ener ACQUIRED eport TMMUNE DEFICIENCY SYNDROME Surgeon ACQUIRED Report JMMUNE on DEFICIENCY SYNDROME T his is a report from the Surgeon General of the US. Public Health Service to the people of the United States on AIDS. Acquired Immune Deficiency Syndrome is an epidemic that has already killed thousands of people, mostly young, productive Americans. In addition to illness, disability, and death, AIDS has brought fear to the hearts of most Americans — fear of disease and fear of the unknown. Initial reporting of AIDS occurred in the United States, but AIDS and the spread of the AIDS virus ig an international problem. This report focuses on prevention that could be applied in all countries. My report will inform you about AIDS, how it is transmitted, the relative risks of infection and how to prevent it. It will help you understand your fears. Fear can be useful when it helps people avoid behav- ior that puts them at risk for AIDS. On the other hand, unreasonable fear can be as crippling as the disease itself, If you are participating in activities that could expose you to the AIDS virus, this report could save your life. In preparing this report, I consulted with the best medical and scientific experts this country can offer. I met with leaders of organizations concerned with health, education, and other aspects of our society to gain their views of the problems associated with AIDS. The information in this report is current and timely. This report was written personally by me to provide the necessary understanding of AIDS. . The vast majority of Americans are against illicit drugs. As a health officer Iam opposed to the use of illicit drugs. As a practicing physician for more than forty years, I have seen the devastation that follows the use of illicit drugs — addiction, poor health, fam- ily disruption, emotional disturbances and death. I applaud the President's initiative to rid this nation of the curse of illicit drug use and addiction. The success of his initiative is critical to the health of the American people and will also help reduce the number of persons exposed to the AIDS virus. Some Americans have difficulties in dealing with the subjects of sex, sexual practices, and alternate lifestyles. Many Americans are opposed to homo- sexuality, promiscuity of any kind, and prostitution. This report must deal with all of these issues, but does so with the intent that information and educa- tion can change individual behavior, since this is the primary way to stop the epidemic of AIDS. This report deals with the positive and negative conse- quences of activities and behaviors from a health and medical point of view. Adolescents and pre-adolescents are those whose behavior we wish to especially influence because of their vulnerability when they are exploring their own sexuality (heterosexual and homosexual) and perhaps experimenting with drugs. Teenagers often consider themselves immortal, and these young people may be putting themselves at great risk. Education about AIDS should start in early ele- mentary school and at home so that children can grow up knowing the behavior to avoid to protect themselves from exposure to the AIDS virus. The threat of AIDS can provide an opportunity for par- ents to instill in their children their own moral and ethical standards. Those of us who are parents, educators and com- munity leaders, indeed all adults, cannot disregard this responsibility to educate our young. The need is critical and the price of neglect is high. The lives of our young people depend on our fulfilling our responsibility. AIDS is an infectious disease. It is contagious, but it cannot be spread in the same manner as a common cold or measles or chicken pox. It is con- tagious in the same way that sexually transmitted diseases, such as syphilis and gonorrhea, are conta- gious. AIDS can also be spread through the sharing of intravenous drug needles and syringes used for injecting illicit drugs. AIDS is not spread by common everyday contact but by sexual contact (penis-vagina, penis-rectum, mouth-rectum, mouth-vagina, mouth-penis). Yet there is great misunderstanding resulting in unfounded fear that AIDS can be spread by casual, non-sexual contact. The first cases of AIDS were reported in this country in 1981. We would know by now if AIDS were passed by casual, non-sexual contact. Today those practicing high risk behavior who become infected with the AIDS virus are found mainly among homosexual and bisexual men and male and female intravenous drug users. Heterosexual trans- mission is expected to account for an increasing proportion of those who become infected with the AIDS virus in the future. At the beginning of the AIDS epidemic many Americans had little sympathy for people with AIDS. The feeling was that somehow people from certain groups “deserved” their illness. Let us put those feelings behind us. We are fighting a disease, not people. Those who are already afflicted are sick people and need our care as do all sick patients. The country must face this epidemic as a unified society. We must prevent the spread of AIDS while at the same time preserving our humanity and intimacy. AIDS is a life-threatening disease and a major pub- lic health issue. Its impact on our society is and will continue to be devastating. By the end of 1991, an estimated 270,000 cases of AIDS will have occurred with 179,000 deaths within the