIV infection as protected under their programs. On the federal level, one federal circuit court has found infectious diseases, and by implication AIDS and possibly HIV infection, covered under federal law preventing discrimination against the handicapped (Arline v.
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From page 135... ...
1986. Consensus Statement on HTLV-III Antibody Testing and Related Issues.
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From page 136... ...
1984. Health behavior and sexually transmitted diseases.
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From page 137... ...
1985. $1.2 million goes to AIDS education but explicit programs shunned.
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