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4 Altering the Course of the Epidemic AIDS and the HIV epidemic present a fundamental challenge to "guardians" of the public health. This chapter discusses the range of possible public health interventions, the resources and talents that will be necessary to implement them, and the hallmarks of programs that are both responsive to the crisis and consonant with a respect for human dignity and individual freedom. 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. The incubation period of AIDS may be a number of years; asymptomatic carriers of the virus appear to be infectious for the remainder of their lives. Public health programs are based on the presumption that this is so. AIDS is also a disease of behaviors- generally private, consensual behaviors such as sexual intercourse and IV drug abuse. Finally, the groups at greatest risk of infection were already subject to social stigma and prejudice; that vulnerability entails unique considerations for public health officials (Walters, 1988~. In considering how to fashion interventions to confront the HIV epidemic, it is useful to review the conceptual framework for the operation of public health programs. They are frequently classified by the 61

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62 CONFRONTING AIDS: UPDATE 1988 level of prevention they are intended to provide: primary, secondary, or tertiary; that is, by efforts to prevent the problem altogether, to detect the problem early and provide definitive treatment, or to avert or mitigate the long-term consequences of the problem. Programs organized to combat the HIV epidemic can be considered in that manner, although some program activities may have an effect on more than one type of prevention. Primary prevention, which is aimed at preventing new cases of infec- tion, focuses on three groups. First, there are those who have not begun to engage in high-risk behaviors, principally young persons who are not sexually active or who do not abuse drugs. Activities may be directed at preparing these individuals to avoid risk behavior entirely or to learn safer practices prior to initiation. Second, there are those who engage in high-risk behavior but who have not yet been infected. These individuals may be approached to stop the risk behavior or to learn safer practices. Finally, those persons who are currently infected can be supported in practices that minimize the opportunities for transmitting the virus to uninfected persons. Secondary and tertiary levels of prevention are harder to define in the absence of definitive treatment for HIV infection. Current research indicates that there is a role for early case finding, not only for the contribution early identification can make to primary prevention but also to allow for medical supervision of the asymptomatic individual and for medical care of the symptomatic person. As additional treatment methods are developed, it may be possible to define a tertiary prevention level. The committee believes that the HIV epidemic should prompt a reexam- ination of the fiscal and institutional barriers that impede elective public health efforts in all program areas related to the control of HIV infection. Public health efforts to combat the spread of HIV infection are not limited to programs with "AIDS" in their titles. Sexually transmitted disease clinics (Aral et al., 1986; Solomon and DeJong, 1986), drug abuse treatment centers (Carlson and McClellan, 1987), private physicians' offices (Koop, 1987b), 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. The continued reprogramming of funds from these activities to AIDS programs may have a deleterious net impact on the public health. ANTIDISCRIMINATION PROTECTIONS Evidence accumulated since the publication of Confronting AIDS gives us further confidence in our conclusions about the modes of HIV

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ALTERING THE COURSE OF THE EPIDEMIC 63 transmission (see Chapter 2~. There are no grounds for discriminating against persons with AIDS or HIV infection because of fears that they pose a health risk in the workplace or in housing. The fear of AIDS can be a healthy and useful reaction when it helps people avoid behaviors that put them at risk of contracting HIV infection. Unreasonable fears can have a debilitating effect on both the individual and the body politic (Eisenberg, 1986~. 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. In many instances, discrimination has thwarted access to health care (hospitals, nursing homes, dental care, and private physicians' services), employment, housing, education, health insurance, and even funeral services (Rapoport and Parry, 1987; Dickens, 19881. A few systematic studies have attempted to determine the range and scope of AIDS-related discrimination and legal protections (National Gay Rights Advocates, 1986; ASTHO, 19871. Although it is impossible to tell whether AlDS-related discrimination has paralleled the rise in AIDS cases, dramatic anecdotal accounts reflect problems that increasingly confront those with AIDS or with lesser manifestations of HIV infection, those who are without symptoms but are seropositive, or those who are merely members of risk groups. For example, an apparent rise in violence against gays has been attributed to fears of AIDS (NGLTF, 1988~. Many court cases have been filed involving victims of AIDS-related discrimination in a variety of settings (Boorstin, 1987), and complaints have been docketed with state and local human rights commissions. Courts have ordered schools to admit HlV-infected students and have allowed teachers with AIDS to remain on duty in the classroom. It is likely that many other episodes of discrimination are being resolved privately, or they may simply not be pursued by AIDS patients who are too debilitated to press their claims (Ansberry, 19874. Protection from irrational discrimination is a hallowed function of U.S. law (Parmet, 19871. In particular, Section 504 of the Federal Rehabilita- tion Act of 1973 specifically proscribes discrimination against '`otherwise qualified" disabled or handicapped individuals in programs receiving federal funds. Although persons with AIDS may readily establish their disabled status, the legal posture of those who are seropositive but asymptomatic may be unclear. These individuals may not be considered handicapped under common law or statutory definitions although they may still face discrimination and threats to their livelihood, health, or residence.