decade since the disease was first recognized. In the year 1991, an estimated 145,000 patients with AIDS will need health and supportive services at a total cost of between $8 and $16 billion. However, AIDS is preventable. It can be controlled by changes in personal behavior. It is the responsibility of every citizen to be informed about AIDS and to exercise the appropriate preven- tive measures, This report will tell you how. The spread of AIDS can and must be stopped. Ube kay C. Everett Koop, M.D., Se.D. Surgeon General AIDS AIDS Caused by Virus T he letters A-l-D-S stand for Acquired Immune Deficiency Syndrome. When a person is sick with AIDS, he/she is in the final stages of a series of health prob- lems caused by a virus (germ) that can be passed from one person to another chiefly during sexual contact or through the sharing of intravenous drug needles and syringes used for “shooting” drugs. Scientists have named the AIDS virus “HIV or HTLV-II or LAV"! These abbreviations stand for information denoting a virus that attacks white blood cells (T-Lymphocytes ) in the human blood. Throughout this publication, we will call the virus the “AIDS virus.” The Antists drawing of AIDS virus with cut away view showing genetic ( reproductive ) material \These are different names given to AIDS virus by the scientific community: HIV — Human Immunodeficiency Virus HTLV-II — Human T-Lymphotropic Virus Type HI LAV — Lymphadenopathy Associated Virus AIDS virus attacks a person’s immune system and damages his/her ability to fight other disease. Without a functioning immune system to ward off other germs, he/she now becomes vulnerable to becoming infected by bacteria, protozoa, fungi, and other viruses and malignancies, which may cause life-threatening illness, such as pneumonia, meningitis, and cancer. No Known Cure There is presently no cure for AIDS. There is presently no vaccine to prevent AIDS. Virus Invades Blood Stream When the AIDS virus enters the blood stream, it begins to attack certain white blood cells (T-Lymphocytes ). Sub- stances called antibodies are produced by the body. These antibodies can be detected in the blood by a simple test, usually two weeks to three months after infection. Even before the antibody test is positive, the victim can pass the virus to others by methods that will be explained. Once an individual is infected, there are several possi- bilities. Some people may remain well but even so they are able to infect others. Others may develop a disease that is less serious than AIDS referred to as AIDS Related Complex (ARC). In some people the protective immune system may be destroyed by the virus and then other germs (bacteria, protozoa, fungi and other viruses) and cancers that ordi- narily would never get a foothold cause “opportunistic diseases” — using the opportunity of lowered resistance to infect and destroy. Some of the most common are Pneumocystis carinii pneumonia and tuberculosis. Indi- viduals infected with the AIDS virus may also develop certain types of cancers such as Kaposi's sarcoma. These infected people have classic AIDS. Evidence shows that the AIDS virus may also attack the nervous system, causing damage to the brain. 10 Signs and Symptoms No Signs Some people remain apparently well after infection with the AIDS virus. They may have no physically apparent symp- toms of illness. However, if proper precautions are not used with sexual contacts and/or intravenous drug use, these infected individuals can spread the virus to others. Anyone who thinks he or she is infected or involved in high risk behaviors should not donate his/her blood, organs, tissues, or sperm because they may now contain the AIDS virus. ARC AIDS-Related Complex (ARC) is a condition caused by the AIDS virus in which the patient tests positive for AIDS infection and has a specific set of clinical symptoms. How- ever, ARC patients symptoms are often less severe than those with the disease we call classic AIDS. Signs and symptoms of ARC may include loss of appetite, weight loss, fever, night sweats, skin rashes, diarrhea, tiredness, lack of resistance to infection, or swollen lymph nodes. These are also signs and symptoms of many other diseases and a physician should be consulted. AIDS Only a qualified heaith professional can diagnose AIDS, which is the result of a natural progress of infection by the AIDS virus. AIDS destroys the body’s immune (defense) system and allows otherwise controllable infections to invade the body and cause additional diseases. These opportunistic diseases would not otherwise gain a foothold in the body. These opportunistic diseases may eventually cause death. Some symptoms and signs of AIDS and the “opportunistic infections” may include a persistent cough and fever asso- ciated with shortness of breath or difficult breathing and 11 may be the symptoms of Pneumocystis carinii pneumonia. Multiple purplish blotches and bumps on the skin may be a sign of Kaposi's sarcoma. The AIDS virus in all infected people is essentially the same; the reactions of individuals may differ. Long Term The AIDS virus may also attack the nervous system and cause delayed damage to the brain. This damage may take years to develop and the symptoms may show up as memory loss, indifference, loss of coordination, partial paralysis, or mental disorder. These symptoms may occur alone, or with other symptoms mentioned earlier. AIDS: the present situation T he number of people estimated to be infected with the AIDS virus in the United States is about 1.5 million. All of these individuals are assumed to be capable of spread- ing the virus sexually (heterosexually or homosexually ) or by sharing needles and syringes or other implements for intravenous drug use. Of these, an estimated 100,000 to 200,000 will come down with AIDS Related Complex (ARC). It is difficult to predict the number who will develop ARC or AIDS because symptoms sometimes take as long as nine years to show up. With our present knowledge, scientists predict that 20 to 30 percent of those infected with the AIDS virus will develop an illness that fits an accepted definition of AIDS within five years. The number of persons known to have AIDS in the United States to date is over 25,000; of these, about half have died of the disease. Since there is no cure, the others are expected to also eventually die from their disease. The majority of infected antibody positive individuals who carry the AIDS virus show no disease symptoms and may not come down with the disease for many years, if ever. 12 No Risk from Casual Contact There is no known risk of non-sexual infection in most of the situations we encounter in our daily lives. We know that family members living with individuals who have the AIDS virus do not become infected except through sexual contact. There is no evidence of transmission (spread) of AIDS virus by everyday contact even though these family members shared food, towels, cups, razors, even tooth- brushes, and kissed each other. Heaith Workers We know even more about health care workers exposed to AIDS patients. About 2,500 health workers who were caring for AIDS patients when they were sickest have been carefully studied and tested for infection with the AIDS virus. These doctors, nurses and other health care givers have been exposed to the AIDS patients’ blood, stool and other body fluids. Approximately 750 of these health workers reported possible additional exposure by direct 3 contact with a patient’s body fluid through spills or being accidentally stuck with a needle. Upon testing these 750, only 3 who had accidentally stuck themselves with a needle had a positive antibody test for exposure to the AIDS virus. Because health workers had much more contact with patients and their body fluids than would be expected from common everyday contact, it is clear that the AIDS virus is not transmitted by casual contact. Control of Certain Behaviors Can Stop Further Spread of AIDS Knowing the facts about AIDS can prevent the spread of the disease. Education of those who risk infecting them- selves or infecting other people is the only way we can stop the spread of AIDS. People must be responsible about their sexual behavior and must avoid the use of illicit intrave- nous drugs and needle sharing. We will describe the types of behavior that lead to infection by the AIDS virus and the personal measures that must be taken for effective protec- tion. If we are to stop the AIDS epidemic, we all must under. stand the disease — its cause, its nature, and its prevention. Precautions must be taken. The AIDS virus infects persons who expose themselves to known risk behavior, such as certain types of homosexual and heterosexual activities or sharing intravenous drug equipment. Risks Although the initial discovery was in the homosexual com- munity, AIDS is not a disease only of homosexuals. AIDS is found in heterosexual people as well. AIDS is not a black or white disease. AIDS is not just a male disease. AIDS is found in women, it is found in children. In the future AIDS will probably increase and spread among people who are not homosexual or intravenous drug abusers in the same manner as other sexually transmitted diseases like syphilis and gonorrhea. 14 Sex Between Men Men who have sexual relations with other men are espe- cially at risk. About 70 percent of AIDS victims throughout the country are male homosexuals and bisexuals. This percentage probably will decline as heterosexual transmis- sion increases. infection results from a sexual relationship with an infected person. Multiple Partners The risk of infection increases according to the number of sexual partners one has, male or female. The more partners you have, the greater the risk of becoming infected with the AIDS virus. Vulnerable rectum lining provides ‘avenue for entry of AIDS virus into the blood stream. KS x4 + ' Dy RU ee Vm ' AS ‘ | To Si SS Di ROS t 4 € ‘ UT Ss a a Stim \ mh e , . ~ 5 How Exposed Although the AIDS virus is found in several body fluids, a person acquires the virus during sexual contact with an infected person's blood or semen and possibly vaginal secretions. The virus then enters a person's blood stream through their rectum, vagina or penis. Smail (unseen by the naked eye) tears in the surface lining of the vagina or rectum may occur during insertion of the penis, fingers, or other objects, thus opening an avenue for entrance of the virus directly into the blood stream; therefore, the AIDS virus can be passed from penis to rectum and vagina and vice versa without a visible tear in the tissue or the presence of blood. Prevention of Sexual Transmission — Know Your Partner Couples who maintain mutually faithful monogamous rela- tionships (only one continuing sexual partner) are pro- tected from AIDS through sexual transmission. If you have been faithful for at least five years and your partner has been faithful too, neither of you is at risk. If you have not been faithful, then you and your partner are at risk. If your partner has not been faithful, then your partner is at risk which also puts you at risk. This is true for both hetero- sexual and homosexual couples. Unless it is possible to know with absolute certainty that neither you nor your sexual partner is carrying the virus of AIDS, you must use protective behavior. Absolute certainty means not only that you and your partner have maintained a mutually faith- ful monogamous sexual relationship, but it means that neither you nor your partner has used illegal intravenous drugs. 