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OCR for page R1
Confront
r
l
Directions
for Public Health,
Health Care,
and Research
Institute of Medicine
National Academy of Sciences
NATIONAL ACADEMY PRESS
Washington, D.C. 1986
OCR for page R2
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the
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Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the
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appropriate balance.
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a Report Review Committee consisting of members of the National Academy of Sciences, the National
Academy of Engineering, and the Institute of Medicine.
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Library of Congress Catalog~ng-in-Publication Data
Institute of Medicine (U.S.).
Confronting AIDS.
Report prepared by the Committee on a National Strategy for AIDS of the Institute of Medicine.
Includes bibliographies and index.
1. AIDS (DiseaseWPrevention~overnment policy-United States. 2. AIDS (Disease - United States-
Prevention. 3. AIDS (Disease0Research~overnment policy-United States. 4. AIDS (DiseaseWRe-
search-United States. 5. AIDS (DiseaseWTreatment~overnment policy-United States. 6. AIDS
(DiseaseWTreatment-United States. I. Institute of Medicine (U.S.). Committee on a National Strategy for
AIDS. II. Title. [DNLM: 1. Acquired Immunodeficiency Syndrome. 2. Health Policy-United States. WD
308 I59cl ~. ~ . . ~ . . .AA
RA644.A25I57 1986 362.1'9797'9200973 86-23779
ISBN 0-309-03699-2
Copyright @) 1986 by the National Academy of Sciences
First Printing, October ~ 9~6
Second Printing, January ~ 907
Third Printing, March 1907
Fourth Printing, March 1987
Fifth Printing, June ~ 9~7
Sixth Printing, September ~ 987
Seventh Printing, December 19S7
Eighth Printing, June ~ 988
Ninth Printing, September ~ 9 BS
Tenth Printings,, October 1989
No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in
the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise
copied for public or private use, without written permission from the publisher, except for the purposes
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Printed in the United States of America
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Committee on a National Strategy for AIDS
STEERING COMMITTEE
DAVID BALTIMORE (Cochair), Whitehead Institute for Biomedical
Research and Massachusetts Institute of Technology, Cambridge
SHELDON M. WOLFF (Cochair), Tufts University School of Medicine
and New England Medical Center Hospital, Boston
JOHN J. BURNS, Roche Institute of Molecular Biology, Nutley, New
Jersey
LEON EISENBERG, Harvard Medical School, Boston
BERNARD N. FIELDS, Harvard Medical School, Boston
HARVEY V. FINEBERG, Harvard School of Public Health, Boston
FRANK LILLY, Albert Einstein College of Medicine, Bronx
JUNE E. OSBORN, School of Public Health, University of Michigan,
Ann Arbor
MARGERY W. SHAW, University of Texas Health Science Center,
Houston
PAUL VOLBERDING, San Francisco General Hospital
IRVING WEISSMAN, Stanford University School of Medicine
HEALTH CARE AND PUBLIC HEALTH PANEL
SHELDON M. WOLFF (Chair), Tufts University School of Medicine
and New England Medical Center Hospital, Boston
JAMES CHIN, California State Department of Health Services,
Berkeley
WILLIAM J. CURRAN, Harvard School of Public Health, Boston
DAVID W. FRASER, Swarthmore College, Swarthmore, Pennsylvania
JEFFREY E. HARRIS, Massachusetts Institute of Technology, Cambridge
ARTHUR LIFSON, Equitable Life Assurance Society of the United
States, New York City
DOROTHY NELKIN, Cornell University, Ithaca, New York
JUNE E. OSBORN, School of Public Health, University of Michigan,
Ann Arbor
SAMUEL W. PERRY, Cornell University Medical Center, New York City
PAUL VOLBERDING, San Francisco General Hospital
LeROY WALTERS, Kennedy Institute of Ethics, Georgetown
University, Washington, D.C.
RESEARCH PANEL
DAVID BALTIMORE (Chair), Whitehead Institute for Biomedical
Research and Massachusetts Institute of Technology, Cambridge
LEON EISENBERG, Harvard Medical School, Boston
. . .
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RESEARCH PANEL (Continued)
BERNARD N. FIELDS, Harvard Medical School, Boston
JEROME E. GROOPMAN, Harvard Medical School, Boston
MAURICE R. HILLEMAN, Merck Institute for Therapeutic Research,
Merck Sharp & Dohme Research Labs, West Point, Pennsylvania
RICHARD T. JOHNSON, Johns Hopkins University School of Medicine,
Baltimore, Maryland
ROBERT F. MURRAY, Jr., Howard University College of Medicine,
Washington, D.C.
