Making the Connections in the Response to AIDS:
Bridging Gaps in HIV, Substance Abuse Treatment
and Social Services

Jacksonville, FL
2/18/99

June E. Osborn, M. D.

I am very pleased to be here today to speak about your chosen
theme, "making the connections in response to AIDS," because I think
that topic is central to dealing with the two on-going epidemics
with which we have yet to deal effectively -- HIV/AIDS and
substance abuse. Illicit substance use has been with us for some
time, although not so long as one might think, in epidemic terms. But
for most of the twentieth century it -has been neglected by medicine
and public health, and has been considered almost solely as a matter
for the criminal justice system to deal with.

The 1970s saw a brief respite as President Nixon backed an

_ aggressive and effective methadone program, but by the 1980s the
specter of addiction began to loom larger and larger, especially after
crack cocaine made its grim appearance.

And, believe it or not, there was a time when AIDS wasn't --
when parents could cross their fingers and hope their kids'
adolescent rebelliousness would heal itself in due course without
major consequences. But then, about twenty years ago, HIV/AIDS
made its entrance into communities. Especially along the east coast
of the United States, the two epidemics joined forces quickly and
grew to extraordinary proportions that were unimaginable at the
outset.

In the early years, AIDS was viewed as a looming infectious ©
disease crisis of awful proportions -- which it was. The reaction to
the viral epidemic allowed the biomedical world to focus quickly;

 
but those of us in the infectious diseases community were slow to
spot the centrality of substance abuse in maintaining its momentum
-- nor was it widely appreciated that both epidemics were such
grave threats to our kids. |

I guess I was lucky to have had children who were pre-teen at
that time, for I am sure that my sense of urgency about the
perceived threat in 1981 had not only to do with my training as a
microbiologist/infectious disease person, but also with the fact that
my three kids were perched on the brink of their teenage years.
Happily they made it to adulthood unscathed, but throughout the
epidemic, I have always tried to say to myself, "There, but for the
grace of God, go I." ...and as new crops of teenagers perch on that

adolescent brink, I worry deeply that we are leaving them unwarned

and unarmed.

Let me focus for a while on early responses to AIDS, about
which I know far more than I do about substance abuse and
addiction. Those early times of the HIV epidemic were momentous,
and we were aware of it; something new had been launched upon
the world and, at first, it almost defied description. Young people,
previously healthy, were becoming immunosuppressed, wasting and
dying with only their sexual or drug using histories to unite their
fates, and it took nearly three years to learn that a brand newly
epidemic virus was abroad in the land. It took a little longer to
discover that a silent interval of seven or more years had preceded
the virus' recognition through disease production, and thus that it
had a massive lead-time on our ability to respond. Those features
were not unheard of in veterinary medicine, but they were
unprecedented. in humans, and it took a little while to make the
connection with animal models of retrovirus infection.

As all that unfolded, and as it became clear that infection with
HIV was, ultimately, almost uniformly lethal, we were in due awe of
the problems we faced. We were confronted with a need to cope
with human sexuality, homophobia, adolescent self-assertion and an

 
on-going but interlinked substance abuse epidemic all in the same
effort; and until then we had done rather poorly at any of those, not
-to mention our poor track record at interceding in much less
mysterious unhealthy behaviors linked to known diseases such as
lung cancer or heart. disease.

I must say that I am proud of my colleagues in that effort:
the early years of AIDS were full of heroism and astonishing
accomplishment as people sought ways to deal with that deadly
threat. Both nationally and globally, there was a rallying around,
spurred by a sense of common cause; my late, beloved friend
Jonathan Mann mobilized the Global Programme on AIDS of the
World Health Organization in a way that had never been seen before,
bringing the first glimpses of reality to the concept of a global village,
and making a firm conceptual link between health and human rights.

