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1 9. H IV I nfection an d AI DO
When the health objectives for 1990 were developed,
AIDS-acquired immune deficiency syndrome-had not
even entered the medical vocabulary. By 1990, how-
ever, 128,319 AIDS cases had been reported in the
United States, approximately ~ million Americans
are infected. and it is projected that more than
400,000 persons will have been diagnosed with AIDS
by 1993. Thus, preventing the spread of this fatal
disease is seen by witnesses as a top public health
priority.
A total of 60 witnesses concentrated on AIDS or
infection by human immunodeficiency virus (HIV), the
virus that transmits it. Many other witnesses referred
to it in the context of drug addiction, reproductive
health, occupational safety, and other areas.
The testimony highlighted several important issues.
Some of the most dramatic testimony related to the
serious problem of HIV infection among intravenous
(IV) drug users and the need for aggressive action to
combat it. The concern was not only with the drug
users themselves, but also with transmission of HIV
from them to others through sexual contact. Already,
perinatal transmission of AIDS is occurring at alarm-
ing rates. Most of these cases are associated with
illicit drug use, according to testimony. (~376J
Many witnesses agree that expanded and improved
drug treatment must be a priority in the fight against
AIDS.
In addition, some observers predict that as a large
number of HIV-positive drug users develop AIDS, the
health service delivery system will be overwhelmed.
Unlike the homosexual community, where many
people with AIDS have private health insurance and
support systems, drug users with AIDS tend to be far
more dependent on governmental health and welfare
programs.
Speakers discussed several populations who, in ad-
dition to IV drug users, are at high risk for AIDS or
in need of special education, testing, and counseling.
They included children and adolescents, minorities,
mothers and infants, and at-risk professionals. Several
testifiers also emphasized the need to provide these
programs for jail and prison inmates. Charles
Carpenter of Brown University calls attention to the
[act that certain segments of the prison population in
some northeastern states have among the highest pre-
valence rates of seropositivity in North America.
(~789) Kenneth Kizer of the California Department
of Health Services recommends "a greater focus on
incarcerated populations" as a means of reaching IV
drug using populations with information and educa-
tion about AIDS and HIV infection. (#591 J
The bulk of the testimony on AIDS and HIV
infection focused on expanding education, testing, and
counseling programs, with some emphasizing the
importance of confidentiality, compassion, and nondis-
crimination in these efforts. Witnesses also addressed
the role of personal behavior (using condoms, prac-
ticing safer sex, not sharing needles), together with
preventive services (education, testing, and coun-
seling), as ways to prevent HIV from spreading.
EDUCATION, TESTING, AND COUNSELING
Many witnesses stressed that education and other
prevention activities must be tailored to specific target
groups: no single approach can reach IV drug users,
homosexual/bisexual men, prison inmates, childbearing
women, health professionals, minorities, or others at
increased risk. Even within these groups, many
subgroups exist arid require special attention.
Testifiers say that these activities must take place
at sites as diverse as the populations they attempt to
reach: public schools, sexually transmitted disease
(STD) clinics, family planning clinics, drug use
"communities, and health professional schools, to
name a few. Similarly, a varieW of service providers
must be involved, including grass roots gay organiza-
tions, teachers, health care providers, community
groups in minority neighborhoods, outreach workers,
and others who can effectively reach a target Donula-
tion.
