ORIGINAL
yo DIS

PREPARE ENT

BY

C, EVERETT KOOP, K.D., SC.D.
SURGEON GeNERAL
U.S, PUBLIC HEALTH SERVICE
DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED BEFORE THE PRESIDENTIAL
COMMISSION ON THE HUMAN IMMUNODEFICIENCY
VIRUS EPIDEMIC

WASHINGTON, D.C.
MARCH 1, 1988
MR. CHAIRMAN. I WELCOME THIS OPPORTUNITY TO APPEAR BEFORE
YOU AND DISCUSS THE PREVENTION AND EDUCATION ISSUES CONCERNING
AIDS AND HIV INFECTION,

FIRST. 1 WOULD LIKE TO CONGRATULATE YOU AND THE MEMBERS OF
THE COMMISSION FOR THE MANNER IN WHICH YOU ARE EXERCISING YOUR
CRITICAL ROLE IN THE NATIONAL EFFORT TO CONTAIN THE HIV EPIDEMIC.

SINCE OCTOBER 1986 WHEN I RELEASED THE SURGEON GENERAL’S
REPORT ON AIDS, THIS COUNTRY HAS DONE MUCH THAT WE CAN BE PROUD
OF. THE NEWS MEDIA, PRINT AND ELECTRONIC, HAVE RENDERED
TREMENDOUS SERVICE IN GETTING OUT CLEAR INFORMATION TO THE
PUBLIC, THE ENTERTAINMENT MEDIA HAVE ALSO PUT OUT THE AIDS
MESSAGE IN WAYS THAT CAN CHANGE BEHAVIOR AND SAVE LIVES, THE
ADMINISTRATION AND THE CONGRESS HAVE GIVEN HIGH PRIORITY TO AND
GREATLY INCREASED RESOURCES FOR THE FIGHT AGAINST AIDS AND HIV
INFECTION,
THE RESEARCH AND HEALTH CARE COMMUNITIES ARE WORKING HARD ON
THESE PROBLEMS. IT IS THE HIGHEST LEVEL OF ACTIVITY AND
COMMITMENT TO A PUBLIC HEALTH PROBLEM THAT I HAVE SEEN IN MY
LIFETIME, THERE IS AN INCREASING PUBLIC AWARENESS OF THIS HEALTH
ISSUE AND A STRONG DESIRE TO TAKE PERSONAL AND PUBLIC ACTION,

BUT THERE IS MUCH MORE TO BE DONE AND MANY ISSUES WHICH WE
MUST ENJOIN IF WE ARE TO CONTAIN THE SPREAD OF HIV INFECTION.
LET ME SHARE A FEW ISSUES OF SPECIAL CONCERN.
I AM CONCERNED ABOUT NEEDLE SHARING AMONG IV DRUG ABUSERS,
A RECENT NATIONAL INSTITUTE ON DRUG ABUSE (NIDA) STUDY OF HEROIN
ADDICTS ADMITTED TO METHADONE TREATMENT PROGRAMS INDICATED THAT
93% HAD SHARED NEEDLES (MOST IN THE LAST YEAR) AND 26% REPORTED
DAILY NEEDLE SHARING: AND ONLY 14% REPORTED CONDOM USE. THESE
FIGURES HAVE ALARMING IMPLICATIONS, FOR BOTH IV DRUG USERS AND
THEIR SEXUAL PARTNERS. IT IS CURRENTLY ESTIMATED THAT THERE ARE
ABOUT 1.1 MILLION IV DRUG ADDICTS.

THE SOLUTIONS ARE NOT READILY OBVIOUS. IV DRUG ABUSERS LEAD
DISJOINTED LIVES AND MANY OF THEM ARE FUNCTIONALLY ILLITERATE,
IT IS CRITICAL THAT WE FIND THE RIGHT COMBINATION OF STRATEGIES
TO GET PEOPLE OFF DRUGS AND AWAY FROM CONTAMINATED NEEDLES.
ADDITIONAL DRUG TREATMENT CAPACITY IS NEEDED BUT SIMPLY
PROVIDING MORE DOLLARS DOES NOT IMMEDIATELY TRANSLATE INTO
ADDITIONAL “SLOTS” AVAILABLE FOR ADDICTS. THERE NEEDS 10 BE
INCREASED SHARING OF EXPERTISE AND PROGRAMMATIC EXPERIENCE
BETWEEN THE FEDERAL. STATE AND LOCAL GOVERNMENTS WORKING IN CLOSE
CONJUNCTION WITH COMMUNITY ORGANIZATIONS AND THE PROFESSIONAL
PROVIDER COMMUNITY. OUR ONLY HOPE LIES IN THE SOLUTIONS THAT
COME FROM THIS TYPE OF COLLABORATIVE ACTIVITY.