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64 CONFRONTING AIDS: UPDATE 1988 A case decided by the U.S. Supreme Court since the publication of Confronting AIDS involving a teacher with tuberculosis would seem clearly to extend the protections of Section 504 to HIV-infected individ- uals who display symptoms. Yet in a footnote, the Court explicitly reserved judgment about the status of asymptomatic carriers of infectious diseases (School Board of Nassau County, Florida v. Arline, 107 U.S. 1129, 1987~. However, the Ninth Circuit Court of Appeals has recently held that Section 504 specifically covers AIDS in finding that a public school teacher with AIDS could not be dismissed because of his illness (Chalk v. U.S. District Court for the Central District of California, No. 87-6418, 840 F.2 701, February 26, 19881. The committee supports the enactment of a federal statute specifically designed to prevent discrimination on the basis of HIV infection or AIDS. The committee also supports the consideration by states and localities of statutes and ordinances designed to prevent discrimination in employ- ment, education, housing, health insurance, or the receipt of health care services. However, the committee does not support measures that would abrogate insurers' rights to distinguish among applicants for life insur- ance. States should consider whether their handicapped antidiscrimina- tion, civil rights, education, and insurance laws sufficiently address HIV infection and AIDS. Executive orders and administrative regulations are other possible avenues of reform. It may also be appropriate to review the time it takes to consider claimsif discrimination charges take years to resolve, many AIDS patients may die before their rights can be upheld. EDUCATION Educational efforts to foster and sustain behavioral change remain the only presently available means to stem the spread of HIV infection. 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. The past 2 years, on the other hand, have seen many state and local efforts to educate the general public and those in high-risk groups, as well as a nationwide education campaign funded by the federal government and directed by CDC. These significant efforts are laudable. Nevertheless, formidable obstacles to effective AIDS education remain. Merely com- municating information about the risks of infection will not suffice; individuals must also have the motivation and means to translate an awareness of risk into changes in fundamental areas of human behavior. The committee believes that the urgency of the HIV epidemic warrants a multiplicity of educational efforts, including the use of paid advertising

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ALTERING THE COURSE OF THE EPIDEMIC 65 on television or in other media. Currently, a number of federal entities, including the armed forces, the postal service, Amtrak, and the mint use paid advertisingover $300 million worth each year. Administrative restrictions from the Department of Health and Human Services (HHS) preclude CDC from doing the same. The committee is aware of concerns about paying for advertising: that paid advertising for AIDS could have a detrimental effect on the amount of time or space donated for public service announcements in general. Nevertheless, it is doubtful that public service announcements are adequate to the task of increasing public awareness of the risks of HIV infection and encouraging behavioral change. The gravity of the HIV epidemic is such that CDC, like other government entities, should be allowed to purchase advertising time and space and should be supplied with the funds to do so. Any administrative regulations that preclude such actions should be withdrawn immediately. Content of the Message The implementation of AIDS education programs has continued to founder over questions involving their content. Although a great deal is known about the modes of transmission of the virus, much of this information is difficult to convey. Only the scientist or physician trained in epidemiology may be able to appreciate the fact that HIV is at once fragile and deadly unable to live outside of the body for very long and yet lethal once it is introduced by sexual intercourse or through the bloodstream. Yet it is essential that educational programs convey to the public this scientifically accurate message. Moreover, these efforts should be aimed beyond those in what traditionally have become identified as high-risk groups. The further spread of HIV is sufficiently daunting to warrant educational efforts to promote personal caution and prudent behaviors on the part of all sexually active persons. 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 mar- riage, or IV drug abuse as immoral may believe that frank, straightfor- ward educational or public health programs encourage such activities. These concerns continue to stymie educational efforts (Booth, 1987b). The committee believes that government at all levels, as well as private sources, should continue to fund ellective, factual educational programs designed to foster behavioral change. This may mean supporting AIDS education efforts that contain explicit, practical, and perhaps graphic advice targeted at specific audiences about safer sexual practices and how to avoid the dangers of shared needles and syringes.

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66 CONFRONTING AIDS: UPDATE 1988 Confronting AIDS expressed skepticism about the approach taken by CDC in establishing local boards to review the degree of explicitness of AIDS educational materials (the so-called "dirty words" issue) because of concern that such a process might keep explicit information from those for whom it would be most beneficial. Efforts to stifle candid materials that discuss safer sexual practices and that are targeted at appropriate audiences may take a toll in human lives. In 1987 an amendment to the HHS appropriations bill (P.L. 100-202, Title 5, Sec. 514, 1988) passed the House and Senate with overwhelming majorities. It precludes the use of CDC funds for educational materials "that promote or encourage, directly, homosexual sexual activities" (Booth, 1987a). Explicit information on the risks associated with gay sex and the way those risks can be minimized does not "promote or encourage" homosexual activities. Its sole function is to help homosexuals avoid an illness that endangers their lives and those of their sexual partners and costs the nation billions of dollars. School-Based Education The committee believes that school-based educational programs are an essential part of efforts to increase awareness of the risk of HIV and to combat the spread of infection. Ideally, such education would begin at a young age, with a level of detail and explicitness appropriate for the age group. Education about sexuality and drug abuse, including specific information about HIV, should be part of a systematic and comprehen- sive program of health education. 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. Since then, at least nine more states have passed similar statutes, some of which specifically address AIDS (Asso- ciated Press, 19881. A number of states have also acted in the absence of specific legislation. By early 1987 half of the nation's largest school districts had instituted some kind of HIV education program. Unfortunately, in many states, HIV education proposals have hit formidable roadblocks. The locus of responsibility for shaping the content of AIDS curricula remains a highly charged issue, reflecting historical tensions between state and local control of education. State mandates also vary widely as to the degree of parental control that may be permitted. Some states have provisions that allow parents or guardians to inspect curricular material in advance or to exempt their children from the courses (Koop, 1987a). Colleges are another key site for AIDS prevention and education efforts. Because of the lengthy incubation period of the virus and the

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ALTERING THE COURSE OF THE EPIDEMIC 67 timing of the onset of sexual (and drug abuse) activity, there may be few cases of fulminant AIDS among college students. 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. Within the college setting, there are many opportunities for reaching students with AIDS prevention messages (Fraser, 19871. Dormitory advisors, health centers, and peer groups are beginning to offer HIV counseling on some campuses. More campuses are beginning to offer serologic testing or, if not, to advertise off-campus services. At some colleges, condoms are available through clinics, bookstores, or dormito- ries. A few schools are also carefully evaluating the effectiveness of . . various program mixes. Effect of Educational Programs Awareness of AIDS is widespread. The deaths from AIDS of a number of celebrities have rendered the disease less of an abstraction. During the 12-month period ending October 1987, the number of Americans who reported that they knew someone with AIDS grew from 4 to 6 percent (New York Times, 1988~. The ways in which HIV is spread are also widely known. According to the National Health Interview Survey of August 1987, 92 percent of the public know that AIDS can be contracted by having sex with someone who is infected; more than 80 percent believe that condoms are a somewhat or very effective means of avoiding infection. Unfortunately, serious misunderstandings persist: 25 percent of the general public believe incorrectly that HIV can be acquired by donating blood; 38 percent believe incorrectly that mosquitoes are a likely mode of transmission; and 21 percent believe incorrectly that there is a risk of infection from merely working near someone with AIDS (Dawson et al., 19871. The committee believes that more studies are needed to determine the effects of various types of educational campaigns on specific populations. For example, there have been few systematic assessments of the impact of AIDS education programs or media efforts on the behavior of hetero- sexuals (as opposed to the impact on their beliefs or understanding). The National Research Council's CBASSE study on AIDS research and the behavioral, social, and statistical sciences (see Chapter 3) will explore the effectiveness of educational interventions in depth. The committee's report, to be released in the fall of 1988, will present general principles of health behavior and recommendations about AIDS intervention strategies. Especially critical are educational efforts aimed at persons at risk within minority populations. The prevalence of AIDS in the black and