--a ~a-- r~r-~-
Charles E. McKinney, education director of the
Gay Men's Health Crisis, characterizes AIDS educa-
tion this way:
Education as a life saving strategy in the fight
against AIDS is more than a public service
announcement recommending sexual abstinence,
saying "No!~ to drugs, or using condoms. It is
multifaceted, omnidirectional, relentless, and
immediate. It is round the clock, in the streets,
in recreational facilities, churches and syna-
gogues, social clubs, homes, schools and local
HIV Infection and AIDS 153
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supermarkets. It is where the people are,
whenever they are there. It is communicating in
a common language and level of literary. It is
nonjudgmental. It is sensitive to the cultural
differences, patterns of speech, rituals and mores
of diverse populations that make up a com-
munity. (#453)
Many witnesses emphasized the importance of
educating people about AIDS, HIV transmission, safer
sex, and needle-sharing behavior; but there was also
testimony reflecting the gaps in knowledge about how
to provide education that will result in health-
promoting behaviors. Education must be grounded in
an understanding of health behavior and attitudes in
the high-risk populations, according to witnesses;
homosexual men and IV drug users, for example, have
different help-seeking behaviors. However, informa-
tion about the ways to implement educational efforts
is incomplete.
Lew Gilchrist of the University of Washington says
more knowledge is needed about how to construct
effective education messages.
We have a beginning technology. We know, for
example, that public response to fear messages
is not optimal. It results in short-term behavior
change, but no behavior change over the long
run. We need to expand our technology for
defining and evaluating health education.
(~691)
Yet regardless of the audience, site, or specific
message, all AIDS educational programs should teach
"mercy, compassion, and the insidious effects of
stigma and prejudice," say Linda Hawes Clever of the
Pacific Presbyterian Medical Center. (#803)
MANDATORY TESTING, REPORTING, AND
CONTACT NOTIFICATION
Most witnesses supported voluntary testing programs
to inform individuals about their own HIV status; a
few suggested that mandatory testing may be appro-
priate in certain cases. Glenn Heckmann, Executive
Director of the Texas Board of Pardons and Paroles,
for example, said that all inmates entering or leaving
penal institutions should be tested. He also noted,
however, that placement for those that are HIV posi-
tive has been very difficult and urged the development
of more community resources for these people.
(#093) Two overriding concerns in both testing and
154 Healthy People 2000: Citizens Chart the Course
contact notification among all populations, including
prisoners, are confidentiality and documentation.
(#215) Suggestions were made that the screening of
new inmates be forestalled "until civil liberty
protection, segregation policy, and housingimedical
care issues have been addressed." (~591)
Franklyn Judson of the Denver Public Health De-
partment calls for reporting HIV-positive individuals.
Noting that Colorado requires such reporting while
providing strong guarantees of confidentiality, Judson
says that the law has not had the adverse outcomes
some feared. There are no indications that human
rights violations have occurred and no evidence that
reporting has discouraged at-risk individuals from
being tested. The importance of confidentiality in
reporting was stressed. (~3 76)
The controversial topic of contact notification also
came up in testimony. A few witnesses favored
mandatory contact of all people named as sex or
needle-sharing partners of people with a positive HIV
test. According to Charles Mahan of the Florida
Department of Health and Rehabilitative Services, an
objective for the year 2000 should be the notification
of 75 percent of such contacts. (~138,} Although
most witnesses did not include mandatory partner
notification in the preventive strategies proposed - ue
to difficult in obtaining names, the cost of tracing
contacts, and possible negative reaction to a man-
datory effort (#787~olunta~y identification of
partners by HIV-infected individuals was seen as a
valid and important objective.
SPECIAL POPULATIONS
Many witnesses addressed education, testing, and
counseling needs in the context of specific target
populations at risk. The groups discussed most
frequently were school children, minorities, drug users,
homosexuals, and women of childbearing age.
Children and Adolescents
A large number of witnesses emphasized the
importance of comprehensive education programs in
the schools. According to Texas Commissioner of
Health Robert Bernstein and others, AIDS education
should be a part of the regular health education
curricula, beginning in the early grades. (#020; #273)
Education should be explicit and should teach stu-
dents how to prevent HIV infection, including the
role of condoms and abstinence. According to several
witnesses, to be effective, this education must be part
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of a comprehensive health education program that
establishes the relationship among personal decision
making, self-esteem, behavior, and health. f#2 73; Minorities
#591) Some witnesses favor standardizing the
material so that the quality and uniformity of the
information presented are assured. (~273) Kizer
calls for standardized federal AIDS instructional
programs: This would ensure that any individual
presenting information to the public on AIDS has a
minimum level of understanding of the AIDS disease,
as well as ongoing access to updated information."
