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Cal
A
Institute of Medicine
Nadona1 Academy of Sciences
NATIONAL ACADB~Y PRESS
Washington, D.C. 1988
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National Academy Press ~ 2101 Constitution Avenue, NW ~ Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the
National Research Council, whose members are drawn from the councils of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the
committee responsible for the report were chosen for their special competences and with regard for
appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by
a Report Review Committee consisting of members of the National Academy of Sciences, the National
Academy of Engineering, and the Institute of Medicine.
The National Academy of Sciences was established in 1863 by Act of Congress as a private, nonprofit,
self-governing membership corporation for the furtherance of science and technology, required to advise
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Academy established the National Research Council in 1916 and the National Academy of Engineering
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distinguished members of the appropriate professions in the examination of policy matters pertaining to
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Support for this project was provided in part by the National Research Council (NRC) Fund, a pool of
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Library of Congress Catalogue Card Number 88-61558
ISBN 0-309-03879-0
First Printing, June 1988
Second Printing, November 1988
Third Printing, June 1989
Copyright ~ 1988 by the National Academy of Sciences
No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in
the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise
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of official use by the U.S. government.
Printed in the United States of America
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Committee for the Oversight of AIDS Activities
THEODORE COOPER (Chair), The Upjohn Company, Kalamazoo, Michigan
STUART ALTMAN, Brandeis University, Waltham, Massachusetts
DAVID BALTIMORE, Whitehead Institute for Biomedical Research and
Massachusetts Institute of Technology, Cambridge
KRISTINE GEBBIE, Oregon Health Division, Portland
DONALD R. HOPKINS, The Carter Presidential Center, Atlanta
KENNETH PREWITT, The Rockefeller Foundation, New York
HOWARD M. TEMIN, University of Wisconsin School of Medicine, Madison
PAUL VOLBERDING, San Francisco General Hospital
STAFF
ROBIN WEISS, Project Director and Director, AIDS Activities
LESLIE HARDY, Project Officer
MARY JANE POTASH, Project Officer
GAIL SPEARS, Administrative Assistant
KATHLEEN ACHOR, Senior Secretary
HOLLY DAWKINS, Secretary
JOANNE INNIS, Secretary
APRIL POWERS, Secretary
CONSULTANTS
MARK FEINBERG, Whitehead Institute for Biomedical Research, Cambridge,
Massachusetts
LYNN I. LEVIN, Institute of Medicine
LEAH MAZADE, National Academy Press
JEFF STRYKER, University of Michigan School of Public Health, Ann Arbor
ROY WIDDUS, Global Programme on AIDS, World Health Organization
. . .
111
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Preface
Twenty months ago, in October 1986, the Institute of Medicine/National
Academy of Sciences (IOM/ NAS) issued Confronting AIDS: Directions for
Public Health, Health Care, and Research. That report described what was
known then about the acquired immune deficiency syndrome (AIDS). It
contained the information on which the IOM/ NAS Committee on a National
Strategy for AIDS based its conclusions and recommendations. Appendix A
in this volume is the summary and recommendations from that report.
In March 1987, IOM/ NAS created a new committee, the AIDS
Activities Oversight Committee, and charged it to monitor and assess the
nation's response to the problems raised by AIDS in matters of public
health, health care, and research. The committee was also asked to
coordinate and oversee studies and activities concerning AIDS through-
out the National Academy of Sciences complex.
One of the committee's first undertakings was to review Confronting
AIDS, a year and a half later, with an eye toward assessing the nation's
progress against AIDS and appraising the quality and extent of its responses.
To supplement its expertise, the committee identified approximately 60
correspondents; these included experts in the fields of molecular biology,
immunology, virology, drug and vaccine development, clinical medicine,
epidemiology, public health, international health, infectious diseases, ethics,
law, education, social sciences, the history of science, and other disciplines,
as well as administrators of the major federal agencies concerned with AIDS
and some state and local officials. These correspondents were asked to
prepare papers for the committee describing progress and events in their
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V1 PREFACE
fields since the fall of 1986. Appendix C is a list of the correspondents from
whom material was received.