ROLAND K. ROBINS, Molecular Research Institute and ICN
Pharmaceuticals, Costa Mesa, California
P. FREDERICK SPARLING, University of North Carolina School of
Medicine, Chapel Hill
CLADD E. STEVENS, New York Blood Center, New York City
HOWARD M. TEMIN, University of Wisconsin School of Medicine,
Madison
IRVING WEISSMAN, Stanford University School of Medicine
EPIDEMIOLOGY WORKING GROUP CHAIRMAN
J. THOMAS GRAYSTON, University of Washington, Seattle
STAFF
ROY WIDDUS, Project Director and Director, Division of International
Health
DEBORAH COTTON, Deputy Project Director
MARK FEINBERG, Staff Officer
JEFF STRYKER, Staff Officer
JUDE PAYNE, Research Assistant
KAREN ZWEIG, Research Assistant
GAIL SPEARS, Administrative Secretary
STEVE OLSON, Project Editor
DOROTHY SAWICKI, Book Editor, National Academy Press
CAROL COFIELD, Secretary
CAREY O'BRIEN, Secretary
KATHLEEN ACHOR, Secretary
CONSULTANTS
PETER E. DANS, Johns Hopkins Medical Institutions, Baltimore, Maryland
JESSE GREEN, New York University Medical Center, New York City
1V
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Preface
In October 1985 the Institute of Medicine devoted its annual meeting to
the subject of acquired immune deficiency syndrome (AIDS). The infor-
mation presented at that meeting has been summarized in a nontechnical
volume entitled Mobilizing Against AIDS: The Unfinished Story of a
Virus (Harvard University Press, 1986), which surveys knowledge on
AIDS and the issues raised by the disease. That annual meeting was not
intended to develop recommendations about the best course of action for
dealing with the problems it surveyed, but the Institute of Medicine
realized that recommendations were needed and that, to develop them,
national leadership was essential. As a result, in early 1986 the presidents
of the National Academy of Sciences (NAS) and the Institute of Medicine
(IOM), with the approval of the councils of these organizations, decided
to initiate a special effort to assess the extent of the problems arising from
AIDS and to propose an appropriate national response. The congressional
charter establishing the National Academy of Sciences, under which it
and the Institute of Medicine operate, specifies that they shall undertake
studies of issues of vital importance to the nation. This report results from
such self-initiated activity.
The topics to be addressed in the study were specified as follows:
The committee shall assess the current understanding of the virus that causes
acquired immune deficiency syndrome (AIDS), its transmission, the natural
history of infection and associated disease, the epidemiology of conditions
associated with the virus, and the likely trends in these.
v
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vi PREFACE
The committee also shall review the nation's response to AIDS both in the
public and private sector and the current planning in regard to:
· research necessary for prevention and treatment
· provision of care and its financing
· public health measures designed to control the disease.
The committee shall evaluate methods whereby the ultimate goals of controlling
and combating the disease may be achieved. Questions to be addressed should
include, but are not necessarily limited to, the following:
· Are there neglected research opportunities or needs with regard to the
biology and epidemiology of the virus, the animal models of infection and disease,
or the prospects for vaccines or antiviral agents?
· What are the impediments to the most expeditious pursuit of these opportu-
nities and needs, and how can they be overcome? Specifically, what mechanisms
should be instituted to achieve promotion of productive research, timely utiliza-
tion of new knowledge, optimal communication among persons engaged in
research and development (and with health care and public health professionals),
integration and coordination of the R&D effort, recruitment of appropriate
investigators, and the optimal involvement of industry?
· Is the care of AIDS and AIDS-related complex (ARC) patients (and
seropositive persons) properly coordinated? What are the best approaches to the
provision of care and what are the local, regional, and national implications of
these models for the health care system?
· How are the costs of care being met? Are there ways in which these costs
could be met in a more rational and/or equitable fashion?
· What public health measures (including educational programs) are desirable
in light of present knowledge and circumstances? By whom should these be
promoted, implemented, coordinated, and revised?
· What are the legal and ethical issues raised by the questions posed above; in
particular, in the formulation of public health policy, how is a balance best
achieved between the interests of the public and those of the individual?
· How should the United States address the international ramifications of the
problem of AIDS? What will be its magnitude; what is the appropriate role for the
United States; and what are its responsibilities?