I CONTINUE TO BE CONCERNED ABOUT THE SPREAD OF HIV AMONG
HETEROSEXUALS. 1 AM OUTRAGED AT RECENT NEWSPAPER AND MAGAZIN
ARTICLES STATING THAT THERE IS NO DANGER OF HETEROSEXUAL
TRANSMISSION FROM "NORMAL VAGINAL INTERCOURSE”. ALTHOUGH
HOMOSEXUAL SEX AND IV DRUG ABUSE ARE THE PRINCIPAL MODES BY WHICH
MOST CASES ARE TRANSMITTED, IT IS JUST NOT TRUE THAT THERE IS NO
DANGER FROM NORMAL VAGINAL INTERCOURSE, WHAT IS UNKNOWN IS THE
LEVEL OF DANGER; THERE IS ALWAYS A DANGER WHENEVER
PEOPLE ENGAGE IN CASUAL SEX, TO DATE THERE HAVE BEEN 2,092 CASES
OF REPORTED HETEROSEXUAL TRANSMISSION OUT OF A TOTAL OF 52,249
ADULT CASES OF AIDS (ABOUT 4 PERCENT). IF YOU EXCLUDE THE
FOREIGN-BORN, THE FIGURE DROPS TO 2,5 PERCENT AND MOST OF THOSE
CASES ARE THE SEXUAL PARTNERS OF IV DRUG ABUSERS. THE CENTERS
FOR DISEASE CONTROL (CDC) ESTIMATES THAT BY 1991 HETEROSEXUAL
TRANSMISSION WILL ACCOUNT FOR 5 PERCENT OF THE TOTAL ADULT
CASELOAD,

WE KNOW FROM THE INFECTED SPOUSES OF PERSONS WITH HEMOPHILIA
THAT HIV CAN BE SPREAD THROUGH “NORMAL VAGINAL INTERCOURSE”.
WHAT CONCERNS ME IS THE POTENTIAL FOR A MORE RAPID SPREAD OF HIV
INFECTION INTO THE GENERAL POPULATION.
THIS CONCERN ABOUT A MORE RAPID SPREAD IS REFLECTED IN THE
REPORTED INCREASE OF INFECTIOUS SYPHILIS CASES BY APPROXIMATELY
30 PERCENT FROM 1986 TO 1987, THE GREATEST INCREASES WERE IN
FLORIDA, NEW YORK, AND CALIFORNIA, AREAS OF HIGH HIV INCIDENCE.
RELATIVE INCREASES WERE GREATEST FOR FEMALES AND HETEROSEXUAL
MALES OF ALL RACIAL AND ETHNIC BACKGROUNDS.

I] WANT TO TAKE THIS OPPORTUNITY TO ADD A SPECIAL WORD OF
PRAISE FOR THOSE WHO DEDICATED THEMSELVES TO THE COMPASSIONATE
CARE OF PEOPLE WITH AIDS AND ARC -- THE PHYSICIANS, NURSES,
TEACHERS, SOCIAL WORKERS, AND OTHERS, ESPECIALLY IN AREAS WITH
THE HIGHEST CONCENTRATIONS OF AIDS CASES...SPECIFICALLY, THE
CITIES OF NEW YORK, SAN FRANCISCO, AND LOS ANGELES.
HOWEVER, EVEN THERE -- AND IN MANY OTHER CITIES ACROSS THE
COUNTRY -- WE ARE SEEING A NUMBER OF INSTANCES IN WHICH HEALTH
PROFESSIONALS REFUSE NOT ONLY TO TREAT PERSONS WITH AIDS, BUT
ALSO TUR AWAY PATIENTS ALLEGED TO BE IDENTIFIED WITH HIGH-RISK
BEHAVIORS: HOMOSEXUAL AND BISEXUAL SEX AND INTRAVENOUS DRUG
ABUSE,

THE DECISION BY SOME HEALTH PROFESSIONALS TO DENY CARE TO
HOMOSEXUALS, IV DRUG ABUSERS, OR OTHERS SUSPECTED OF CARRYING THE
AIDS VIRUS IS HISTORICALLY UNCHARACTERISTIC AND UNWORTHY OF
ANYONE IN THE HEALTH OR SOCIAL SERVICE PROFESSIONS,

FOR GOVERNMENT, FOR THE PROFESSIONS INVOLVED, AND FOR
AMERICANS GENERALLY, THIS KIND OF BEHAVIOR EVEN BY A SMALL NUMBER
OF HEALTH PROFESSIONALS MUST BE A CAUSE FOR GRAVE CONCERN,

OF COURSE, THE REASON MOST OFTEN GIVEN IS THAT AIDS IS
CONTAGIOUS AND FATAL AND “I DON’T WANT TO GET IT.”
BUT THE PLAIN FACT IS THAT THE RISK OF CONTRACTING HIV FROM
AN INFECTED PATIENT IS EXTREMELY SMALL AND VIRTUALLY ALWAYS
PREVENTABLE. OF THE NEARLY 7 MILLION AMERICANS IN THE HEALTH
PROFESSIONS, WE KNOW THAT FEWER THAN ONE DOZEN HAVE BECOME
INFECTED WITH THE VIRUS WHILE DOING THEIR JOBS,

AND IN MOST OF THOSE CASES, HIV EXPOSURE COULD HAVE BEEN
PREVENTED, IF THE PERSON HAD FOLLOWED THE WORKPLACE GUIDELINES
PUBLISHED BY THE CENTERS FOR DISEASE CONTROL MORE THAN 5 YEARS
AGO.