16 AIDS: you can protect yourself from infection S ome personal measures are adequate to safely protect yourself and others from infection by the AIDS virus and its complications. Among these are: « Ifyou have been involved in any of the high risk sexual activities described above or have injected illicit intra- venous drugs into your body, you should have a blood test to see if you have been infected with the AIDS virus. » If your test is positive or if you engage in high risk activ- ities and choose not to have a test, you should tell your sexual partner. If you jointly decide to have sex, you must protect your partner by always using a rubber (condom) during (start to finish) sexual intercourse (vagina or rectum). + If your partner has a positive blood test showing that he/ she has been infected with the AIDS virus or you suspect that he/she has been exposed by previous heterosexual or homosexual behavior or use of intravenous drugs with shared needles and syringes, a rubber (condom) should always be used during (start to finish) sexual intercourse (vagina or rectum). 17 « Ifyou or your partner is at high risk, avoid mouth contact with the penis, vagina, or rectum. e Avoid all sexual activities which could cause cuts or tears in the linings of the rectum, vagina, or penis. + Single teen-age girls have been warned that pregnancy and contracting sexually transmitted diseases can be the result of only one act of sexual intercourse. They have been taught to say NO to sex! They have been taught to say NO to drugs! By saying NO to sex and drugs, they can avoid AIDS which can Rill them! The same is true for teenage boys who should also not have rectal intercourse with other males. It may result in AIDS. +» Do not have sex with prostitutes. Infected male and female prostitutes are frequently also intravenous drug abusers; therefore, they may infect clients by sexual inter- course and other intravenous drug abusers by sharing their intravenous drug equipment. Female prostitutes also can infect their unborn babies. Dirty intravenous needle and syringe contaminated with blood that may contain the AIDS virus. 18 Intravenous Drug Users Drug abusers who inject drugs into their veins are another population group at high risk and with high rates of infec- tion by the AIDS virus. Users of intravenous drugs make up 25 percent of the cases of AIDS throughout the county. The AIDS virus is carried in contaminated blood left in the needle, syringe, or other drug related implements and the virus is injected into the new victim by reusing dirty syringes and needles. Even the smallest amount of infected blood left in a used needle or syringe can contain live AIDS virus to be passed on to the next user of those dirty implements. No one should shoot up drugs because addiction, poor health, family disruption, emotional disturbances and death could follow. However, many drug users are addicted to drugs and for one reason or another have not changed their behavior. For these people, the only way not to get AIDS is to use a clean, previously unused needle, syringe or any other implement necessary for the injection of the drug solution. Hemophilia Some persons with hemophilia (ablood clotting disorder that makes them subject to bleeding) have been infected with the AIDS virus either through blood transfusion or the use of blood products that help their blood clot. Now that we know how to prepare safe blood products to aid clotting, this is unlikely to happen. This group represents avery small percentage of the cases of AIDS throughout the country. Blood Transfusion Currently all blood donors are initially screened and blood is not accepted from high risk individuals. Blood that has been collected for use is tested for the presence of antibody to the AIDS virus. However, some people may have had a blood transfusion prior to March 1985 before we knew how to screen blood for safe transfusion and may have become 19 infected with the AIDS virus. Fortunately there are not now a large number of these cases. With routine testing of blood products, the blood supply for transfusion is now safer than it has ever been with regard to AIDS. Persons who have engaged in homosexual activities or have shot street drugs within the last 10 years should never donate blood. Mother Can Infect Newborn If a woman is infected with the AIDS virus and becomes pregnant, she is more likely to develop ARC or classic AIDS, and she can pass the AIDS virus to her unborn child. Approximately one third of the babies born to AIDS-infected mothers will also be infected with the AIDS virus. Most of the infected babies will eventually develop the disease and die. Several of these