And in the United States, people like Jim Curran at CDC, Tony
Fauci at NIH, Gerry Friedland at Montefiore and Paul Volberding at
the University of California-San Francisco saw their lives turned
upside down and their young families stressed by the urgency of the
new fact of life. One of the most indefatigable of all, Don DesJarlais,
of Beth Israel, has worked steadily and brilliantly to bring out the
AIDS-drugs connection, and I owe him. much gratitude for his ~
patients in the early years as I began to learn about substance abuse.

All that was then. This is now. For some strange reason, the
sense of drama seems to have receded. Just as the National
Commission on AIDS started up and we began the tortuous legislative
process that resulted in the Ryan White Care Act, I remember being
bemused to watch the urgent, national response to the the 1989 San
Francisco earthquake. I was struck by the ease with which federal
emergency resources were mobilized, rescue crews put to work, and
engineering wizardry commandeered to deal with that acute,
physical crisis that put a few hundred people at risk. By that stage
of the AIDS epidemic, we were dealing with thousands upon
thousands of desperately ill young people, and an estimated million
who were infected but not yet sick. In due course, the Ryan White
Care Act came into being -- but believe me, it was a close call.

It occurred to me then that perhaps, as a society, we don't
know how to deal with chronic catastrophe. Despite the fact that —
the numbers of people living with HIV is now at its highest level
ever, AIDS has become part of the scenery. Individual groups and
agencies "do their thing” with variable effectiveness. One hears, —
regularly and repeatedly, that "AIDS is just one disease, and has
been given unfair favoritism in the national response." The inference
is that we should downscale our efforts, return to the older scourges
of heart disease or breast cancer -- stop coddling those people foolish
enough to engage in dangerous behavior -- by which is meant
substance abuse...and sex? AIDS is, after all, primarily a sexually
transmitted disease, and while there are variations in efficiency of
sexual spread, no gender or expression of sexuality is protected from

this new risk.

‘Strikingly, throughout the epidemic people have responded
preferentially and sometimes exclusively to pediatric AIDS -- to
-small children with HIV -- even though they have never constituted
more than 2% of the total affected. Even though I am a pediatrician,
I have often wondered what that implies -- whether, somehow, we
have a statute of limitations on childhood. If we do, I fear it is at the
onset of adolescence with all its difficulties and search for self-
expression -- which coincides tragically with the transmission
patterns of HIV.

[As a small historical note, the final spasm of resistance to the
Ryan White Care Act came in the form of an amendment on the
Senate floor that would have directed that 25% of funds be devoted
to that 2% of cases that were pediatric AIDS. Happily, that was
altered in the final minutes to read "family AIDS," thus averting a
significant derailing of scarce resources].

 
The Ryan White Care Act was a remarkably successful
innovation and helped to demonstrate that, in the best of
circumstances, communities can rise to a level of coordinated
prevention and care that dulls the pain of on-going loss of young,
talented people who have not had time to realize their potential. But
more often and increasingly, the losses are assumed to be inexorable,
the pain non-negotiable, and worst of all, the scenery is commonly
and harmfully painted with blame, recrimination and social stigma.
That has to sound sadly familiar to those of you who have spent long
careers struggling to bring about a constructive response to issues of
substance abuse. Once again, the twin epidemics of AIDS and
substance abuse share striking features.

At the beginning of AIDS, it was so exciting to think what we
could do if only we knew....what was causing it, how to stop
transmission, how to protect our youth? Who would have thought
we could have reached our present stage of mal-adaptation? I
suppose it could have been guessed, if one looked at the hubris of the
decades preceding. No disease was considered beyond conquering.
All one needed was a new drug and, ultimately, a vaccine, and the
world would revert to normal. After all, it had only been a few years
before the advent of HIV that infectious diseases were declared, by
the U. S. Surgeon General, to be a thing of the past.

But then the world changed, and we have now lived with
AIDS for nearly eighteen years. As so often happens in human
affairs, familiarity seems to have bred contempt.