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68 CONFRONTING AIDS: UPDATE 1988 Hispanic communities is substantially higher than the prevalence among whites. Culturally specific programs to address the needs of minority communities, especially in the inner cities, are of paramount importance. In August 1987 CDC sponsored a conference on minorities and AIDS, the outgrowth of which has been a number of new efforts in this regard. A second such conference is planned for the summer of 1988. Gay and Bisexual Men Community-based programs in the two cities hardest hit by the epi- demic, New York and San Francisco, are the oldest examples of aggressive HIV educational efforts. These programs began at the grass roots level with privately raised funds and volunteer support from many in the gay community. Today, they feature a multipronged attack funded by a variety of government and private sources and include media campaigns, peer counseling, literature distribution, and support groups. In addition, local efforts in cities such as New York, Boston, San Francisco, and Los Angeles have been expanded to the state level. It has been shown that substantial changes in behavior can be effected among gay and bisexual men in areas with firmly established gay social and political structures (Winkelstein et al., 1987~. Unfortunately, even the dramatic changes that have occurred in San Francisco and New York are faint reassurance when half or more of the male homosexual population may already be infected (Fineberg, 1988~. The high rates of seropositivity among gay men in these cities and the widespread appreciation of the risk posed by AIDS are not sufficient reasons to abandon educational efforts for homosexual men or curtail local, state, or federal government funding support, despite the claims of some critics (Kilpatrick, 19871. The mere understanding that one may be at risk will not necessarily translate into sustained behavioral change in the absence of concerted educational and counseling efforts. The challenge also remains to educate and inculcate behavioral change among gay men outside of urban areas with active gay social communities and among men who may not see themselves as belonging to the gay community but who nevertheless engage in homosexual behavior that puts them at risk. The committee also believes it is essential to develop effective methods for reaching youth who are just becoming homosexually active. 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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ALTERING THE COURSE OF THE EPIDEMIC 69 Studies of the effectiveness of condoms as a barrier against HIV and other viral agents have resulted in recommendations for the use of latex (as opposed to natural membrane) condoms, supplemented by creams or jelly containing nonoxynol 9, a proven virucidal agent (Rietmeijer et al., 1988~. Condoms are regulated as medical devices under the Federal Food, Drug, and Cosmetics Act, and the Food and Drug Administration (FDA) has recently moved to ensure the adequacy of condom manufacture. FDA batch testing and manufacturer quality control programs have resulted on occasion in product recalls. Ensuring that condoms meet quality specifications is only an initial step, however. The occasional failure of condoms is more likely to be attributable to "user failure" than to "product failure" (CDC, 1988a). Greater familiarity with condom use should be fostered to promote a willingness to incorporate them routinely into heterosexual and homosex- ual intercourse. 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). One obstacle to effective AIDS education has been the long-standing refusal of the media to accept commercial condom advertising in the belief it would offend a substantial portion of their audience. In 1987 some companies relented, including the New York Times, Newsweek, and Time, Inc. (Aiken, 19871. These changes in policy were accompanied by the proviso that the advertising message stress the role of condoms in disease prevention rather than in contraception. Although a few local television affiliates have broken ranks and agreed to accept condom advertising, the networks have continued to balk. Many have pointed out the irony of the numerous steamy sexual encounters that take place on daytime TV soap operas and during prime time with seldom even a mention of the need to exercise precautions. The committee believes that there must be continued attention to the development of policies to foster the use of condoms. Allowing condoms to be advertised through the major media, increasing the number and types of outlets for their sale and distribution, and taking steps to ensure their quality are among the measures the committee has consid- ered. In addition, continued education is needed to ensure their effective use. HIV ANTIBODY SCREENING AND TESTING The proper role of tests for HIV infection has continued to be one of the most controversial AIDS-related public policy issues. Arguments for and against testing (of individuals) and screening (of populations) depend

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70 CONFRONTING AIDS: UPDATE eggs largely on the circumstances in which the tests are to be applied. In order to assess the utility of testing or screening in any particular setting, it is essential that the purpose of such activities be clearly spelled out. A few possible rationales related to public health and medical care include the following: HIV antibody (and, possibly in the future, antigen) screening is essential to ensure the safety of donated blood, tissues, and organs. Antibody screening is critical in surveillance and planning to obtain geographic and demographic data about the spread of disease. These data are needed to plan targeted public health efforts and earmark patient care services. Increased antibody testing is also an adjunct to patient care. The advent of zidovudine (i.e., AZT) 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. Testing and counseling may also help foster individual behavioral change. Testing may be especially useful to women of childbearing years confronted with reproductive decisions. HIV testing may be useful in identifying index cases, which will allow the identification of contacts and others who may have been exposed, such as female partners of bisexual men or recipients of contaminated blood products. Testing will ascertain whether exposed persons have become infected. Screening has also been proposed as an adjunct to infection control procedures in hospitals to help ensure that appropriate precautions are exercised when invasive procedures are performed on seropositive pa- tients. These varied rationales offer a backdrop against which to examine the array of proposals for more widespread testing. Yet a number of other factors must also be taken into account: the social and psychological ramifications of the test, the expense of testing and the labor-intensive nature of counseling, the accuracy of the test in terms of the number of false-positive and false-negative results (in both the ideal and the "real world" laboratory settings), and the degree to which test information can be protected from unauthorized access (Barry et al., 1987~. At- tributes of the population to be screened are also critical factors. The degree to which a population is at risk and the reservoir of infection within the population to be screened are further considerations. Insti- tutionalized populations pose special concerns (Gostin and Curran, 1987~.