babies have been born to wives of hemophiliac men infected with the AIDS virus by way of contaminated blood products. Some babies have also been born to women who became infected with the AIDS virus by bisexual partners who had the virus. Almost all babies with AIDS have been bom to women who were intravenous 20 drug users or the sexual partners of intravenous drug users who were infected with the AIDS virus. More such babies can be expected. Think carefully if you plan on becoming pregnant. If there is any chance that you may be in any high risk group or that you have had sex with someone in a high risk group, such as homosexual and bisexual males, drug abusers and their sexual partners, see your doctor. Summary AIDS affects certain groups of the population. Homosexual and bisexual males who bave bad sexual contact with other homosexual or bisexual males as well as those who “shoot” street drugs are at greatest risk of exposure, infec- tion and eventual death, Sexual partners of these high risk individuals are at risk, as well as any children born to women who carry the virus. Heterosexual persons are increasingly at risk. AIDS: what is safe Most Behavior is Safe Everyday living does not present any risk of infection. You cannot get AIDS from casual social contact. Casual social contact should not be confused with casual sexual contact which is a major cause of the spread of the AIDS virus. Casual social contact such as shaking hands, hugging, social kissing, crying, coughing or sneezing, will not transmit the AIDS virus. Nor has AIDS been contracted from swimming in pools or bathing in hot tubs or from eating in resturants (even ifa restaurant worker has AIDS or carries the AIDS virus.) AIDS is not contracted from sharing bed linens, towels, cups, straws, dishes, or any other eating utensils. You cannot get AIDS from toilets, doorknobs, telephones, office machinery, or household furniture. You cannot get AIDS from body massages, masturbation or any non- sexual contact. 21 Donating Blood Donating blood is nof risky at all. You cannot get AIDS by donating blood. Receiving Blood In the US. every blood donor is screened to exclude high risk persons and every blood donation is now tested for the presence of antibodies to the AIDS virus. Blood that shows exposure to the AIDS virus by the presence of antibodies is not used either for transfusion or for the manufacture of blood products. Blood banks are as safe as current tech- nology can make them. Because antibodies do not form immediately after exposure to the virus, a newly infected person may unknowingly donate blood after becoming infected but before his/her antibody test becomes posi- tive. It is estimated that this might occur less than once in 100,000 donations. There is no danger of AIDS virus infection from visiting a doctor, dentist, hospital, hairdresser or beautician. AIDS 22 cannot be transmitted non-sexually from an infected per- son through a health or service provider to another person. Ordinary methods of disinfection for urine, stool and vomitus which are used for non-infected people are ade- quate for people who have AIDS or are carrying the AIDS virus. You may have wondered why your dentist wears gloves and perhaps a mask when treating you. This does not mean that he has AIDS or that he thinks you do. He is protecting you and himself from hepatitis, common colds or flu. There is no danger in visiting a patient with AIDS or caring for him or her. Normal hygienic practices, like wip- ing of body fluid spills with a solution of water and house- hold bleach (1 part household bleach to 10 parts water), will provide full protection. Children in School None of the identified cases of AIDS in the United States are known or are suspected to have been transmitted from one child to another in school, day care, or foster care settings. Transmission would necessitate exposure of open 2 cuts to the blood or other body fluids of the infected child, a highly unlikely occurrence. Even then routine safety pro- cedures for handling blood or other body fluids (which should be standard for all children in the school or day care setting) would be effective in preventing transmission from children with AIDS to other children in school. Children with AIDS are highly susceptible to infections, such as chicken pox, from other children. Each child with AIDS should be examined by a doctor before attending school or before returning to school, day care or foster care settings after an illness. No blanket rules can be made for all school boards to cover all possible cases of children with AIDS and each case should be considered separately and individualized to the child and the setting, as would be done with any child with a special problem, such as cere- bral palsy or asthma. A good team to make such decisions with the school board would be the child's parents, physi- cian and a public health official. Casual social contact between children and persons infected with the AIDS virus is not dangerous. Toa 24 insects There are no known cases of AIDS transmission by insects, such as mosquitoes. Pets Dogs, cats and domestic animals are not a source of infec- tion from AIDS virus. Tears and Saliva Although the AIDS virus has been found in tears and saliva, no instance of transmission from these body fluids has been reported. AIDS comes from sexual contacts with infected persons and from the sharing of syringes and needles. There is no danger of infection with AIDS virus by casual social contact. Testing of Military Personnel You may wonder why the Department of Defense is cur- rently testing its uniformed services personnel for presence of the AIDS virus antibody. The military feel this procedure is necessary because the uniformed services act as their own blood bank in a time of national emergency. They also need to protect new recruits (who unknowingly may be AIDS virus carriers) from receiving live virus vaccines. These vaccines could activate disease and be potentially life-threatening to the recruits. 