The committee shall prepare a report outlining a strategy (or strategies)
whereby these concerns can be addressed. The report shall contain recommen-
dations for its implementation directed to the Executive Branch, the Congress,
the research community, those who treat patients, state and local governments,
corporate leadership, and the public. The report shall include a description of the
basis for the committee's conclusions.
To prepare this report, a committee with an impressive breadth of
credentials was established. To cover the broad range of issues raised in
combating AIDS, two panels were constituted, one addressing issues in
research, the other addressing issues in health care and public health. To
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PREFACE vii
integrate the activities of the panels, a steering group was formed,
consisting of four members from each panel and four at-large members.
Collectively, the panels and the steering committee comprised individuals
with expertise in molecular biology, virology, immunology, epidemiol-
ogy, neurology, psychiatry, infectious diseases, general medicine, health
care, public health, economics, law, ethics, and other disciplines. They
represented research experience in academia, several branches of the
federal government, and industry, with substantial experience in manag-
ing research and development projects in all three of these areas. In
addition, the panels and the steering committee included individuals with
experience in developing and implementing public health programs at the
national, state, and local levels, as well as those closely involved in the
care of patients.
The councils of the National Academy of Sciences and the Institute of
Medicine requested that a report be produced by the committee within six
months of its initial meeting, reflecting the urgency with which they felt
the problem should be addressed. In response, the committee undertook
an intensive schedule of activities. Each panel held four meetings, which
were attended by many of the at-large members of the steering commit-
tee. Also, two working groups were formed, one consisting of approxi-
mately 30 individuals who studied both the short- and long-term epidemi-
ology of the disease, and the other a somewhat smaller group that met on
two occasions to discuss issues in the financing of health care for AIDS
patients.
The committee held two public meetings, one in San Francisco and one
in New York City, where many individuals concerned with various
problems raised by AIDS expressed their views. In addition to the public
meetings, the committee invited a large number of individuals from the
scientific, health care, and public health communities to contribute their
thoughts. Many excellent papers were prepared at the committee's
request and will be available upon request to the Institute of Medicine
(see Appendix H). Many individuals involved in AIDS-related activities
were also kind enough to submit prepublication data, greatly aiding the
committee's awareness of ongoing research.
Committee and staff members participated in a workshop held by the
Public Health Service at Coolfont, Berkeley Springs, West Virginia, June
4-6, 1986, to produce a plan for the prevention of AIDS and the control of
the AIDS virus. A number of committee members and a representative of
the staff also attended the Second International Conference on AIDS in
Paris, June 22-25, 1986, where much new information was presented. In
July 1986 the steering committee held its final meeting in Woods Hole,
Massachusetts, to integrate the contributions from the panels and the
working groups.
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viii PREFACE
TERMINOLOGY
AIDS poses a number of problems related to terminology. First, the
etiologic agent of AIDS has been given several different names, including
lymphadenopathy-associated virus (LAV), human T-cell lymphotropic
virus type III (HTLV-III), and AIDS-associated retrovirus (ARV). The
committee followed the usual practice of NAS/IOM committees in using
the name recommended by the appropriate international body charged
with giving advice on nomenclature. In this case, the appropriate body is
the International Committee on the Taxonomy of Viruses, a subcommit-
tee of which has proposed that the virus be called human immunodefi-
ciency virus (HIV). This designation for the virus is used throughout this
report.
Terminology related to AIDS and other conditions related to HIV
infection may also be confusing. The term AIDS itself was coined as a
surveillance definition for epidemiologic purposes. It does not include the
full spectrum of conditions now known to be associated with lIIV infection.
Reference to the "AIDS epidemic" has become ubiquitous in discus-
sions and publications on this topic. It must be understood, however, that
the epidemic in its full extent includes not only individuals with AIDS but
other infected individuals who have less severe manifestations of the
disease or who are asymptomatic. (In some sense, the epidemic can even
be said to encompass reactions such as fear of the disease and of the virus
among the general public.) Indeed, because infection of humans with HIV
is a relatively new phenomenon, the full spectrum of signs and symptoms
that the virus may cause is yet to be known. Furthermore, the manifes-
tations of HIV infections and immunodeficiency reflect, at least in part,
the environmental pathogens to which individuals are exposed. Thus,
these manifestations may appear to vary in different population groups in
different parts of the world, but they still resect the basic, underlying HIV
infection. In general, the evolution of terminology related to HIV-
associated conditions should be regarded as natural and desirable as our
knowledge of the pathogen and its consequences increases.