This report presents the committee's findings and the recommendations
that arose from them. It should be viewed as an update of and a
supplement to Confronting AIDS; it makes no attempt to duplicate the
breadth and depth of information available in the original report. The
preponderance of the factual material in Confronting AIDS remains
accurate as of May 1988. For a basic understanding of the scientific
knowledge that underlies both recent advances and the current recom-
mendations, the committee refers the reader to that volume.
This update highlights new information or events that have given rise to
the need for new directions; it also focuses on recommendations from the
earlier report that deserve reemphasis. Chapters tend to vary in length and in
the depth of their analysis, reflecting the reality that more or less progress has
occurred in different areas and also the committee's intent to provide useful
information to a varied audience of laypersons, scientists, and policymakers.
The committee plans to address some areas more fully in the future; the U.S.
role in combating the global epidemic, for example, awaits further study.
It is now clear that the "AIDS epidemic" is really an epidemic of HIV
infection, and when referring to the epidemic in general, we use the terms
interchangeably. When we discuss target populations for intervention,
however, we distinguish among asymptomatic infected persons, sympto-
matic individuals, or people with AIDS as defined for surveillance
purposes by the Centers for Disease Control (see Appendix B). As is true
for any new disease, we expect that terminology will continue to evolve
as our understanding increases.
Finally, like its predecessor body, the AIDS Oversight Committee was
continually aware that it was assessing a "moving target." As new
developments occur and new knowledge is acquired, the committee will
pause again for reflection and evaluation.
ACKNOWLEDGMENTS
The committee wishes to thank the many persons who took time from
their activities to assess the current status of their fields for the purposes of
this report. Thanks are also due to the members of the AIDS Oversight
Committee, all of whom made exceptional efforts to fulfill the requirements
of the update. Finally, I wish to acknowledge the remarkable contribution
and tireless assistance of the IOM/ NAS staff headed by Robin Weiss.
THEODORE COOPER
Chairman of the Board and
Chief Executive Officer
The Upjohn Company
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Contents
EXECUTIVE SUMMARY
Introduction, ~
HIV Infection and Its Epidemiology, 2
The Spectrum of HIV Infection, 2; Modes and
Efficiencies of HIV Transmission, 3; Prevalence and
Incidence of Infection in the United States, 4
Understanding the Epidemic's Course, 5
Altering the Epidemic's Course, 5
Antidiscrimination Protections, 6; Education, 6;
Screening and Testing for HIV Antibody, 8; Other
Public Health Measures, 11; AIDS and IV Drug Abuse,
12; Resources for Public Health Measures, 13
Care of Persons Infected with HIV, 13
Care Needs of Special Patients, 13; Health Care
Providers, 14; Costs of Health Care for Persons with
AIDS, 16; Financing Health Care for Persons with
AIDS and Other HIV-Infected Individuals, 16;
Possible Financing Mechanisms, 17
The Biology of HIV and Biomedical Research
Needs, 17
HIV Biology, 18; Drug Development and Testing, 18;
Vaccine Development and Testing, 20; Roundtable on
vat
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· · ~
Vlll CONTENTS
Drugs and Vaccines, 20; Animal Models of AIDS, 21;
Resources for the Campaign, 21
international Aspects of AIDS and HIV Infection, 22
A National Commission on HIV Infection and AIDS, 24
INTRODUCTION
References, 31
2 HIV INFECTION AND ITS EPIDEMIOLOGY
HIV: The Etiologic Agent of AIDS, 33
Proportion of Infected Individuals Who Will Develop
AIDS, 35
The Spectrum of HIV Infection, 36
Modes and Efficiencies of HIV Transmission, 38
Heterosexual Transmission, 39; Efficiencies of
Transmission, 42; Relative Efficiencies of HIV
Transmission, 45
Prevalence and Incidence of HIV Infection in the
United States, 46
HIV Prevalence in Groups at Recognized Risk, 46;
HIV Prevalence Among Selected Segments of the
General Population, 47; Incidence of New Infections,
49; National Estimates of HIV Infection, 49; The
Program of HIV Surveys and Studies, 50
AIDS Cases in the United States, 51
The Demographic Impact of AIDS, 52
Future Research Needs, 52
References, 53
l
. 27
.. 33
3 UNDERSTANDING THE COURSE OF
THE EPIDEMIC ................