As I speak in 1999, the number of young Americans we have
lost to AIDS is astonishing -- and two more youth become infected
every hour in the United States! In the early years of struggle
against this newly lethal hazard, a great many things were learned
about potentially effective responses. Biomedical scientists made
remarkable strides; social and behavioral scientists learned to -
intervene in useful ways in the interest of. prevention. And yet, for
all that uplifting progress, we are in deepest trouble because of
failure to recognize that the coordination of personal, family, health
and social service responses -- which is to say, making the
connections -- is central to whether we can mobilize and capitalize
on the usefulness of all that we have learned.

I have been involved with the AIDS epidemic as a public health

policy advisor since its beginning. As you can imagine, it has been

awesome to take part in so momentous a change in the course of
human history. HIV isn't smallpox -- it is much worse, because of its
universally pertinent mode of transmission and the long, silent
interval before its presence can be recognized overtly through the
development of AIDS. What is more, it is a prototype of what we
have learned to call an "emerging infection," and we need to learn its
lessons carefully, for this is surely not the last time the global
community will face a comparable threat.

For all those reasons I think it is fair to predict that HIV, AIDS
and (probably) subsequent emerging infections will be with us for
generations to come. So when I get a chance to talk to a committed
and thoughtful group about the AIDS epidemic, I tend to have to
restrain myself from becoming overly ambitious. They say you can
--only hope to accomplish so much in an hour, and we have slightly
less than that.

With that in mind, my plan for the rest of our time together
today is as follows: first I want to summarize briefly where we are
currently with the AIDS epidemic, highlighting trends that I consider
important and ominous. Then, in the interest of timeliness, -I will
make some comments about one or two themes that dominate the
AIDS debate at present. And finally I will deal with a few key issues
concerning substance abuse and HIV that make it clear that
coordinated, community-based activity is crucial for ultimate control
of both epidemics. I hope, when I am finished, that there will be
time for some questions and discussion.

 
Before I start on that plan, however, there are three major

_ points that I want to make, in hopes of underscoring them as I go
along. For an audience as experienced and sophisticated as this, they
may be obvious; but if there is one thing I have learned during the
AIDS years, it is not to let the obvious go un-spoken.

First, the epidemic isn't over. It isn't even "almost over," as
has been inferred in recént months by many enthusiastic biomedical
scientists in discussions of the new drug therapies. In fact, in my
personal opinion HIV/AIDS is much more threatening now than at
any time since it was first recognized in 1981, precisely because of
the false confidence those therapies have engendered and the
continued neglect of the substance abuse connection.

Second, we have learned a great deal in the first years of AIDS
-- about viruses and immune responses and pharmacology, of course.
But also about the critical importance of individual and community |
roles in behavior change, and most dramatically about the real
possibility of prevention of HIV infection in that context. In fact,
those insights about effective interventions are the most powerful
of all that we have learned, and yet -- perhaps because they are so
"low-tech" -- we have ignored them and placed new generations at
risk for lack of understanding or commitment. Put most succinctly,
we are not using what we know.

Third, we must not fall prey to the temptation to "wait til the
vaccine comes,” for that piece of progress, should it occur, is by
definition far off into the future. Even were there a truly promising
vaccine candidate ready to test (which there is not), those tests
would take some years. What is more, a vaccine will be problematic
in its deployment, and almost certainly less effective in prevention
than the avoidance strategies we know about already.

I understand why everyone wants so much to have a vaccine,
for vaccines have proved truly miraculous in the context of simpler
infectious diseases. But also, the wish is there to avoid the thorny
questions that AIDS has begged. About that, I simply have to say
"Sorry! The hard work of dealing with sex, drugs and adolescent
experimentation cannot be avoided." If we come to grips with that
fact of life, we will do a far better job at community-based responses
to the complex dynamics of the AIDS epidemic.