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ALTERING THE COURSE OF THE EPIDEMIC 7~ Technical Considerations Tests to measure the development of antibodies against HIV have been commercially available since the spring of 1985. Eight different tests have been licensed for antibody detection, including seven enzyme-linked immunoassay (ELISA) tests and one Western blot test kit. As of 1987 these tests had been approved by FDA for clinical diagnostic use in addition to their original purpose of screening the blood supply. Since their introduction, a number of manufacturing modifications have been approved to bolster the sensitivity (the test's performance among infected individuals), specificity (the test's performance among uninfected individ- uals), 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. The more widespread testing programs that have been proposed under a variety of public and private auspices have prompted concerns about the ability to replicate the military's record of testing accuracy (Burke, 1987~. The risk of false-positive results (which is greater in the screening of low-prevalence populations) and the danger of imposing an unneces- sary burden of fear and stigma on uninfected individuals have been sources of misgivings about expanding screening programs (Okie, 1987~. The issue of the number of false test results that might have to be endured to achieve the intended public health result of screening programs presents ethical and political as well as technical questions (Meyer and Pauker, 19871. The committee believes the federal government should give more atten- tion to establishing standards for laboratory proficiency in HIV antibody testing, setting criteria for interpreting assays, and instituting quality assurance procedures. When appropriate, FDA should continue to move rapidly to license new diagnostic tests. Additional resources should be provided to allow state and local governments to expand their testing capabilities, shorten waiting periods, and improve the quality of test results. Informed Consent and Confidentiality In addition to ensuring that tests for infection with HIV are accurate, properly confirmed, and conducted by experienced, proficient laborato- ries, other essential requisites of testing and screening (in addition to counseling) include securing the consent of the individual to be tested and maintaining the confidentiality of the results.

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82 CONFRONTING AIDS: UPDATE 1988 The feasibility of contact tracing among high-risk groups in areas with a high prevalence of HIV infection for example, among gay men in urban settings such as San Francisco and New York City has been viewed skeptically. Those in high-risk groups may know already what behaviors put them at risk; they would not, however, know whether or not they had become infected. The committee believes that voluntary contact notification programs can be useful in preventing the spread of HIV infection. Trained counselors in local public health departments have experience in notifying contacts of patients with other venereal diseases; the ethos of client confidentiality is highly valued. 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. These programs may be of greatest value when directed at those who otherwise might be unaware they had risked infection. For example, San Francisco has pursued a limited program to notify female contacts of bisexual men (Echenberg, 19871. Reporting of HIV-Seropositive Cases Approximately a dozen states now require the reporting of seroposi- tivity. Several rationales have been offered for this requirement. First, the reporting of all seropositive test results broadens the state's information base about the prevalence of infection in the state. Second, reporting seropositive index cases facilitates the contact notification process. Third, reporting HIV infection is consistent with the view that the disease is really a continuum from HIV infection to AIDS. Finally, treating HIV infection and AIDS like other reportable diseases helps to dissipate some of the stigma associated with HIV infection and thus "normalize" the disease. Although the committee recognizes these arguments, it believes that mandatory reporting of seropositive test results with identifiers should not be required at this time. Contact notification does not necessarily demand the reporting of seropositive cases with identifiers. Further- more, for determining seroprevalence rates, well-designed population surveillance studies are more useful than ad hoc collections of cases in which the size of the underlying populations is unknown. The commit- tee believes that the effect of mandatory reporting may be to discourage individuals from seeking voluntary testing, a cost that does not justify its potential benefits. Neither are the arguments about treating HIV infection like other diseases sufficiently compelling to risk deterring individuals from being tested.

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ALTERING THE COURSE OF THE EPIDEMIC 83 Personal Control Measures Since the publication of Confronting AIDS, there has been increasing attention given to measures aimed at controlling the behavior implicated in the spread of HIV infection, whether through isolation or quarantine, criminal penalties, or civil liability for the intentional transmission of the virus. Scores of criminal cases have been filed involving intentional or reckless attempts to transmit HIV through sexual conduct, giving blood, spitting, or biting. Since the HIV epidemic first appeared, a few states, including Colorado, Connecticut, Indiana, and Florida, have even en- acted statutes providing for the isolation of infectious disease carriers. The problems with many of these measures are manifest: it is difficult to determine intent and to predict with certainty who among the infected are dangerous to others; enforcing prudent behavior is difficult when private sexual activity is involved; the incubation period of the virus makes the determination of causation problematic; and only the poorest and most disenfranchised individuals are likely to come within the bounds of personal control measures (Field and Sullivan, 1987; Gostin, 1987a). Despite these difficulties, if it can be demonstrated that a person know- ingly or recklessly transmits HIV to unwitting partners, there is no reason why such an individual should be beyond the reach of the law. There have been a number of celebrated cases of "recalcitrant" individuals who refused to conform in their behavior to the advice of health officials. (For example, "Patient Zero" was the centerpiece of a popular chronicle of the AIDS epidemic [Shilts, 19871.) The use of criminal law sanctions or legal provisions for isolation will not address the core problems of the spread of HIV infection; neverthe- less, the inability or unwillingness of authorities to deal with such hard cases may undermine confidence in those who are entrusted with the protection of the public health. It is unclear how the numerous laws already on the books would apply to HIV and AIDS, given some of the properties (especially the incubation period of the virus) that distinguish AIDS from other sexually transmitted diseases. Indeed, such laws may be ineffective, protecting neither the public health nor civil liberties. The committee believes that there may be rare instances in which the state should act to restrict the personal liberties of some infected individuals, and states should review their statutes to ensure that such authority exists. Legal measures to restrict personal liberty should be used only when the following conditions have been met: (1) the individual is infected; (2) the individual is putting others at risk; (3) voluntary efforts to prevent the individual from jeopardizing others have failed; and (4) the restrictive measure is the least restrictive alternative available. Furthermore, restric- tive measures should also entail the provision of intensive counseling, job

