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OCR for page 326
G
PHS Plan for Prevention and Control of AIDS and the
AIDS Virus
Foreword
In 1985, the Public Health Service's Executive
Task Force on AIDS published a comprehensive
plan that included a set of objectives to control
and prevent the spread of acquired immune defi-
ciency syndrome by the year 2000 (1). In the year
since the plan was developed, considerable
progress has been made. Our knowledge base has
expanded many fold during 5 cumulative years of
experience with AIDS and the AIDS virus. New
information permits tentative long-range dem-
ographic projections, a better understanding of
pathogenesis, a refined approach to research and
development of vaccines and therapeutic agents, a
refocus of prevention and control efforts, and the
incorporation of patient care issues.
The Public Health Service (PHS) convened a
meeting at the Coolfont Conference Center in
Berkeley Springs, WV, June 4-6, 1986. Eighty-five
experts in various aspects of AIDS, including
clinicians, epidemiologists, public health policy
makers, and basic research scientists were invited
to review and modify the plan according to current
information, needs, and demographic projections
through 1991. The following plan is the result of
that meeting; it represents a renewed commitment
by the Public Health Service to prevent and
control AIDS infection and its sequelae.
Donald Ian Macdonald, MD
Acting Assistant Secretary for Health
Purpose
This document provides a framework for the
steps that must be taken in five broad areas-
pathogenesis and clinical manifestations, therapeu-
tics, vaccines, public health control measures, and
patient care and health care needs-to achieve
prevention and control of AIDS. The current plan
is based on estimated changes in the demographics
of AIDS through 1991. It calls for concerted
action by Federal agencies, State and local health
departments, professional organizations, and vol-
unteer groups.
Goals
The following goals were first published in the
1985 plan and remain valid for guiding the
continuing national effort.
· By 1987, reduce the transmission of the HTLV-
III/LAV infection.
· By 1990, reduce the increase in the incidence of
AIDS.
· By 2000, eliminate transmission of HTLV-
III/LAV infection with a decline in the incidence
of AIDS thereafter.
Background
Five years have elapsed since the initial report of
Pneumocystis carinii pneumonia from Los Angeles
marked the recognition of what has become known
as AIDS. By 1984, a human retrovirus, HTLV-
III/LAV (human T-cell lymphotropic virus type
III/lymphadenopathy-associated virus) had been
determined to be the etiologic agent of AIDS. (The
International Committee on the Taxonomy of
Viruses proposed the name "human immunodefici-
ency virus" for these viruses (2).) By early 1985,
serologic tests for antibody to the virus were
licensed and widely available.
In retrospect, when AIDS was initially reported
in June 1981, some 5 years already had elapsed
since the introduction of HTLV-III/LAV into the
United States, and 3 years had elapsed since the
first clinical cases had occurred. AIDS cases have
been reported from all 50 States, the District of
Columbia, and 4 Territories. Cases have been
reported from more than 100 foreign countries.
The rapid development and implementation of
sensitive and specific assays for HTLV-lII/LAV
antibodies have permitted screening of donated
blood and plasma, and the research use of these
SOURCE: Public Health Reports 101 (July-August 1986):341-348.
326
OCR for page 327
APPENDIX G 327
'During 1991 alone, more than
145,000 cases of AIDS will require
medical care and more than 54,000
AIDS patients are predicted to die,
bringing the cumulative number of
deaths due to AIDS to more than
179,000. '
and other assays has elucidated the modes of
transmission, the natural history of infection, and
a bette- understanding of the clinical manifesta-
tions of HTLV-III/LAV infections.
The predominant defect in AIDS is a profound
and, so far, irreversible immune dysfunction that
results when HTLV-III/LAV preferentially infects
the helper-inducer subset of T-lymphocytes. Al-
though the virus can also infect other cells of the
immune system, as well as cells of the central
nervous system, it is the infection of these T-
lymphocytes that ultimately le. ds to a breakdown
in the ability of an infected individual to mount an
immune response. In the past 5 years, more
effective therapies for some of the opportunistic
infections that accompany AIDS have been found,
but no cure for AIDS is yet available.