Current Status of the U. S. Epidemic

Let me turn, then, to the current status of the epidemic in the
United States. The numbers are quite astounding! Keep in mind that
the first five cases of what turned out to be AIDS were reported in
the Morbidity_and_ Mortality Weekly Report from CDC only in June of
1981. From that small, deadly beginning we have escalated to
almost three-quarters of a million Americans diagnosed with
AIDS in ensuing years, of whom at least 400,000 have died.

Oddly enough, as the toll of AIDS has mounted, public interest
and awareness have almost receded. I used to think that things
would get tragically easier as the numbers climbed, for everyone
would know someone who.... But the effect of shame and stigma
dominated, and I was wrong. Rather than being recognized as a
massive and uniquely deadly threat to youth by the press, coverage
of epidemic events tends to be quirky, remote and episodic.

To make that point I jotted down, a couple of weeks ago, the
topics of articles I came across in The New York Times on a single
day that related to AIDS. There was an excellent, long article by Dr.
Larry Altman, their chief medical correspondent, on issues of HIV in
newborns, worries about breastfeeding transmission of the virus, use
of placebos in international AIDS treatment experiments, and HIV-
related problems associated with the lack of access to sterile injection
equipment in the developing world. He was writing from Chicago,
where an international retrovirus meeting was being held; but it
would have been easy to assume that AIDS was only happening

elsewhere and was not very pertinent to the average American

reader.

 
In another section of the Times there was a well-done article
about possible origins of the human immunodeficiency virus which
probably transferred into the human species from chimpanzees
about fifty years ago. That is a useful insight for virologists, and I
was relieved to see that it was much better handled than in early
years, when gauche, baseless and insulting speculation about the
origins of HIV offended large populations; but it may well have
activated echoes of those times, unhelpfully. And again, the
remoteness of that finding -- another continent, another time --
could serve to feed the tendency to denial.

In yet another section there was an arch statement from the
Governor of New Jersey reaffirming her opposition to needle
exchange programs for injection-drug-users (IDUs), asserting that the
growing mound of evidence of their efficacy in preventing HIV
spread was "dubious at best." ‘That, of course, is not true; the
growing body of evidence supporting needle-exchange as a
consistently helpful strategy for harm reduction is virtually uniform
and convincing; but the Governor chose to deal with it as if it were a
matter of casual opinion. Such resistance in the face of facts was
surely fueled a few months ago by further prohibition of the use of
federal funds for such needle-exchange programs.

And finally on that one day of coverage, as a sad "human
interest story," there was an article telling of my friend Mary Fisher's
decision to discontinue the highly active antiretroviral therapies for
her HIV infection because they were so toxic and distorting of
quality of life that she chose to abandon them to have healthy time
with her sons. The coincident timing of those latter two stories was
especially poignant, since Mary's HIV infection was heterosexually
acquireda from her former husband, who subsequently died of AIDS
acquired on the context of I.V. drug use and probable needle-sharing.

All of that hardly sounds like an epidemic that is over! Indeed,
worldwide we are approaching a cumulative total of 40,000,000

 
10°

cases of AIDS, with at least as dreadful a statistic of 10,000,000 AIDS
orphans by the millenium. And yet public apathy and denial is
striking! I grant you, it is hard to get a handle on such massive
numbers. I find myself constantly searching for comparisons in
order to recapture people's attention -- for instance, the number of
deaths of young Americans from AIDS will soon exceed the total
number killed in all of our armed conflicts since the Civil War!

It is generally agreed that the recent, merciful downturn in
AIDS mortality in the U. S. is likely to be a transient event -- a
respite, as it were, bought largely and dearly by the deployment of
the new highly active antiretroviral therapies. But it is also agreed
that new: HIV infections in our country are occurring at a constant
rate of at least 40,000 per year or more, and as I have already noted,
the ongoing failure to deal effectively with substance abuse means
that its synergistic collusion with HIV lurks like a dreadful shadow
Over even that unsatisfactory "steady state."