He also suggests that these programs include
ethnically sensitive, targeted subcomponents for
specific populations. ¢~591)
Adolescents were identified frequently as a critical
target group. Ralph DiClemente of the University of
California, San Francisco says that the limited data
available indicate that adolescents are not well-in
formed about the prevention of HIV infection. He
recommends required courses in schools, with the
following goals, and makes some specific suggestions
about their content.
The objective of HIV prevention programs
should be to encourage health-promoting
behaviors arid eliminate or reduce high-risk
sexual and drug behaviors. Adolescents cannot
be coerced into changing behavior patterns; but,
by providing clear and developmentally appro
priate information, we can provide an "informa
tional impetus" which, as a direct consequence,
may result in the postponement, reduction, or
elimination of high-risk behavior. (#273)
However, information alone does not change
behavior, says Kizer. Programs must "target denial,
perceived susceptibility, motivation, self-efficacy, and
provide social support for change." (#591) Further
more, they must target those norms that sanction
unsafe sex and drug use behavior, including alcohol
use and needle sharing. (~273; #591)
Some of the suggested objectives for the year 2000
were framed in terms of the proportion of schools
that include education about AIDS or the percentage
of students informed about the disease and its trans
mission. In some testimony, witnesses addressed the
need for broad-based education about all sexually
transmitted diseases, including AIDS. The American
School Health Association, for instance, suggests that
current federal funding for AIDS education be used
for a broader program aimed at all sexually
transmitted diseases; that testimony is summarized in
Chapter 20.
Minorities have disproportionately high rates of HIV
infection and AIDS, and several speakers called for
expanded efforts to reach these groups. This issue is
discussed further in Chapter 6.
The prevalence of AIDS among Blacks and
Hispanics is more than twice that among Whites,
according to Frank Marsh of the University of
Colorado Health Sciences Center,3 and if AIDS
becomes endemic in the heterosexual community, it
will show up in the urban minority community first.
(#677)
Rudolph Jackson of the Morehouse School of
Medicine says that minorities are generally unaware of
important information about AIDS, that programs
should place a higher priority on providing culturally
sensitive information about AIDS to minority com-
munities, and that minority members should be
involved at all levels in planning those efforts. Grass
roots community organizations can be effective in
reaching this population and should get additional
funding for that purpose, he added. Jackson also
called for research to determine the underlying causes
or behaviors that place minorities at greater risk for
AIDS. (#252) Although some Black and Hispanic
preachers are unwilling to become involved in educa-
tion about sex or the use of sterile needles, Leon
Eisenberg of Harvard University suggests that "the
goal of minorities cannot be achieved without par-
ticipation by the church. (~787)
Marsh recommends that a central clearinghouse be
created for collection and dissemination of culturally
relevant materials. (~677)
Intravenous Drug Users
The urgent and growing problem of AIDS among IV
drug users was raised often. According to statistics
from the Centers for Disease Control (CDC) cited in
the testimony, an estimated 900,000 Americans inject
illicit drugs at least once a week; another 200,000 do
so occasionally.4 1-he CDC has estimated that as of
the end of 1987, 250,000 to 300,000 IV drug users in
this country were infected with the HIV virus.s
(#609J
Many witnesses expressed concern about the epi-
demic spreading from this community into the larger
population. (~442; #609; #677) Caswell Evans of
the Los Ankles County Department of Health
HIV Infection and AIDS 155
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Services emphasizes that preventive measures must be
taken immediately if such transmission is to be
stemmed.