Studies of the molecular biology of HTLV-
III/LAV have revealed that a copy of the viral
genetic material becomes an integral and perma-
nent component of the DNA of an infected
individual. As a result, such an individual is likely
to be a carrier of the virus for the rest of his or
her life and, for purposes of public health control,
is assumed to be capable of transmitting the virus
to others.
The HTLV-III/LAV genome has been com-
pletely sequenced and the functions of several of
its genes are known. Considerable differences in
some genes have been found among various iso-
lates. In addition, related viruses have been identi-
fied in man and nonhuman primates. These related
viruses cause a range of different diseases. Studies
in animals indicate the feasibility of vaccination
against retroviruses, and one veterinary vaccine is
available for the prevention of feline leukemia
virus. Although some promising approaches are
under way, as yet no effective vaccine for AIDS
exists.
HTLV-III/LAV is transmitted by sexual,
parenteral, and perinatal contact with the virus.
Although this infection has been most often
recognized in homosexual men and intravenous
(IV) drug abusers, it is clear that this virus does
not discriminate by sex, age, race, ethnic group, or
sexual orientation. Behaviors which are high risk
for the acquisition of HTLV-III/LAV infection
include sexual contact or sharing of drug injection
equipment with an infected person. Studies now
clearly demonstrate that AIDS is not spread by
casual contact, such as sneezing, coughing, or
sharing meals with an AIDS patient.
There were 21,517 cases of AIDS reported in the
United States as of June 1986. Blacks and Hispan-
ics represent 39 percent of total cases. Women
who report no history of IV drug abuse represent
half of the 1,400 cases in women. Approximately
304 cases of AIDS occurred in infants and children
under age 13. Between 2 and 3 percent of the cases
have occurred in transfusion recipients or hemo-
philiacs.
Projections
The following projections, including those in the
table, are based on the Centers for Disease
Control (CDC) surveillance data and epidemiologic
studies of populations at high risk to infection
with the virus.
· Twenty to 30 percent of the estimated 1 to 1.5
million Americans infected with HTLV-III/LAV as
of June 1986 are projected to develop AIDS by the
end of 1991. The latency period between infection
and overt AIDS averages 4 or more years in
adults; therefore, most persons who will develop
AIDS between 1986 and 1991 will be those who
are already infected with HTLV-III/LAV.
· Based on an empirical model that uses reported
cases of AIDS, by the end of 1991, the cumulative
cases of AIDS in the U.S. meeting the CDC
surveillance definition will total more than
270,000. During 1991 alone, more than 145,000
cases of AIDS will require medical care and more
than 54,000 AIDS patients are predicted to die,
bringing the cumulative number of deaths due to
AIDS to more than 179,000.
· The empirical model may underestimate by at
least 20 percent the serious morbidity and mortal-
ity attributable to AIDS, because of underreport-
ing or underascertainment of cases.
OCR for page 328
328 APPENDIX G
Projected cases of AIDS,' United States
Category 1988 1991 1991 range
Cases diagnosed
Cumulative cases at start of year 19,000 196,000 155,000 to 219,000
Diagnosed during year 16,000 74,000 46,000 to 92,000
Cumulative cases at end of year 35,000 270,000 201,000 to 311,000
Alive at start of year 10,000 71,000 50,000 to 83,000
Alive at any time during year 26,000 145,000 96,000 to 174,000
Deaths
Cumulative deaths at start of year 9,000 125,000 105,000 to 137,000
Deaths during year 9,000 54,000 36,000 to 64,000
Cumulative deaths at end of year 18,000 179,000 141,000 to 201,000
Infections
Persons with HTLV-111/LAV infection . . .
...................... 1 million
1.5 million
(estimate)
'These numbers refer only to those cases that meet the CDC definition for
AIDS (see Morbidity end Mortality Weekly Report 34:37~375, June 28, 1985) and
· In 1985, 9,000 cases of AIDS were diagnosed in
the United States and reported to the Centers for
Disease Control. The empirical model predicts that
cases will continue to increase through 1991, that
there will be nearly 16,000 cases reported in 1986,
and that more than 74,000 cases are projected for
1991. The estimates for 1991 range from 46,000 to
90,000.
· More than 70 percent of the cases will be
diagnosed among homosexual or bisexual men,
and 25 percent of the cases will occur among IV
drug abusers with some overlap to continue be-
tween the groups. Because the periods between
infection and disease are long and variable, cases
will continue to be reported among transfusion
recipients and persons with hemophilia.