- Let's look briefly at the shape of some trends that darken that
shadow. First, while many people in the United States have

- conveniently distanced themselves from AIDS as (and I quote) just a
disease of "those gays and addicts," the most constant trend is an
annual increase in the percentage of new AIDS diagnoses in women
--- now more than 20% of the annual total.. Some of those instances of
AIDS in women relate directly to i.v. drug use; but increasingly they
reflect heterosexual spread. That shouldn't be any surprise, since
715% of the worldwide epidemic is convincingly attributed to
heterosexual intercourse; but our reaction is muted by early and
dismissive misperceptions about "risk groups."

Another article in the New York Times just this week carried a
reminder of a further lesson we seem to have forgotten -- that is,
that bisexuality is not rare. The main point of the story was a
demonstrated upswing in HIV infections among young gay men in
New York -- 12% overall, and 18% seropositive among African
American young gay men. But in addition, the reporter noted that

 
11

fully two-thirds of those HIV-infected men -- while self-identifying
as gay -- had had intercourse with women as well as men in the
recent past. That factor of bisexuality is one of which we became
acutely aware ten or fifteen years ago; but it too has faded from
view, to our peril.

Anyway, for a variety of reasons, women are steadily taking
their place among the ranks of people with AIDS -- and of course,
because of the slow expression of HIV-disease, trends concerning
AIDS (which is its late expression) offer only an out-of-date
snapshot of where the virus is now spreading. Other trends: smaller
and smaller cities, rural America ..... in short, it's out there!

If that weren't enough to make one sit up and take notice,
another consistent trend throughout the epidemic years has been a
steady decline in the average age at time of first infection with HIV.
Each year that age has gotten younger; initially one could
extrapolate that about 20% of people with AIDS had been in their
teenage years at the time they became infected. By now that
fraction is much greater; HIV, like smoking, has become an
adolescent plague. |

In such a context, talk of "life-styles" can be lethally self-—
defeating. As a pediatrician I have always looked at adolescence as
an age of experimentation. Some of those experiments have turned
deadly now, and yet we are failing to warn! Recent CDC studies
report that almost three-quarters of high school seniors are sexually
active -- and keep in mind that such data omit out-of-school youth.
The reluctance to talk about "safer sex," or indeed anything but |
abstinence, while trying to counsel about the risk of STDs including
HIV, has to arise from denial of those facts, for nothing otherwise
could explain our failure to warn new generations of youth who are
sexually active youth about the lethal menace around them. It is no
comfort to note that the single most reproducible fact of the AIDS
epidemic around the globe is, indeed, denial.
But back to kids for a moment. People used to say -- when we
got to that stage of discussion -- that after all, youth think they are
immortal and nothing can be done. Not necessarily so: in early years
of the epidemic, impressive work was done to mobilize youth, to
establish supervised peer counselling, and to take advantage of
school-based or community-based clinics where teens could seek
information and guidance. I am sure such efforts continue, but I
suspect they are spotty and, in some places, under community attack.

Nowhere is the youth issue more urgent than in the context of
substance abuse, which is the next trend I want to mention. [I am
aware that I am skirting the important issue of alcohol use, which
plays a demonstrably serious role in "unsafe sex" and risky behavior.
I do so only for lack of time, and because I think this audience knows
much more about that than I do].

Turning, then, to illicit substances: with each passing year of
the American AIDS epidemic, injection drug use has played a larger
and larger role. The efficiency of transmission of HIV when
injection apparatus is shared in the context of illicit drug use has
always constituted a potential "wild card" in predicting the pace and
scope of HIV spread. Whereas sexual transmission is generally
somewhat inefficient -- except when coexistent with other sexually
transmitted diseases -- the sharing of needles and "works" was
recognized early on as a major vehicle for rapid spread. In city after
city around the world, populations of injection drug users have gone
from minimal levels of infection to over 50% -- sometimes as much
as 90% infected -- within the course of just one year. Not only are
they at risk, but so are their sexual partners and offspring.