| CANNOT OVEREMPHASIZE: IT IS ESSENTIAL THAT ALL WORKERS BE
REQUIRED BY THEIR EMPLOYERS TO FOLLOW THESE CDC GUIDELINES AND
THAT THEY BE PROVIDED WITH PROTECTIVE MATERIALS,
IN 1988, THE FEDERAL GOVERNMENT WILL SPEND A TOTAL OF $1,405
BILLION ON AIDS, INCLUDING $575 MILLION THROUGH MEDICAID ON AIDS
TREATMENT: $931 MILLION ON AIDS RESEARCH AND EDUCATION; AND Ail
ADDITIONAL $159 MILLION ON TREATMENT AND PREVENTION EFFORTS. THE
PRESIDENT’S FY 1989 BUDGET INCLUDES $2,026 BILLION FOR THESE
EFFORTS, A 38% INCREASE OVER 1988,
10

IN ADDITION, THERE ARE SOCIAL COSTS, SUCH AS LOST HUMAN
CAPITAL, AND THESE ARE OFTEN TRANSLATED AS LOST WAGES AND
PRODUCTIVITY,

BUT EVEN IF YOU PUT TO ONE SIDE THESE INDIRECT SOCIAL COSTS,
WE WILL STILL FACE, IN THE YEAR 1991, A NATIONAL BILL OF $3 TO $5
BILLION FOR THE COST OF AIDS-RELATED CARE -- BOTH IN-PATIENT AND
OUT-PATIENT, HOSPITAL AND HOSPICE,

THESE 1991 COSTS WILL RESULT FROM THE CARE OF AN ESTIMATED
145,000 PERSONS WITH AIDS WHO WILL BE IN VARIOUS STAGES OF A
TERMINAL ILLNESS,
1]

CLEARLY, WE MUST DO A GREAT DEAL MORE TO DEVELOP
ALTERNATIVE, LESS COSTLY, BUT HIGHLY EFFECTIVE WAYS TO CARE FOR
AIDS PATIENTS. WE NEED TO DO THIS IN LIGHT OF THE SPECIFIC AIDS-
RELATED DISEASES AND CONDITIONS WE KNOW ABOUT AND THE DIFFERENT
STAGES THROUGH WHICH THEY PROGRESS,

THE CHALLENGE TODAY, IS TO GIVE THE COUNTRY A WAY OF CARING
FOR AIDS PATIENTS WHILE PREVENTING AN ESCALATION OF COSTS,

T WOULD ALSO LIKE TO MAKE THE CRITICAL POINT THAT ONE OF THE
COMPLEXITIES OF AIDS IS THAT IT IS AN EPIDEMIC, CHARACTERIZED BY
RELATED ISSUES, A NUMBER OF THEM SOCIAL (E.G., HOMOSEXUALITY, IV
DRUG ABUSE), WE MUST DEVELOP OUR STRATEGIES TO MEET THE SPECIFIC
DIMENSION OF EACH ISSUE RELATED TO THE EPIDEMIC IF WE ARE TO
CONTAIN HIV INFECTION IN THIS COUNTRY.
12

IN MY REMARKS I HAVE LIMITED MYSELF TO A FEW CRITICAL
ISSUES, THERE ARE MANY OTHERS AND THEY MUST ALL BE ADDRESSED IF
WE ARE TO INTERRUPT THE CHAIN OF TRANSMISSION OF HIV AND SPARE
OUR PEOPLE AND THE PEOPLE OF THE WORLD THE PAIN, SUFFERING AND
DEATH OF AIDS. WE NEED TO STOP IT IN A WAY THAT IS EFFECTIVE YET
CONSISTENT WITH AMERICAN LAW AND TRADITION. WE CAN DO THIS JOB
WITH THE HELP OF GOOD SCIENCE AND GOOD EDUCATION, WE CAN DO IT
BY MAKING CERTAIN THAT THE AMERICAN PEOPLE HAVE A CLEAR
UNDERSTANDING OF THE THREAT POSED TO THEM BY THIS DISEASE, AND
THAT THEY ARE READY TO FIGHT BACK WITH THE BEST WEAPON AVAILABLE
TO THEM: THEIR INTELLIGENT CHOICES ABOUT PERSONAL BEHAVIOR,

AS A PRESIDENTIAL COMMISSION WITH HIGH PUBLIC VISIBILITY.
YOU HAVE THE ABILITY TO MARKET GOOD DISEASE PREVENTION, GOOD
SCIENCE AND GOOD HEALTH CARE PRACTICES TO THE PUBLIC. THE
AMERICAN PEOPLE LOOK TO YOUR FINAL REPORT FOR A LEADERSHIP VISION
OF THOSE THINGS WE MUST DO TO CONTAIN THE HIV EPIDEMIC, IN THIS
WAY YOU WILL HAVE SERVED THE BEST INTERESTS OF THE AMERICAN —
PEOPLE.

THANK YOU,