We're beginning now to see the presence of the
second wave of AIDS patients as represented by
the IV drug-using community, which will certain-
ly vastly change our approach to AIDS. If we're
going to stop the spread of HIV in the second
wave, we've got to target that group of seroneg-
ative IV drug users and concentrate on that
group now. We've got a limited window of
opportunity, and if we're not effective at this
point, HIV is going to spread dramatically from
that community. (#286)
Stephen Joseph, New York City Health Commis-
sioner, and Deborah Prothrow-Stith, Massachusetts
Commissioner of Public Health, both cite the extreme
shortage of drug treatment services for those who
cannot pay as a serious obstacle to halting the con-
tinued spread of HIV infection. (~437; #735) One
of the most frequently mentioned objectives for the
year 2000 is that treatment and rehabilitative services
be available to all IV drug users. However, even if
adequate drug treatments were available, about half of
the addicts would probably decline treatment, accord-
ing to Irma Strantz, Director of the Drug Abuse
Program Office at the Los Angeles County Depart-
ment of Health Services. She says that education and
outreach efforts targeted at drug users could increase
the demand for treatment. Strantz emphasizes that
drug treatment can save society money. (#609J Oth-
er witnesses note the importance of continued re-
search into better ways to treat drug addiction.
(#442)
Strantz made many suggestions aimed at aggressive-
ly combating illicit drug use and AIDS among IV
drug users. Her suggestions include putting outreach/
education workers in every area that has a problem
with illicit drugs. These workers would distribute
vouchers for drug treatment centers as an incentive to
obtain treatment quickly and would offer transporta-
tion to HIV testing and counseling sites. Risk reduc-
tion kits, including condoms and bleach for cleaning
needles would be distributed along with culturally
relevant material in appropriate languages. Strantz
also called for drug use prevention programs in the
many settings where youth can be reached before they
become addicted. (#609) Other techniques
suggested for reaching IV drug users included making
HIV prevention education and testing available
156 Healthy People 2000: Citizens Chart the Course
routinely in all drug and alcohol treatment clinics, as
well as in STD clinics (#591~; providing sterile
~works" to all users (~787~; and encouraging "self-
organizations" among IV drug users akin to those
among gays (~787~. However, "the real solution,
says Howard Freeman of the University of California,
Los Angeles, "is drug control, not cleaning up a few
users.n (#792)
Mothers and Infants
The importance of controlling the spread of HIV
infection among drug users also was underscored by
witnesses who addressed the growing problem of
perinatal transmission of AIDS.
There is not much basis for optimism about the
future scope of the problem, says Richard Schwarz of
the State University of New York Health Science
Center at Brooklyn, who represented the American
College of Obstetricians and Gynecologists. (~442)
According to a 1987 survey, 1 infant in 61 born in
New York City tests seropositive for HIV infection.6
On the subject of preventing the perinatal trans-
mission of AIDS, witnesses addressed the importance
of making education, screening, and counseling availa-
ble to women of childbearing age. Some witnesses
called for routine testing of all pregnant women with
risk behaviors for HIV infection. (#3 76J According
to others, Medicaid should again finance abortions for
low-income women who test positive for AIDS or
HIV infection. (~449)
At-risk Professionals
Health care providers and other workers such as
firemen, morticians, and barbers must also be edu-
cated about their own risks and the appropriate
precautions. The American Association of Occupa-
tiona1 Health Nurses calls for companies to establish
policies protecting at-risk workers, particularly health
care workers, while also protecting the rights of HIV-
positive employees. (~558) Others emphasize that
the workplace is an important site for education
about AIDS. (#619J
IMPLEMENTATION
Several testifiers addressed the need for more data on
the prevalence of HIV infection in high-risk sub-
groups and the general population. William Lafferty
of the Washington State Department of Public
Health, for instance, stresses the need for primary
OCR for page 157
prevention to go beyond data on symptomatic illness;
data on HIV prevalence and incidence in both the
general and target populations are required as well.