The importance of substance abuse in the U. S. epidemic was

evident along the east coast from the outset; thus far we have been
spared comparable devastation in other parts of the country, where
infection rates among IDUs hover between 10% and 15%. But such a
reprieve is not something we should count on, for the "flashfire
potential" of injection drugs as a mechanism for dissemination of HIV

 
13

is striking, and the substance abuse "epidemic" is not under control.
Indeed, each year substance abuse contributes directly or indirectly
to a greater fraction of cases of AIDS -- now over 50% of the total.
I'll get back to that topic later.

Two other trends bear noting. First, there has been an
inexorable advance of HIV in communities of color, facilitated in part
by an understandable but crippling mistrust of the so-called
majority. That stems, in part, from the awful racial stresses and
divides that continue to threaten our society; but most directly, it
reflects reaction to revelations about the Tuskegee syphilis
experiment, in which a dreadful, government-sponsored
observational study of untreated syphilis in African American men
was allowed to proceed for decades after it should have been
stopped when effective treatment became available (if it ever should
have been started in the first place).

Since that awful piece of history was revealed just before the

advent of AIDS, it is not so strange to find that the. AIDS virus itself
is suspected by many to be an escapee from a government lab or
other nefarious source. The pall cast by that suspicion was such that
many communities were slow to respond to the AIDS threat, and it is
still a challenge to share insights and interventions promulgated by
"the government." Even in majority settings I have found that it is
easy to set off a wave of laughter with the phrase "I'm from the
government and I'm here to help you;" it is just that much more

difficult to achieve trust in communities where additional suspicions
are in the way.

The final trend I want to mention is, on first glance, a happy
one -- and surely that is true in the short term. I am speaking, of
course, of the marked decline in deaths from AIDS and in diagnoses
of full-blown AIDS, both of which occurred in synch with the fairly
widespread use of the new, so-called highly active antiretroviral
therapies, which began in early 1996. That is surely wonderful
news, for many people who thought themselves as good as gone are

 
14

back to leading productive lives. But there are some cautionary
notes to that upbeat tale.

First, those therapies are toxic, as Mary Fisher said in the
article I quoted earlier -- so much so that as many as half of those
who try to maintain the regimen cannot do so. That isn't trivial,
since it is advocated that the drugs be taken starting very early in
HIV infection, at a time when good health would otherwise prevail.
Furthermore, it has thus far proved impossible to discontinue those
drugs without suffering a return of the virus. Adding to the reality-
problems associated with these new antivirals, it is noteworthy that
the rigor of the therapeutic regimen is extreme. Medical
"compliance" is a difficult accomplishment even in much less

demanding circumstances; but with the highly active antiretroviral

therapies, not only must dozens of pills a day be kept track of, bult
some doses must be taken on an empty stomach, others on a full, and
NONE missed, lest the virus develop resistance (which it sometimes
does anyway).

' So, while the new treatments are powerful and worthy of
celebration, they should be greeted for the reprieve they provide,

_- not as a remedy for an ongoing, global problem. Even where they

can be afforded, they are no solution to the massive HIV epidemic.
Nor will the addition of more and different drugs constitute an
adequate public health solution in and of themselves. An
unwaveringly biomedical approach to AIDS is doomed to
disappointment and potential disaster. There has never been an

_ antiviral drug to which the targeted virus didn't develop resistance;
and I fear that it is likely that the striking propensity of HIV to
develop resistance means that the end of the reprieve is just around
the corner, in which case the happy trend of a downturn in AIDS
morbidity and mortality could be just a transient break in the
relentless epidemic curve.

A Few Issues of Concern

 
Let me turn now to a couple of issues that have been much in
the news of late, but which have not generally been related to
community considerations. First there is the issue of mandatory HIV
reporting. That debate has been with us since earliest days of
antibody testing; from the beginning there was a loud clamor for
official rolls of names of infected individuals. The assertion was that
we should use "good old-fashioned public health practices" just like
those used for other sexually transmitted diseases. [The fact that our
dealing with other sexually transmitted diseases had been a
worrisome failure seemed not to daunt the arguers].