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84 CONFRONTING AIDS: UPDATE 1988 training, and other supportive actions designed to induce behavior change. The time involved should be short and clearly limited. 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~. IV drug abusers are the second largest group of AIDS sufferers; they are the persons most likely to transmit HIV to heterosexual partners. There are an estimated 1.2 million drug abusers in the United States who inject drugs, including heroin and, increasingly, cocaine. Approximately 30 percent of these drug abusers are women. Three-quarters of the IV drug-related AIDS cases come from the New York City metropolitan area, where seroprevalence among IV drug abusers is estimated to be anywhere from 50 to 60 percent (Des Jarlais and Friedman, 1987; Lange et al., 19881. Retrospective reviews of the medical records of drug-related deaths in New York City have uncovered many more deaths (for example, from bacterial endocarditis and tuberculosis) than were originally believed to be related to HIV. The link of IV drug abuse to AIDS is of particular concern to inner-city minority communi- ties, particularly blacks and Hispanics (Ginzburg, 19871. The committee believes that the gross inadequacy of federal efforts to reduce HIV transmission among IV drug abusers, when considered in relation to the scope and implications of such transmission, is now the most serious deficiency in current efforts to control HIV infection in the United States. Correcting this deficiency will require special efforts directed particularly but not exclusively at black and Hispanic populations at risk in New York City and New Jersey (Brown et al., 1987; Rogers and Williams, 19871. The committee supports a number of strategies in the short and long terms to prevent drug abuse and to avoid the risk of HIV infection when such prevention is not possible. The committee urges a greater commit- ment on the part of federal, state, and local governments to the rapid, large-scale expansion of drug abuse treatment slots, both in residential drug-free treatment centers and in methadone maintenance facilities, to offer immediate access to all addicts who request treatment. Without substantially increased funding, however, treatment on demand is a laudable yet distant goal. In January 1988 there were 29,400 methadone maintenance treatment slots for an estimated 200,000 IV drug abusers in New York City. More than 60 percent of those slots were taken by

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ALTERING THE COURSE OF THE EPIDEMIC 85 long-term clients who had been on methadone for 2 or more years (Thomas, 19881. Official waiting lists contain at least a thousand names; thousands of others are assuredly deterred by the prospect of a wait of a month or more. Creating and funding more treatment slots will entail training and hiring more counselors and physicians as well as securing more office space, but these are not the only impediments to more ready access to methadone maintenance. Much of the historical development of methadone clinics has involved philosophical debates over the medical versus moral models of treatment and the competing merits of methadone versus drug-free programs (Newman, 19871. The HIV epidemic has quieted some of this debate, and there has been more willingness to loosen some of the restrictions that accompany the dispensing of methadone. In October 1987 the National Institute on Drug Abuse and FDA proposed lifting the requirement that methadone clinics hire a counselor for every 50 patients. In December 1987 the American Medical Association also recommended loosening enrollment restrictions (Thomas, 19881. Others have urged that physicians in private practice be allowed to prescribe methadone. Intervention Innovations The committee supports the increased use of former IV drug abusers as community health workers to provide "one-on-one" risk reduction coun- seling 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. In San Francisco, former drug abusers and experienced drug counse- lors distributed thousands of 1-ounce vials of bleach, accompanied by instructions for addicts on how to clean "works" (drug injection equip- ment). A study by an independent research group surveyed 387 addicts at four sites in the San Francisco area. Before the program, only 3 percent reported using bleach to clean needles and syringes, although 34 percent used "possibly safe" methods such as boiling syringes or rinsing them with alcohol or hydrogen peroxide. One year later, the results of a survey of 440 addicts showed that 68 percent used bleach to clean their equipment, while another ~ percent used "possibly safe" techniques (Watters, 19881. According to one of the architects of the program, "the outreach workers, and not the bleach bottles are the linchpins of our program; their street wise skills are essential to empower the IVDUs Lintravenous drug users] to take health maintenance into their own hands, and to reinforce adherence to risk-avoidance measures" (letter to R.

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86 CONFRONTING AIDS: UPDATE 1988 Widdus from J. A. Newmeyer, Haight-Ashbury Free Medical Clinic, San Francisco, October 13, 1987~. New Jersey has designed a coupon program using vouchers that entitle prompt entry into drug treatment slots. This policy may allow more precise targeting of the IV drug abuser at greatest risk of infection or in greatest need of intervention while also matching the appropriate treat- ment modality with the particular characteristics of the user. 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. At least four countries the Netherlands, the United Kingdom, Aus- tralia, and Switzerland have begun to experiment with free, govern- ment-supported needle exchange programs, and all report encouraging results (Lofton, 1988~. At a meeting sponsored by the World Health Organization, the Netherlands reported that needle sharing declined from 75 percent to 25 percent from 1985 to 1987. WHO officials caution, however, that programs may not be transplanted readily from one country to another, and they urge nations to begin with small pilot programs. In this country, reluctance to begin to experiment with such programs for fear of encouraging drug abuse has begun to give way to concerns about the risk of AIDS. In New York, where a state statute bans the sale of sterile needles and syringes without a prescription, a proposal to institute such an experiment was made as early as August 1985 by the New York City health commissioner. (Although New York is one of 12 states with statutes banning the sale of sterile needles, the state health commissioner is empowered to waive parts of the law for experimental purposes.) Yet city and state government officials had difficulty agreeing on details of the scope of the programs or the experimental design. In early 1988 a number of events conspired to prompt a change in policy. Concern about the spread of HIV infection in New York City was underscored by a study showing that 1 of every 61 babies born there tested positive for HIV antibodies (Novick et al., 1988~. In another