There are other problems of terminology related to AIDS. Certain
groups-for example, male homosexuals and intravenous drug users-
have been designated as being at high risk of contracting the disease.
However, the designation "at high risk" encompasses more people than
is necessary, because not all members of these groups are at high risk of
being infected with HIV. A more appropriate designation might be
"persons who engage in high-risk behaviors," and references in this
report to "high-risk groups" should be so interpreted. Furthermore,
references to high-risk groups may lead persons outside of these groups to
believe mistakenly that they are not susceptible to HIV infection even if
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PREFACE 1X
they engage in high-risk activities. It may also lead individuals to
consciously or unconsciously deny that they are at risk. For example, a
man who has had infrequent homosexual contacts may regard himself as
predominantly heterosexual and therefore not in danger of infection. This
can lead to misconceptions about the desirability of taking action to avoid
infection or about whether infection may have already occurred.
Identifying the risk of infection as being associated with certain
"high-risk behaviors" is also not without problems. This is particularly so
in the area of sexual transmission, where a multiplicity of sexual partners,
homosexual or heterosexual, has been associated with a high risk of
becoming infected. Unfortunately, some may interpret this to mean that
many partners are required for a person to become infected. In fact, it
merely represents a statistical phenomenon whereby the chances of
having intercourse with an infected person increase as the number of
partners increases.
The term "intravenous drug use" presents additional difficulties. In this
report the term implies the intravenous administration of illicit drugs such
as heroin for nonmedical purposes. Individuals who engage in this activity
may or may not be addicted, and some may not regard their use of such
drugs as abuse.
Care has been taken throughout the report to be as precise as possible.
However, the reader should bear in mind potential problems of this nature
when drawing conclusions from material presented here.
STRUCTURE OF THE REPORT
After a summary chapter that presents the report's major findings and
recommendations, Chapter 2 lays out the present understanding of the
disease and the current status of the AIDS epidemic, providing the
essential background information upon which the committee based its
conclusions and recommendations (which appear throughout succeeding
chapters as well as in the summary chapter). Chapter 3 then projects the
epidemic into the future, suggesting its most likely course and discussing
the uncertainties that any such projections entail. It also includes a brief
discussion of the resources that could be brought to bear on the problems
the epidemic has generated. Chapter 4 examines the measures available
now e.g., education that could alter the course of the epidemic.
Chapter 5 discusses the implications of the epidemic's projections for the
provision and financing of health care related to HIV infection and AIDS
in the United States. Chapter 6 identifies areas of research that will be
critical in the long term for devising better means of prevention and
treatment. Chapter 7 looks at international aspects of HIV infection and
AIDS and at the United States' contribution to solving those problems.
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x PREFACE
Given the complex nature of the problems and the time and resources
available, the committee did not attempt to prepare a definitive mono-
graph on AIDS or to make explicit recommendations on all of the
problems related to the disease. Rather, it identified the most crucial
problems and suggests, when necessary, mechanisms for addressing
them. Some of these problems can be addressed by agencies that already
exist; others may need new mechanisms or require the convening of
disparate groups working together to solve them.
During the preparation of the report, the committee was continually
reminded that it was assessing a "moving target," because the problem of
HIV infection was evolving as it was being studied. Consequently, this
report represents the committee's evaluation as of August 1986. The pace
of developments in this field has also contributed to one of the
committee's major recommendations that the problem should be mon-
itored on a continuing basis.
Limited time precluded the committee's addressing certain important
areas as fully as would have been desirable. The areas needing further
consideration are identified in the report. As discussed in Chapter 1, the
committee hopes that a mechanism will be put in place to take up the
important issues in more detail.
ACKNOWLEDGMENTS
The committee wishes to thank the many persons who took time from
their activities to assess the current status of their fields for purposes of
this report (see Appendix J). In addition, all committee members gave
unstintingly of their time to this endeavor. As cochairmen, we thank them
for their devotion to this important work. Finally, we wish to acknowl-
edge the excellent substantive and organizational assistance provided to
the committee by the staff of the IOM-NAS headed by Roy Widdus.