25 AIDS: what is currently understood Ate AIDS is still a mysterious disease in many ways, our scientists have learned a great deal about it In five years we know more about AIDS than many diseases that we have studied for even longer periods. While there is no vaccine or cure, the results from the health and behavioral research community can only add to our knowl- edge and increase our understanding of the disease and ways to prevent and treat it. In spite of all that is known about transmission of the AIDS virus, scientists will learn more. One possibility is the ww 1. Virus enters white blood cells. 2. Virus attacks T cells and muttiplies. aa 3. T cell no longer stimulates - Q (cellular) defense aaa response. 4. Immune system weakened. 5. Body susceptible to “opportunistic diseases.” 26 potential discovery of factors that may better explain the mechanism of AIDS infection. Why are the antibodies ‘produced by the body to fight the AIDS virus not able to destroy that virus? The antibodies detected in the blood of carriers of the AIDS virus are ineffective, at least when classic AIDS is actually triggered. They cannot check the damage caused by the virus, which is by then present in large numbers in the body. Researchers cannot explain this important observation. We still do not know why the AIDS virus is not destroyed by man's immune system. Summary AIDS no longer is the concer of any one segment of society; it is the concern of us all. No American’s life is in danger if he/she or their sexual partners do not engage in high risk sexual behavior or use shared needles or syringes to inject illicit drugs into the body. People who engage in high risk sexual behavior or who shoot drugs are risking infection with the AIDS virus and are risking their lives and the lives of others, including their unborn children. We cannot yet know the full impact of AIDS on our society. From a clinical point of view, there may be new manifestations of AIDS — for example, mental disturbances due to the infection of the brain by the AIDS virus in carriers of the virus. From a social point of view, it may bring to an end the free-wheeling sexual lifestyle which has been called the sexual revolution. Economically, the care of AIDS patients will put a tremendous strain on our already overburdened and costly health care delivery system. The most certain way to avoid getting the AIDS virus and to control the AIDS epidemic in the United States is for individuals to avoid promiscuous sexual practices, to main- tain mutually faithful monogamous sexual relationships and to avoid injecting illicit drugs. 27 Look to the Future The Challenge of the Future MO enormous challenge to public health lies ahead of us and we would do well to take a look at the future. We must be prepared to manage those things we can pre- dict, as well as those we cannot. At the present time there is no vaccine to prevent AIDS. There is no cure. AIDS, which can be transmitted sexually and by sharing needles and syringes among illicit intrave- nous drug users, is bound to produce profound changes in our society, changes that will affect us all. Information and Education Only Weapons Against AIDS It is estimated that in 1991 54,000 people will die from AIDS. At this moment, many of them are not infected with the AIDS virus. With proper information and education, as many as 12,000 to 14,000 people could be saved in 1991 from death by AIDS. AIDS will Impact All The changes in our society will be economic and political and will affect our social institutions, our educational prac- tices, and our health care. Although AIDS may never touch you personally,the societal impact certainly will. Be Educated ~ Be Prepared Be prepared. Learn as much about AIDS as you can. Learn to separate scientific information from rumor and myth. The Public Health Service, your local public health officials and your family physician will be able to help you. 28 A I D S Concern About Spread of AIDS While the concentration of AIDS cases is in the larger urban areas today, it has been found in every state and with the mobility of our society, it is likely that cases of AIDS will appear far and wide. Special Educational Concerns There are a number of people, primarily adolescents, that do not yet know they will be homosexual or become drug abusers and will not heed this message; there are others who are illiterate and cannot heed this message. They must be reached and taught the risk behaviors that expose them to infection with the AIDS virus. High Risk Get Blood Test The greatest public health problem lies in the large num- ber of individuals with a history of high risk behavior who have been infected with and may be spreading the AIDS virus. Those with high risk behavior must be encouraged to protect others