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ALTERING THE COURSE OF THE EPIDEMIC 87 development, ADAPT, a well-respected local drug treatment group, threatened to break the law openly and distribute sterile needles and syringes. With these added pressures, New York State and City agreed to an experimental program to issue sterile needles and equipment to addicts on methadone maintenance program waiting lists in targeted neighbor- hoods in which drug abuse was rampant (Raymond, 1988b). These needle and syringe exchange programs may be viewed as a way to attract addicts into treatment during which they can be counseled not only about the danger of contaminated needles and syringes but also about unprotected sex. 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. As one tack, the committee supports the immediate extension of serologic testing and counseling for HIV infection to all appropriate settings in which IV drug abusers are seen. Programs should also be developed to promote self-help support groups of former and current drug abusers as a means of providing education about AIDS and drug abuse among at-risk groups. Some treatment centers have designed programs of this type to counsel the families of abusers as well and to assist in obtaining housing, child care, and legal assistance (Raymond, 1988a). Some long-term strategies that deserve increased attention include intensified efforts to prevent IV drug abuse by educating teens and preteens in high-risk populations. Research and evaluation are critical to ascertain which interventions work best. RESOURCES Unlike biomedical research, which is traditionally and overwhelmingly a federal responsibility, funds for AIDS prevention and education right- fully come from a variety of sources, including federal, state, and local governments. It is thus somewhat more difficult to determine whether one of the goals of Confronting AIDSproviding by 1990 $1 billion a year in "newly available funds" for public health and education- is being reached. The goals for public health and education were set with the recognition that, instead of being the sole funding source, the federal government is "the only possible majority funding source." Various private sources have also been marshalled, and charitable contributions in the form of foundation support and individual funding of local AIDS service-providing groups remain a critical part of the effort.

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88 CONFRONTING AIDS: UPDATE Eggs Contributions from private individuals are not only monetary; they also take the form of thousands of hours of volunteer time. The current administration request for $1.3 billion for AIDS in fiscal year 1989 represents a substantial (37 percent) increase over the actual funding of the preceding fiscal year. Of the total Public Health Service AIDS budget, $400 million is earmarked for prevention efforts under the category of public health control measures. This total includes a small portion for the prevention of transfusion-acquired AIDS and the devel- opment and evaluation of blood tests ($26 million). The lion's share ($374 million) is reserved for information and education programs directed at the following audiences: the public at large ($50 million); school- and college-aged youths ($36 million); high-risk or infected individuals ($241 million, including $162 million for testing, counseling, and referrals); and health care workers ($44 million). In addition, communities will receive $93 million for the development of expanded programs to treat drug abusers and another $41 million to develop drug abuse prevention strategies. The committee is encouraged by the growth in federal funding and by the heightened commitment of state and local governments, foundations (Wells, 1987; Seltzer, 1988), and the private sector (Allstate, 1988~. Yet the shortfall is still considerable. The committee believes that several critical areas of AIDS prevention and education still need an infusion of personnel and funds. 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. IOM/NAS is currently conducting a congressionally mandated study to assess the adequacy of third-party coverage for substance abuse treat- ment. The study's assessment of the cost of such treatment will supple- ment the information already compiled by the Presidential Commission on the Human Immunodeficiency Virus Epidemic. That information was used by the commission as the basis of their recommendation that $1.5 billion annually will be necessary for drug abuse treatment and education. The waiting lists for entry into treatment programs are a clear indication that the caliber of the ammunition in the war on drugs needs to be increased. A number of other specific programs are deserving of particular mention for example, the support of counseling linked to antibody testing. There is a growing realization of the need for such counseling that is, beyond the short-term counseling of antibody-positive individuals.

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ALTERING THE COURSE OF THE EPIDEMIC 89 In a health care system skewed toward the reimbursement of procedures rather than counseling, this need is particularly acute, especially if HIV antibody testing is going to be increasingly relied on as a public health measure. The long-term impact of such knowledge is cntical. Counselor training and the development of counseling programs must accompany the expansion of testing efforts. The recent demand for testing in sexually transmitted disease clinics and family planning and maternal and child health clinics is currently outstripping the availability of trained counse- lors. Because they are labor intensive, expanded counseling programs will require a major infusion of funds. Minority groups are not being adequately reached by current educa- tional and outreach efforts. The rates of syphilis cases are an example. Syphilis has declined significantly among gay and bisexual white men; at the same time, there have been small increases in the number of cases among black and Hispanic gay and bisexual men and substantial in- creases among heterosexual black and Hispanic men and women. Edu- cational 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. REFERENCES Aiken, J. H. 1987. Education as prevention. Pp. 90-105 in AIDS and the Law, S. Harris, H. Dalton, and the Yale AIDS Law Project, eds. New Haven, Conn.: Yale University. Allstate Forum on Public Issues. 1988. AIDS: Corporate America Responds. Chicago: Allstate. AMA (American Medical Association). 1987. Report of the Council on Ethical and Judicial Affairs: Ethical Issues Involved in the Growing AIDS Crisis. Chicago: American Medical Association. Ansberry, C. 1987. AIDS, stirring panic and prejudice, tests the nation's character. Wall Street Journal, October 9, p. Al. Aral, S. O., W. D. Mosher, M. C. Horn, and W. Cates. 1986. Screening for sexually transmitted disease by family planning providers: Is it adequate and appropriate? Fam. Planning Perspect. 18:255-258. Associated Press. 1988. School boards favor AIDS mandate. New York Times, February 27, p. Ale. ASTHO (Association of State and Territorial Health Officials). 1987. Guide to Public Health Practice: AIDS Confidentiality and Anti-Discrimination Principles. Washington, D.C.: Public Health Foundation. Barry, M. J., P. D. Cleary, and H. V. Fineberg. 1987. Screening for HIV infection: Risks, benefits, and the burden of proof. Law Med. Health Care 14:259-267. Biemiller, L. 1987. Health experts assail colleges for wasting opportunity to lead AIDS- education drive among students. Chronicle of Higher Education, September 23, p. A37. Boorstin, R. O. 1987. Criminal and civil litigation on spread of AIDS appears. New York Times, June 19, p. Al.