For a time that debate settled uneasily on a compromise --
cases of AIDS were required to be reported, but individuals who
were HIV positive were not subject to the same requirement. While
it would obviously be somewhat easier to track the path of the
epidemic with such information, the "down-side" of such a reporting
requirement caused serious concern. That down-side took the form |
of avoidance of testing (which was well documented in areas where
state rules put it in force) and, for that matter, avoidance of available
care. I don't suppose the argument would have gotten so heated
were it not for the stigma associated with HIV, which took on such
non-trivial forms as difficulty with insurance, employment and -
housing opportunities. The Americans with Disabilities Act of 1991
was intended to redress some of those worries; but in fact it became
clear rather quickly that federal legislation alone did not translate
directly into community action or redress.

The situation began to change, for better or for worse, as states
or communities took to screening infant cord blood samples in an
"unlinked" or anonymous manner, in order to get some grasp of the
magnitude of heterosexual spread. Such testing, of course, identified
infected mothers but did not say which 25% of their infants was

truly infected and which simply carried antibody that had crossed
the placenta.

 
Then a major finding reframed the discussion. In 1995 it was
found, in an NIH-sponsored study fondly referred to as "076", that
treatment of HIV-infected mothers with AZT during the last 8 weeks
of pregnancy and during delivery, coupled with treatment of infants
for six weeks thereafter, resulted in a 2/3 diminution in the number
of infected infants -- a drop from 25% in the untreated group to 8% |
in the treated infant-mother pairs. The study was well done, and the
finding represented the first dramatically encouraging therapeutic
success against HIV. It was immediately embraced without
qualification and became the standard of care in the developed
world.

The effect differed, however, in the developed versus the
developing world. It wasn't long, in the U. S., before it became
evident that treatment of adults with HIV had to include three drugs
at least to achieve the results of the highly active antiretroviral |
therapies. The 076 study actually didn't deal with sustained
treatment for mothers, only for their infants; but nonetheless the
issue of so-called "monotherapy" prompted further studies that are
now nearing completion, and it seems most likely that those complex
regimens will soon replace the initial recommendation for AZT alone,
but will be virtually mandated for HIV-positive mothers and their
infants. I worry about that, since many of those young women
already avoid prenatal care, and coercive intervention surely won't
help. On the brighter side, European studies have suggested recently
that only the peripartum and infant treatment intervals are needed
to achieve the effect of 076. Thus, the exact protocols for dealing
with HIV-infected women are under review, but the complexity of
the multiple problems often implicit in such circumstances seems to
have been'‘lost in the discussion..

All that notwithstanding, the perceived success of the first trial
is such that the argument for mandatory HIV testing of pregnant
women has gained momentum dramatically, with all its complexities

intact -- including the issues of stigma already noted, problematic
access to care, even more problematic access to substance abuse

 
17

treatment as needed, and a background of spousal abuse that often
accompanies revealed HIV infection. I am delighted that fewer
infants are acquiring HIV, make no mistake, for pediatric AIDS is
dreadful. But this is an area in which the complexities of community
response must be factored into any policies, especially mandatory
ones.

I can't take time to. dwell on the even greater complications
surrounding this issue in the developing world. It is a fact -- not a
bit of hyperbole -- that in many of the countries where HIV is
entirely out of control, infecting as many as 25% of women of child-
bearing age, the average health expenditure per year per person is
under $10. Furthermore, the effects of perinatal treatment for HIV
are steadily eroded if children then breastfeed; and yet where the
water supply is not secured and nutritional resources are marginal,
breastfeeding may be the only genuine life-line for infants,
regardless of their mothers' HIV status. These matters aren't
susceptible to ready solution, and we certainly don't have time for
them here; but I mention them because there has been what I
consider to be quite simplistic press coverage over recent months of
what is a truly thorny conundrum for the global community.