DAVID BALTIMORE
Director, Whitehead Institute for
Biomedical Research, and Professor of
Biology, Massachusetts Institute of
Technology
SHELDON M. WOLFF
Chairman, Department of Medicine, Tufts
University School of Medicine, and
Physician-in-Chief, New England Medical
Center Hospital
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Contents
ABSTRACT
CONFRONTING AIDS:
SUMMARY AND RECOMMENDATIONS
Status of the Epidemic, 5
Infection and Transmission, 6; Clinical Manifestations
of the Disease, 7; Statistical Dimensions of the
Epidemic, 7
The Future Course of the Epidemic, ~
Opportunities for Altering the Course of the Epidemic, 9
Public Education, 9; Public Health Measures, 13;
Funding for Education and Other Public Health
Measures, 16; Discrimination and AIDS, 19
Care of Persons Infected with HIV, 19
Health Care Costs Resulting from HIV Infection, 21; The
Financing of Health Care for HIV-Related Conditions, 22
Future Research Needs, 23
Basic Research, 23; The Natural History of HIV
Infection, 23; Epidemiologic Approaches, 24; Animal
Models, 25; Antiviral Agents, 25; Vaccines, 26; Social
Science Research Needs, 27; Funding for Research on
AIDS and HIV, 28
X1
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xii CONTENTS
International Aspects of AIDS and H]:V Infection, 28
Rationale for U.S. International Involvement, 29;
Risks of Infection Outside the United States, 29;
International Research Opportunities, 30
Guidance for the Nation's Efforts, 31
What Is Needed?, 32; Establishment of the
Commission, 32
Major Recommendations, 33
2 UNDERSTANDING OF THE DISEASE AND
DIMENSIONS OF THE EPIDEMIC.......
The Causative Agent of AIDS, 38
Features of Retroviruses, 40; Related Viruses, 41
Pathogenesis of AIDS, 42
Natural History of the Disease, 44
Clinical Manifestations of HIV Infection, 46
Opportunistic Infections, 46; Kaposi's Sarcoma, 47;
Other Malignancies, 48; Neurologic Complications
Associated with HIV Infection, 49; Pediatric AIDS, 49
Modes of Transmission of HIV, 50
Sexual Transmission, 51; Parenteral Transmission, 52;
Maternal-Infant Transmission, 56
Population Groups at Increased Risk of HIV Infection, 57
Homosexual Men, 57; Intravenous Drug Users, 59;
Hemophiliacs, 60; Recipients of Blood Transfusions,
60; Heterosexual Contacts of HIV-Infected
Persons, 61; Infants and Children, 61; Health Care
Workers, 62
Epidemiologic Studies and Findings, 63
Surveillance, 63; National Disease Reporting, 63;
Epidemiologic Research, 65; Findings of
Epidemiologic Studies, 69
HIV Infection and AIDS Outside the United States, 73
African Countries, 74; Other Countries, 76
References, 77
3 THE FUTURE COURSE OF THE EPIDEMIC AND
AVAILABLE NATIONAL RESOURCES ........
Projections by the Public Health Service, 85
Problems in Making Projections, 86
. 37
· 85
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CONTENTS xiii
The Epidemic Within and Beyond High-Risk
Groups, 89
The Proportion of Seropositive Individuals Who Will
Develop AIDS, 91
Long-Term Prospects, 91
National Resources for Dealing with AIDS and HIV, 92
Impediments to Involvement, 92; Mechanisms for
Coordinating Activities, 93
References, 94
4 OPPORTUNITIES FOR FILTERING THE COURSE
OF THE EPIDEMIC ...........................
Public Education, 96
What Should Be the Content of Public Education?, 97;
What Are the Aims of Public Education?, 100; Who
Needs Education?, 100; Who Should Do the
Educating?, 103; Assessing Educational Interventions,
104; A Special Case Changing Behavior Among IV
Drug Users, 105; Recommendations, 110
Public Health Measures, ~12
Tests for Infection with HIV, 113; Blood Banking,
115; Surveillance, 117; Reporting Schemes, 118;
Contact Tracing and Notification, 119; Mandatory
Screening, 120; Voluntary Testing, 122; Compulsory
Measures, 126; Recommendations, 129
Funding for Education and Other Public Health
Measures, 130
Recommendation, 133
Discrimination and AIDS, 133
Recommendations, 135
References, 135
CARE OF PERSONS INFECTED WITH HIV
Roles of Health Care Providers, :139
Recommendations, 140
Health Care Settings for AIDS Patients, 141
Hospital Care, 141; Outpatient Care, 142;
Community-Based AIDS Care, 143;
Recommendations, 145
Needs of Specific Patient Populations, 146
. 95
. 139
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XiV CONTENTS
Psychiatric and Psychosocial Support, 148
Needs of Patients with AIDS, 148; Needs of Patients
with ARC, 149; Needs of Patients with Subclinical
HIV Infections, 150; Needs of Seronegative Persons,
151; Recommendations, 152
Ethical Aspects of Providing Care, 153
Costs of Health Care for HIV-Related Conditions, 155
Direct Costs of Care for AIDS Patients, 156; Costs
of Care for ARC Patients and Seropositive
Individuals, 158; Indirect Costs of HIV-Related
Conditions, 159; Cost Implications of Projected AIDS
Cases, 159; Projected Hospitalization Facilities, 160;