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90 CONFRONTING AIDS: UPDATE eggs Booth, W. 1987a. Another muzzle for AIDS education? Science 238:1036. Booth, W. 1987b. The odyssey of a brochure on AIDS. Science 237:1410. Brandt, A. M . 1987. AIDS: From social history to social policy. Law Med. Health Care 15:231-242. Brown, L. S., D. L. Murphy, and B. J. Primm. 1987. Needle sharing and AIDS in minorities. J. Am. Med. Assoc. 258:1474-1475. Burke, D. S. 1987. HIV screening by the U. S. Army: Two years of experience in quality control. Testimony before the House Committee on Small Businesses, Subcommittee on Regulation and Business Opportunities, Washington, D.C., October 19. Carlson, G. A., and T. A. McClellan. 1987. The voluntary acceptance of HIV-antibody screening by intravenous drug users. Public Health Rep. 102:391-394. Caruso, B. A., and J. R. Haig. 1987. AIDS on campus: A survey of college health service priorities and policies. J. Am. Coll. Health Assoc. 36:32-34. CDC (Centers for Disease Control). 1987a. Antibody to human immunodeficiency virus in female prostitutes. Morbid. Mortal. Wkly. Rep. 36:157-160. CDC. 1987b. Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. Morbid. Mortal. Wkly. Rep. 36:509-515. CDC. 1987c. Recommendations for prevention of HIV transmission in health-care settings. Morbid. Mortal. Wkly. Rep. 36:1-18. CDC. 1988a. Condoms for the prevention of sexually transmitted diseases. Morbid. Mortal. Wkly. Rep. 37:33-39. CDC. 1988b. Semen banking, organ and tissue transplantation, and HIV antibody testing. Morbid. Mortal. Wkly. Rep. 37:57-63. Cleary, P. D., M. J. Barry, K. H. Mayer, A. M. Brandt, L. Gostin, and H. V. Fineberg. 1987. Compulsory premarital screening for the human immunodeficiency virus: Technical and public health considerations. J. Am. Med. Assoc. 258:1757-1762. Cotton, D. 1988. Pediatric AIDS: Compelling areas of need in research, treatment, and prevention. Correspondent paper. AIDS Activities Oversight Committee, Washington, D.C. Curran, W. J., M. E. Clark, and L. Gostin. 1987. AIDS: Legal and policy implications of the application of traditional control measures. Law Med. Health Care 15:27-35. Dawson, D. A., M. Cynamon, and J. E. Fitti. 1987. AIDS knowledge and attitudes. Provisional data from the National Health Interview Survey, August 1987. Natl. Cent. Health Stat. Advance Data 146:1-11. Des Jarlais, D. C., and S. R. Friedman. 1987. Editorial review. HIV infection among intravenous drug users: Epidemiology and risk reduction. AIDS 1:67-76. Des Jarlais, D. C., S. R. Friedman, and R. L. Stoneburner. 1988. HIV infection and intravenous drug use: Critical issues in transmission dynamics, infectious outcomes, and prevention. Rev. Infect. Dis. 10:151-158. Dickens, B. M. 1988. Legal rights and duties in the AIDS epidemic. Science 239:580-586. Echenberg, D. F. 1987. Education and contact notification for AIDS prevention. N.Y. State J. Med. 87:296-297. Eisenberg, L. 1986. The genesis of fear: AIDS and the public's response to science. Law Med. Health Care 14:243-249. Field, M. A., and K. M. Sullivan. 1987. AIDS and the criminal law. Law Med. Health Care 15:46-60. Fineberg, H. V. 1988. Education to prevent AIDS: Prospects and obstacles. Science 239:592-596. Fox, D. M. 1986. From TB to AIDS: Value conflicts in reporting disease. Hastings Cent. Rep. 16:11-15. Fraser, D. W. 1987. AIDS education in colleges: Recent issues. Correspondent paper. AIDS Activities Oversight Committee, Washington, D.C.