· Additional cases in heterosexual men and
women are projected; the 1,100 (7 percent of the
total) for 1986 will increase to nearly 7,000 (more
than 9 percent) by 1991. This group includes
patients who reported heterosexual contact with an
infected person or someone in a risk group. It also
includes patients in groups in which epidemiologic
studies suggest heterosexual transmission as the
major risk factor. By 1991, more than 3,000 cases
will have been diagnosed in infants and children.
· Through 1985, fewer than 60 percent of cases
were diagnosed in persons outside New York City
and San Francisco, but by 1991 more than 80
percent of cases are predicted to be reported from
other localities.
· Homosexual-bisexual men and men and women
who use drugs of abuse intravenously will continue
to be the populations at highest risk for HTLV
do not include other manifestations of infection, such as AIDS-reliated complex
and lymphadenopathy syndrome.
III/LAY infection during the next 5 years. Using
estimates published by Kinsey (3), more than 2.5
million (4 percent) of U.S. men between 16 and 55
years of age are exclusively homosexual through-
out their lives; an estimated 5-lO million more will
have some homosexual contact. An estimated
750,000 Americans inject heroin or other drugs
intravenously at least once a week; a similar
number inject drugs less often.
· The prevalence of HTLV-III/LAV seropositivity
among homosexual men and IV drug users paral-
lels the frequency of AIDS in various cities. In
1984-85, 20 to 50 percent of homosexual men who
participated in research studies had evidence of
HTLV-III/LAV infection. Similarly, seropreval-
ence estimates among IV drug abusers ranged from
10 percent to more than 50 percent in various U.S.
cities. By extrapolating all available data, we
estimate that there are approximately 1 to 1.5
million infected persons in those groups at present.
Thus estimates of a 20 to 30 percent progression to
AIDS by 1991 in this group are consistent with the
total number of AIDS cases predicted by the
empirical model.
· Uninfected homosexual men have continued to
acquire HTLV-III/LAV infections during the past
year, but at a lower rate than would be predicted
from the increases in previous years and from the
increase in the number of potentially infectious
persons. This observation is consistent with
changes reported in sexual behavior and declines in
other sexually transmitted infections in homosexual
men. Nonetheless, due to the large present and
future populations at risk, hundreds of thousands
OCR for page 329
APPENDIX G 329
of additional homosexual men, IV drug abusers,
and others may become infected during the next 5
years.
· Because of heat and chemical treatment of
clotting factor concentrates. donor deferral. and
serologic screening of donated blood and plasma,
only a very small number of additional infections
are likely to occur through blood and plasma
transfusions.
· Current information is insufficient to predict the
future incidence of HTLV-III/LAV infection in
heterosexual populations, but increases in hetero-
sexual transmission are likely. Those at highest risk
will be heterosexual sexual partners of infected
persons and those who have sexual contact with
past or present IV drug abusers, bisexual men,
prostitutes, or others at increased risk for HTLV-
III/LAV infection. As is true for homosexual men,
sexual contact with multiple partners will increase
one's risk for HTLV-III/LAV infection.
· Additional increases in HTLV-III/LAV infection
in infants are expected as more women in child-.
bearing years become infected.
The following five sections summarize the delib-
erations and recommendations made by the work
groups at the Coolfont meeting.
Pathogenesis and Clinical Manifestations
Infection with HTLV-III/LAV results in a broad
range of clinical manifestations including an acute
retroviral syndrome, asymptomatic disease, chronic
lymphadenopathy, and serious diseases including
Kaposi's sarcoma and other malignant neoplasms,
fatal opportunistic infections, and neurological and
psychiatric disorders.
The factors that determine the expression and
progression of disease in an individual are largely
unknown. Techniques are available to diagnose
and treat many of these opportunistic diseases,
although they often recur. However, once Kaposi's
sarcoma or certain opportunistic infections occur,
an ultimately fatal outcome for the patient has
been the rule.
· Clinical and epidemiologic studies need to be
conducted to
- Clarify the natural history of infection, includ-
ing the role which may be played by exogenous or
endogenous factors in determining which clinical
manifestations occur, and
-Continue to expand the spectrum of clinical
manifestations.