by adopting safe sexual practices and by the use of clean equipment for intravenous drug use. If a blood test for antibodies to the AIDS virus is necessary to get these individuals to use safe sexual practices, they should get a blood test. Call your local health department for information on where to get the test. Anger and Guilt Some people afflicted with AIDS will feel a sense of anger and others a sense of guilt. In spite of these understand- able reactions, everyone must join the effort to control the epidemic, to provide for the care of those with AIDS, and to do all we can to inform and educate others about AIDS, and how to prevent it. 29 Confidentiality Because of the stigma that has been associated with AIDS, many afflicted with the disease or who are infected with the AIDS virus are reluctant to be identified with AIDS. Because there is no vaccine to prevent AIDS and no cure, many feel there is nothing to be gained by revealing sexual contacts that might also be infected with the AIDS virus. When a community or a state requires reporting of those infected with the AIDS virus to public health authorities in order to trace sexual and intravenous drug contacts — as is the practice with other sexually transmitted diseases — those infected with the AIDS virus go underground out of the mainstream of health care and education. For this reason current public health practice is to protect the privacy of the individual infected with the AIDS virus and to maintain the strictest confidentiality concerning hiss her health records. State and Local AIDS Task Forces Many state and local jurisdictions where AIDS has been seen in the greatest numbers have AIDS task forces with heavy representation from the field of public health joined by others who can speak broadly to issues of access to care, provision of care and the availability of community and psychiatric support services. Such a task force is needed in every community with the power to develop plans and policies, to speak, and to act for the good of the public health at every level. State and local task forces should plan ahead and work collaboratively with other jurisdictions to reduce transmis- sion of AIDS by far-reaching informational and educational programs. As AIDS impacts more strongly on society, they should be charged with making recommendations to pro- vide for the needs of those afflicted with AIDS. They also will be in the best position to answer the concerns and direct the activities of those who are not infected with the AIDS virus. 30 The responsibility of State and local task forces should be far reaching and might include the following areas: . Insure enforcement of public health regulation of such practices as ear piercing and tattooing to prevent trans- mission of the AIDS virus. . Conduct AIDS education programs for police, firemen, correctional institution workers and emergency medical personnel for dealing with AIDS victims and the public. » Insure that institutions catering to children or adults who soil themselves or their surroundings with urine, stool, and vomitus have adequate equipment for cleanup and disposal, and have policies to insure the practice of good hygiene. School Schools will have special problems in the future. In addition to the guidelines already mentioned in this pamphlet, there are other things that should be considered such as sex education and education of the handicapped. Sex Education Education concerning AIDS must start at the lowest grade possible as part of any health and hygiene program. The appearance of AIDS could bring together diverse groups of parents and educators with opposing views on inclu- sion of sex education in the curricula. There is now no doubt that we need sex education in schools and that it must include information on heterosexual and homosexual relationships. The threat of AIDS should be sufficient to per mit a sex education curriculum with a heavy emphasis on prevention of AIDS and other sexually transmitted diseases. Handicapped and Special Education Children with AIDS or ARC will be attending school along with others who carry the AIDS virus. Some children will develop brain disease which will produce changes in mental 31 behavior. Because of the right to special education of the handicapped and the mentally retarded, school boards and higher authorities will have to provide guidelines for the management of such children on a case-by-case basis. Labor and Management Labor and management can do much to prepare for AIDS so that misinformation is kept to a minimum. Unions should issue preventive health messages because many employees will listen more carefully to a union message than they will to one from public health authorities. AIDS Education at the Work Site Offices, factories, and other work sites should have a plan in operation for education of the work force and accom- modation of AIDS or ARC patients before the first such case appears at the work site. Employees with AIDS or ARC should be dealt with as are any workers with a chronic illness. In-house video programs provide an excellent source of education and can be individualized to the needs of a specific work group. Strain on the Health Care Delivery System The health care system in many places will be overbur- dened as it is now in urban areas with large numbers of AIDS patients. It is predicted that during 1991 there will be 145,000 patients requiring hospitalization at least once and 54,000 patients who will die of AIDS. Mental disease (dementia) will occur in some patients who have the AIDS virus before they have any other manifestation such as ARC or classic AIDS. State and local task forces will have to plan for these patients by utilizing conventional and time honored sys- tems but will also have to investigate alternate methods of treatment and alternate sites for care including homecare. 