Studies of the size, sexual behaviors, drug use pat-
terns, and so on of high-risk populations are seen as
essential to prevention efforts. (~698) Studies and
more accurate data on the prevalence of homosexual
and bisexual behavior also are needed; current Public
Health Service estimates are based on data that are
decades old. (#787)
Many proposed objectives were expressed in terms
of a specific reduction in the prevalence of HIV
infection or AIDS, for example, the percentage of IV
drug users who would test positive for HIV infection.
Some witnesses suggested a percentage of the popula-
tion that should be practicing safer sex or needle
behavior or should be well informed about HIV and
its transmission. f#286J
lithe American Medical Association, for example,
says that by the year 2000, the incidence rate of HIV
infection should be half of that in the first representa-
tive national sampling. Its testimony includes specific
REFERENCES
1. Centers for Disease Control: HIV/AIDS Surveillance, Atlanta: April 1990
goals for subgroups: among sexually active males, the
incidence of HIV infection should be reduced to ~
percent of the present rate; among needle-sharing
drug users, it should be reduced to 50 percent of the
present rate; among sexually active partners of those
likely to be infected, it should be reduced to 10
percent of the present rate; and among newborns of
high-risk parents, it should also be reduced to 10
percent of the present rate. (#095)
However, as many testifiers noted, setting quantifi-
able goals for limiting the spread of HIV infection
and AIDS in the next decade is a tricly business.
Much depends on the path this epidemic takes and
whether preventive vaccines, cures, or other events
could drastically alter its course. Witnesses proposed
continued research aimed at vaccines and better
therapeutic agents, and noted that soon treatment will
be provided for those who are HIV positive but
asymptomatic. In the meantime, however, if progress
is to be made in halting the spread of HIV infection
and AIDS, it will have to come from preventive
strategies, according to witnesses.
2. Centers for Disease Control: Estimates of HIV prevalence and projected AIDS cases: Summary of a
workshop, October 31-November 1, 1989. Morbid Mortal Wkly Rep 39(7):110-119, 1990
3. Centers for Disease Control: Human immunodeficiency virus infection in the United States: A review of
current knowledge. Morbid Mortal Wkly Rep Supplement 36(S6):1-48, 1987
4. Centers for Disease Control: op. cit., reference 2
5. Ibid.
6. Lambert B: "One in 61 babies in New York City has AIDS antibodies study sassy New York Times: At,
January 13, 19~
TESTIFIERS CITED IN CHAPTER 19
020 Bernstein, Robert; Texas Department of Health
093 Heckmann, Glenn; Texas Board of Pardons and Paroles
095 Hendee, William; American Medical Association
138
215 Turnock, Bernard; Illinois Department of Public Health
252 Jackson, Rudolph; Morehouse School of Medicine
273 DiClemente, Ralph; University of California, San Francisco
286 Evans, Caswell; Los Angeles County Department of Health Services
376 Judson, Franklyn; Denver Public Health Department
437 Joseph, Stephen; New York City Department of Health
Mahan, Charles; Florida Department of Health and Rehabilitative Services
HIV Infection and AIDS 157
OCR for page 158
442 Schwarz, Richard; State University of New York Health Center at Brooklyn
449 Santee, Barbara; Women and AIDS Resource Network
453 McKinney, Charles; Gay Men's Health Crisis (New York)
558 Babbitz, Matilda; American Association of Occupational Health Nurses
591 Kizer, Kenneth; California Department of Health Services
609 Strantz, Irma; Los Angeles County Department of Health Services
619 Schramm, Carl; Health Insurance Association of America
677 Marsh, Frank; Universitr of Colorado Health Sciences Center
691 Gilchrist, Lew; University of Washington
698 Lafferty, William; Washington State Department of Public Health
735 Prothrow-Stith, Deborah; Massachusetts Department of Public Health
787 Eisenberg, Leon; Harvard University
789 Carpenter, Charles C. J.; Brown University
792 Freeman, Howard; University of California, Los Angeles
803 Clever, Linda Hawes; Pacific Presbyterian Medical Center (San Francisco)
158 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
drug users