Conclusions and Recommendations, 161
Financing of Health Care for HIV-Related
Conditions, 162
Sources of Financing, 162; Improving the Coverage of
Health Care Costs, 165; Emerging Issues, 166; Policy
Issues, 171; Conclusions and Recommendations, 172
References, 173
6 FUTURE RESEARCH NEEDS .................
The Structure and Replication of HIV, 178
Retroviral Structure, 178; Retroviral Replication, 179;
Definition of the Structural and Functional
Constituents of HIV, 181; Determination of the
Structure of the HIV Virion, 182; Interrupting
Infection by HIV, 183; Conclusions and
Recommendations, 187
Natural History of HIV Infection, I89
Transmission of HIV, 189; The Immune System
Response to HIV Infection, 191; The Immunologic
Consequences of HIV Infection, 193;
Recommendations, 198
Epidemiologic Approaches to Understanding the
Transmission and Natural History of HIV
Infection, 199
Recommendations on Surveillance, 199;
Recommendations on Natural History of HIV
Infection, 200; Recommendations on Transmission of
HIV, 202; Recommendations on the Need for
Improved Serologic and Virologic Tests, 203
. 177
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CONTENTS xv
Animal Models, 204
HIV Infection of Chimpanzees, 205; HIV-Related
Viruses in Old World Primates, 205; Lentiviruses
of Ungulates, 206; Conclusions and
Recommendations, 207
Antiviral Agents, 209
Drug Evaluation in Vitro, 212; Drug Evaluation in
Humans, 212; Current Antiviral Agents Under Clinical
Study, 213; New Antiviral Agents Against AIDS, 218;
Conclusions and Recommendations, 219
Vaccines, 221
Animal Retrovirus Vaccines, 222; Vaccines Against
HIV, 225; Models of Vaccine Delivery, 226;
Approaches to HIV Vaccine Development
and Evaluation, 228; Conclusions and
Recommendations, 229
Social Science Research Needs, 230
Breaking the Chain of Transmission, 231; Reducing
Public Fear and Its Effects, 234; Organizing Health
and Social Services, 237; Conclusions and
Recommendations, 238
Funding for Research Related to AIDS and HIV, 238
Current Levels of and Mechanisms for Funding, 239;
Current NIH Funding Mechanisms, 241; Distribution
of Funds Among Agencies and to Specific Research
Areas, 244; Assessing Desirable Levels of Research
Support, 244; Recommendations, 248
References, 249
7 INTERNATIONAL ASPECTS OF AIDS AND
HIV INFECTION ............................
Projections of the Disease Outside the United States, 261
International Organizations, 263
Rationale for U.S. :international Involvement, 264
Foreign Policy Considerations, 264; Health Improvement
Assistance, 265; International Spread of Diseases, 266;
Opportunities for Mutually Beneficial Research, 266;
Agencies and Organizations with International
Responsibilities or Operations, 267; Importation, 268
Infection Risks Outside the United States, 268
Sexual Exposure, 268; Exposure Through Blood
. 261
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XV} CONTENTS
Transfusion, 269; IV Drug Use, 270; Use of Unsterile
Needles and Implements, 270; Lack of Evidence
for Transmission by Insect Vectors and Casual
Contact, 271; Conclusions, 271
International Research Opportunities, 272
The U.S. Contribution to International Efforts, 274
Conclusions and Recommendations, 276
References, 277
APPENDIXES
A. Clinical Manifestations of HIV Infection . . . . . . . . . . . . 281
B. Serologic and Virologic Testing 304
C. Risk of HIV Transmission from Blood Transfusion 309
D. U.S. Public and Private Sector Resources for Fighting
AIDS
E. The Centers for Disease Control's Surveillance
Definition of AIDS ....................
F. CDC Classification System for HIV Infections
G. PHS Plan for Prevention and Control of AIDS
314
316
........ 320
and the AIDS Virus 326
H. List of Background Papers 334
I. List of Presentations at Public Meetings 336
I. Acknowledgments 339
K. Biographical Notes on Committee Members 343
GLOSSARY
INDEX
353
361
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Confronting
A.
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