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ALTERING THE COURSE OF THE EPIDEMIC 9~1 Ginzburg, H. M. 1987. Intravenous drug abusers and HIV infections: A consequence of their actions. Law Med. Health Care 15:268-272. Gostin, L. 1987a. AIDS: Law, ethics, and public policy. Correspondent paper. AIDS Activities Oversight Committee, Washington, D.C. Gostin, L. 1987b. Viewpoint. The nucleus of a public health strategy to combat AIDS. Law Med. Health Care 15:226-230. Gostin, L., and W. J. Curran. 1987. AIDS screening, confidentiality, and the duty to warn. Am. J. Public Health 77:361-365. Gostin, L., and A. Ziegler. 1987. A review of AIDS-related legislative and regulatory policy in the United States. Law Med. Health Care 15:5-16. Grimes, D. A. 1987. The CDC and abortion in HIV-positive women (letter). J. Am. Med. Assoc. 258:1176. Hein, K. 1987. AIDS in adolescents: A rationale for concern. N.Y. State J. Med. 87:290-295. Helquist, M. 1987. Your HIV status: Should you take the test? The Advocate, July 7, p. 45. Henry, K., M. Maki, and K. Crossley. 1988a. Analysis of the use of HIV antibody testing in a Minnesota hospital. J. Am. Med. Assoc. 259:229-232. Henry, K., K. Willenbring, and K. Crossley. 1988b. Human immunodeficiency virus antibody testing: A description of practices and policies at U.S. infectious disease teaching hospitals and Minnesota hospitals. J. Am. Med. Assoc. 259:1819-1822. Hentoff, N. 1987. The assault on routine AIDS testing. Washington Post, June 28, p. C7. Hunter, N. D. 1987. AIDS Prevention and Civil Liberties: The False Promise of Proposals for Mandatory Testing. New York: American Civil Liberties Union Foundation. IHPP (Intergovernmental Health Policy Project). 1987. AIDS: A Public Health Challenge, M. Rowe and C. Ryan, eds., 3 vole. Washington, D.C.: George Washington University. Jackson, J., and L. Rotkiewicz. 1987. A coupon program: AIDS education and drug treatment. P. 156 in Abstracts of the Third International Conference on AIDS, Washing- ton, D.C., June 1-5. Kilpatrick, J. J. 1987. Why should we pay to teach gays safe sex? Detroit Free Press, November 17, p. All. Koop, C. E. 1987a. AIDS instruction and local control. Wall Street Journal, May 19, p. A28. Koop, C. E. 1987b. Physician leadership in preventing AIDS. J. Am. Med. Assoc. 258:2111. Lambert, B. 1988. Confidentiality for AIDS patients is at issue in disputes around the U.S. New York Times, March 4, p. A13. Lange, W. R., F. R. Snyder, D. Lozovsky, V. Kaistha, M. A. Kaczaniuk, J. H. Jaffe, and the ARC Epidemiology Collaborating Group. 1988. Geographic distribution of human immuno- deficiency virus markers in parenteral drug abusers. Am. J. Public Health 78:443-446. Lofton, D. 1988. Nations report on needle distribution: WHO report backed by some experience. American Medical News, March 4, p. 6. Martin, J. L. 1986. AIDS risk reduction recommendations and sexual behavior patterns among gay men: A multifactorial categorical approach to assessing change. Health Educ. Q. 13:347-358. Medical World News. 1987. AIDS home test kit poised to hit market, but FDA's balking. November 9, p. 40. Meyer, K. B., and S. G. Pauker. 1987. Screening for HIV: Can we afford the false positive rate? N. Engl. J. Med. 317:238-241. Miller, L. B. 1987. Plans for mail-in kit for testing for AIDS are drawing criticism. New York Times, August 9, p. A1. New York Times. 1988. SRI-Gallup poll conducted October 1987. January 8, p. B6. NGLTF (National Gay and Lesbian Task Force). 1988. Anti-Gay Violence: Victimization and Defamation in 1987. Washington, D.C.: National Gay and Lesbian Task Force.

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92 CONFRONTING AIDS: UPDATE 19f~fY National Gay Rights Advocates. 1986. AIDS and Discrimination: A Survey of the 50 States and the District of Columbia. San Francisco: National Gay Rights Advocates. Newman, R. 1987. Methadone treatment: Defining and evaluating success. N. Engl. J. Med. 317:447-450. Novick, L. F., D. Berns, R. Stricof, and R. Stevens. 1988. New York State Department of Health newborn seroprevalence study. Interim report draft, March 15. Albany. Okie, S. 1987. AIDS "false positives": A volatile social issue. Low-risk groups may have a high error rate. Washington Post, July 23, p. A3. Parkman, P. D. 1988. Serologic and virologic testing. Correspondent paper. AIDS Activities Oversight Committee, Washington, D.C. Parmet, W. E. 1987. AIDS and the limits of discrimination law. Law Med. Health Care 15:61-72. Rapoport, D., and J. Parry, eds. 1987. Legal, Medical, and Governmental Perspectives on AIDS as a Disability. Washington, D.C.: American Bar Association. Raymond, C. A. 1988a. Combating a deadly combination: Intravenous drug use, acquired immune deficiency syndrome. J. Am. Med. Assoc. 259:329-330. Raymond, C. A. 1988b. First needle-exchange program approved; other cities await results. J. Am. Med. Assoc. 259:1289-1290. Rietmeijer, C. A. M., J. W. Krebs, P. M. Feorino, and F. N. Judson. 1988. Condoms as physical barriers against human immunodeficiency virus. J. Am. Med. Assoc. 259: 1851-1853. Rogers, M. F., and W. W. Williams. 1987. AIDS in blacks and Hispanics: Implications for prevention. Issues Sci. Technol. 3:89-94. Seltzer, M. 1988. Meeting the Challenge: Foundation Responses to Acquired Immune Deficiency Syndrome. New York: Ford Foundation. Sherer, R. 1988. Physician use of the HIV antibody test. The need for consent, counseling, confidentiality and caution. J. Am. Med. Assoc. 259:264-265. Shilts, R. 1987. And The Band Played On: Politics, People and the AIDS Epidemic. New York: St. Martins. Solomon, M. Z., and W. DeJong. 1986. Recent sexually transmitted disease prevention efforts and their implications for AIDS health education. Health Educ. Q. 13:301-316. Thomas, P. 1988. AIDS prevention for addicts: Methadone favored. Medical World News, January 11, p. 78. U.S. Medicine. 1987. CNS decrement in AIDS uncertain. U.S. Med. 23:3. Walters, L. 1988. Ethical issues in the prevention and treatment of HIV infection and AIDS. Science 239:597-603. Ward, J. W., S. D. Holmberg, J. R. Allen, D. L. Cohn, S. E. Critchley, S. H. Kleinman, B. A. Leves, O. Ravenholt, J. R. Davis, M. G. Quinn, and H. W. Jaffe. 1988. Transmission of human immunodeficiency virus by blood transfusions screened as negative for HIV antibody. N. Engl. J. Med. 318:473-477. Watters, J. K. 1987. Preventing human immunodeficiency virus contagion among intrave- nous drug users: The impact of street-based education on risk-behavior. P. 60 in Abstracts of the Third International Conference on AIDS, Washington, D.C., June 1-5. Wells, J. A. 1987. Foundation funding for AIDS programs. Health Affairs 6: 113-123. Wilkerson, I. 1988. Prenuptial AIDS screening a strain in Illinois. New York Times, January 26, p. A1. Winkelstein, W., D. M. Lyman, N. Padian, R. Grant, M. Samuel, J. A. Wiley, R. E. Anderson, W. Lang, J. Riggs, and J. A. Levy. 1987. Sexual practices and risk of infection by the human immunodeficiency virus: The San Francisco men's health study. J. Am. Med. Assoc. 257:321-325.