The Uses of Models, 58
Data Needs, 59
References, 60
4 ALTERING THE COURSE OF THE EPIDEMIC
Features of Public Health Programs, 61
Antidiscrimination Protections, 62
. 57
. 61
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CONTENTS iX
Education, 64
Content of the Message, 65; School-Based Education,
66; Effect of Educational Programs, 67; Gay and
Bisexual Men, 68; AIDS and Condoms, 68
HIV Antibody Screening and Testing, 69
Technical Considerations, 71; Informed Consent and
Confidentiality, 71; Voluntary Testing, 74; Mandatory
Screening, 75; Home-Based Testing, 79
Other Public Health Measures, 80
Duty to Warn, 80; Contact Notification, 81; Reporting
of HIV-Seropositive Cases, 82; Personal Control
Measures, 83
AIDS and {V Drug Abuse, 84
Intervention Innovations, 85; Distribution of Sterile
Needles and Syringes, 86
Resources, 87
References, 89
5 CARE OF PERSONS INFECTED WITH HIV
Care Needs of Special Patient Groups, 94
IV Drug Abusers, 94; Infants and Children, 95; Patients
with Dementia or Other Neuropsychological Deficits, 96
Health Care Providers, 96
Ethical Aspects of Providing Care, 97; Health Care
Provider Training, 101; The Psychological Burden of
AIDS Patient Care, 103
Health Care Costs for HIV-Related Conditions, 104
Direct Costs of Care for AIDS Patients, 104; Indirect
Costs of HIV-Related Conditions, 106; Cost
Implications of Projected AIDS Cases, 107; Research
on Health Care Costs, 109
Financing Health Care for HIV-Related Conditions, ~10
Sources of Financing, 111; Alternative Financing
Mechanisms to Improve Health Care Coverage, 113;
Development of a Financing Strategy, 117
References, IlS
6 THE BlOI~OGY OF HIV AND BIOMEDICAL'
RESEARCH NEEDS ..................
HIV Biology, 123
. 93
. 123
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X CONTENTS
Viral Taxonomy and Disease, 123; Control of Viral
Gene Expression, 127; Regulation and Production of
HIV, 127; Interrupting Infection by HIV, 130; Natural
History of HIV Infection, 132; The Importance of Basic
Research, 135
Drug Development and Testing, 136
Vaccine Development and Testing, 141
Roundtable on Drugs and Vaccines, 146
Animal Models of AIDS, 147
Resources, 149
Facilities, 149; Reagent Distribution Center, 150
Funding for Research, 151
References, 151
7 INTERNATIONAL ASPECTS OF AIDS AND HIV
INFECTION ............................
The WHO Global Programme on AIDS, 160
Rationale for U.S. International Involvement, 161
The U.S. Contribution to International Efforts, 161
References, 164
A NATIONAL COMMISSION ON HIV INFECTION
AND AIDS
· · —
APPENDIXES
.. 159
165
A. Summary and Recommendations from Confronting AIDS:
Directions for Public Health, Health Care, and
Research 171
B. CDC Classification System for HIV Infections and Revised
Case Definition for AIDS 202
C. Correspondents
D. Biographical Notes on Committee Members
INDEX . .
. —
218
.. 221
227
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Confronting
A one
~ L
_ ~
Update
1988
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