32 The strain on the health system can be lessened by family, social, and psychological support mechanisms in the community. Programs are needed to train chaplains, clergy, social workers, and volunteers to deal with AIDS. Such support is particularly critical to the minority communities. Mental Health Our society will also face an additional burden as we bet- ter understand the mental health implications of infection by the AIDS virus. Upon being informed of infection with the AIDS virus, a young, active, vigorous person faces anxi- ety and depression brought on by fears associated with social isolation, illness, and dying. Dealing with these indi- vidual and family concerns will require the best efforts of mental health professionals. Controversial Issues A number of controversial AIDS issues have arisen and will continue to be debated largely because of lack of knowledge about AIDS, how it is spread, and how it can be prevented. Among these are the issues of compulsory blood testing, quarantine, and identification of AIDS carriers by some visible sign. Compulsory Blood Testing Compulsory blood testing of individuals is not necessary. The procedure could be unmanageable and cost prohib- itive. It can be expected that many who test negatively might actually be positive due to recent exposure to the AIDS virus and give a false sense of security to the individual and his/her sexual partners concerning necessary protec- tive behavior. The prevention behavior described in this report, if adopted, will protect the American public and contain the AIDS epidemic. Voluntary testing will be avail- able to those who have been involved in high risk behavior. 33 Quarantine Quarantine has no role in the management of AIDS because AIDS is not spread by casual contact. The only time that some form of quarantine might be indicated is in a situa- tion where an individual carrying the AIDS virus knowingly and willingly continues to expose others through sexual contact or sharing drug equipment. Such circumstances should be managed on a case-by-case basis by local authorities. Identification of AIDS Carriers by Some Visible Sign Those who suggest the marking of carriers of the AIDS virus by some visible sign have not thought the matter through thoroughly. It would require testing of the entire population which is unnecessary, unmanageable and costly. It would miss those recently infected individuals who would test negatively. but be infected. The entire procedure would give a false sense of security. AIDS must and will be treated as a disease that can infect anvone. AIDS should not be used as an excuse to discriminate against any group or individual. Updating Information As the Surgeon General, E will continually monitor the most current and accurate health, medical, and scientific information and make it available to vou, the American people. Armed with this information you can join in the discussion and resolution of AIDS-related issues that are critical to your health, your children’s health, and the health of the nation. Additional Information Telephone Hotlines (Toll Free) PHS AIDS Hotline 800-342-AIDS 800-342-2437 National Sexually Trans- mitted Diseases Hotline/ American Social Health Association 800-227-8922 Information Sources US. Public Health Service Public Affairs Office Hubert H. Humphrey Building, Room 725-H 200 Independence Avenue, SW. Washington, D.C. 20201 Phone: (202 ) 245-6867 National Gay Task Force AIDS Information Hotline 800-221-7044 (212) 807-6016 (NY State) Local Red Cross or American Red Cross AIDS Education Office 1730 D Street, N.W. Washington, D.C. 20006 Phone: (202 ) 737-8300 American Association of Physicians for Human Rights P.O. Box 14366 San Francisco, CA 94114 Phone: (415 ) 558-9353 AIDS Action Council 729 Eighth Street, S.E., Suite 200 Washington, D.C. 20003 Phone: (202) 547-3101 Gay Men's Health Crisis PO. Box 274 132 West 24th Street New York, NY 10011 Phone: (212) 807-6655 Hispanic AIDS Fortum c O APRED 853 Broadway, Suite 2007 New York, NY 10003 Phone: (212) 870-1902 or 8-0-1864 Los Angeles AIDS Project 1362 Santa Monica Boulevard Los Angeles, California 90046 (213) 871-AIDS A I D S Minority Task Force on AIDS National Council of c/o New York City Council Churches/ AIDS Task Force of Churches 475 Riverside Drive, 475 Riverside Drive, Room 572 Room 456 New York, NY 10115 New York, NY 10115 Phone: (212) 870-2421 Phone: (212) 749-1214 San Francisco AIDS Mothers of AIDS Patients Foundation (MAP) 333 Valencia Street, c/o Barbara Peabody 4th Floor 3403 E Street San Francisco, CA 94103 San Diego, CA 92102 Phone: (415) 863-2437 (619) 234-3432 National AIDS Network 729 Eighth Street, S.E., Suite 300 Washington D.C. 20003 (202) 546-2424 National Association of People with AIDS PO. Box 65472 Washington, D.C. 20035 (202) 483-7979 National Coalition of Gay Sexually Transmitted Disease Services c/o Mark Behar P.O. Box 239 Mibwaukee, W1 53201 Phone: (414) 277-7671 36