Finally, on to substance abuse

That brings me, at last, squarely to the issue of the twin
epidemics of substance abuse and AIDS, and here is where
community dynamics permeate the problem completely. As you
know, and as I noted earlier, our "war on drugs" hasn't been working
very well, and especially not in youth. The. so-called "war" has been
waged largely at the borders, with truly disappointing outcomes for
the $17 billion of federal funds expended annually. Inside those
borders, three-strikes-and-out laws have meant that people caught
up in substance abuse and addiction are increasingly concentrated in
our prisons. The sheer numbers of people incarcerated are
astonishing; the fraction that are there for substance abuse and-

 
18

related crimes is high and rising steadiy. And AIDS has, for some
years now, been the leading cause of death in prison.

I referred, at the beginning of this talk, to the almost complete
dissociation of physicians from issues of substance abuse. That has
assured a disconnection between the treatment efforts undertaken in
hard-pressed communities and the potential for diagnostic and
therapeutic contributions that might be offered by medicine. It has
also resulted in a profound ignorance among physicians about the
illnesses and issues associated with substance abuse. While public
health has sometimes been a middle ground, there is much room for
‘improvement in connecting the links of care for people caught in the
path of addiction.

I think the assumption is held by many that substance abuse
treatment doesn't work, and therefore that the disconnection is of
little consequence. Let me take the last few minutes to tell you
about an activity generated in the past year by a group of physicians
to try to redress their lack of involvement. The group is called
Physician Leadership on National Drug Policy, and is constituted by
_- 37 physicians who can be characterized by their high visibility -- not
their direct involvement in substance abuse research or care. It was
brought together under the leadership of Dr. David Lewis, Director of
the Center for Alcohol and Addiction Studies at Brown University,
who serves also as Director of the group.

I am privileged to be its Chairwoman, and Dr. Lonnie: Bristow --
immediate past president of the American Medical Association -- is
vice-chair. The membership includes most of the past assistant
secretaries for health (from either side of the aisle); former Secretary
of Health and Human Services Louis Sullivan; former Surgeon
General Antonia Novello; Nobel Laureate and Emeritus President of
the Institute of Medicine Frederick Robbins, editors of eight leading
medical journals, and the heads of most of the professional academic
medical societies including the American College of Physicians, the
American Psychiatric Association, and so on.

 
The group first met in the summer of 1997 to see if there was
a common medical ground from which such collection of physician
leaders could work. That turned out to be remarkably easy: a
unanimous consensus was quickly reached that led to the following
statement: (read PLNDP)

In the months since that first consensus meeting, we have had
surprising success at pressing our message on Capitol Hill, and in
addition we have been aided by very distinguished experts in the
field of substance abuse who have pulled together the data and
studies that document the favorable efficacy of treatment for
substance abuse relative to other chronic, relapsing disorders; the
remarkably greater cost-effectiveness of therapy versus
incarceration; the dramatic lack of availability of drug treatment in
prisons, and a series of other compelling facts that bolster the claim
that we have been sorely missing a treatment component in our so-
called "war against drugs." We have also urged systematic changes
in medical education in order to address the problem of physician
ignorance.

Along the way, we have created a brief videotape that has
been proving effective in presentation to a variety of audiences, both
lay and professional; and we have established an associates network
to which interested physicians can belong, through which we send
out intermittent updates and reports of the ongoing studies.

The PLNDP, therefore, represents a new locus of action that we
hope can be helpful. By no means is there an intention to suggest
that physicians can come racing to the rescue in this difficult area --
far from it; instead, it is an acknowledgment, in part, that physician
input has been sorely lacking as the nation struggles with the drug

problem, and that we hope to join more effectively with the other
components of community response.

 
If you are interested in learning more about that, the person
and address to contact is: Dr. David Lewis, Box G-BH, Brown
University, Providence, RI 02912....

email: plndp@pindp.caas.brown.edu

WWwW.caas.brown.edu/plndp