· Basic scientific studies on the virology and
immunopathogenesis of HTLV-III/LAV need to
be expanded, especially to
-Assess target cell susceptibility;
- Identify viral and host cell determinants of
transmissibility and pathogenicity including portals
of viral entry, mechanisms of cytopathic effects,
and dysfunction;
- Further elucidate mechanisms of viral latency
and activation;
- identify and assess direct and indirect im-
munopathogenic mechanisms;
- Further delineate the pathogenesis of neurologic
and psychiatric abnormalities; and
-Ascertain more fully the functions of viral gene
products and determine the meaning and mecha-
nisms of genetic heterogeneity.
More suitable animal models for HTLV-
III/LAV infection need to be developed to allow
more comprehensive understanding of pathogenesis
and rapid evaluation of treatment and prophylaxis.
Dedicated efforts must be made to maximize
efficiency of use of limited animal resources.
Improved methodologies are needed to detect
infected and infectious individuals and to identify
and quantitate virus, viral antigen, and viral
antibody.
Therapeutics
No drug with proven clinical efficacy for AIDS
is currently l`.nown. Both antiviral agents and
immunomodulators are being developed, and sev-
eral drugs are under clinical investigation at
present. The ability of an agent to reverse the
disease process or halt its progression may vary
depending upon the stage of infection. Research is
now in progress to develop new methods to inhibit
viral replication and correct the immune deficien-
cies. A safe and effective antiviral agent is not
likely to be in general use for the next several
years. Experimental products are also under study
for treatment of opportunistic infections and neo-
plasms associated with HTLV-III/LAV infection.
The following points should be considered in
OCR for page 330
330 APPENDIX G
order to develop drugs for the treatment of AIDS
in the most expeditious manner:
· Further expansion of the multiinstitutional,
multidisciplinary approach to identify and develop
agents for the treatment and prevention of
HTLV-III/LAV infection and associated diseases,
including central nervous system disease, is neces-
sary. Part of this effort must be the establishment
of a large capacity screening program to measure
the antiviral and immunomodulator activity and
toxic effects of newly identified natural and syn-
thetic compounds.
· A system for classifying HTLV-III/LAV asso-
ciated disease manifestations which is useful in the
design, implementation, and analyses of therapeu-
tic trials must be developed. Standard clinical
criteria for the measurement of efficacy and
toxicity must be formulated to facilitate the perfor-
mance of well organized multicenter clinical trials.
· The most efficient design of clinical trials of
candidate antiviral agents will require the use of
placebo controls. Once an agent has been shown
to be safe and efficacious in a clinical trial, this
agent can generally be substituted for the placebo
control in subsequent clinical trials and can be
used as the standard against which other agents
are compared.
· New therapeutic approaches must be devel-
oped to control or eliminate latent virus and to
specifically direct antiviral compounds to the ap-
propriate target tissues. Combination strategies to
control viral replication and restore the immune
system must be developed and evaluated.
· Since antiviral drugs currently under develop-
ment are likely to repress rather than eliminate the
AIDS virus infection, long-term therapy is ex-
pected and with it the emergence of drug-resistant
.
strains.
· New and existing strategies in the diagnosis,
treatment, and prophylaxis of the opportunistic
infections and neoplasms associated with AIDS all
need to be developed, tested, and improved.
Vaccines
A number of vaccine candidates for human
beings are currently under development, and lim-
ited clinical testing for some could begin within 2
years. Field trials to demonstrate efficacy may
require additional years. Vaccines are not antici-
pated to be useful in individuals who are already
infected. A vaccine for general use is not antici-
pated before the next decade, and its use would
'In the absence of a vaccine and
therapy, prevention and control of
HTL V-III/LA V infection depends
largely upon effective approaches to
decrease sexual transmission,
transmission among I V drug users,
and perinatal transmission from
infected mothers.'
not affect the number of persons infected by that
time.
The following steps need to be taken:
· Vaccines employing recombinant DNA derived
. .
antigens, virus subunits, killed viruses, synthetic
peptides, live recombinant or attenuated viruses,
and antiidiotypes will need to be evaluated as
potential candidates for human trials.
· Vaccination methods will need to be devised
to induce immunity to antigenically distinct strains
of HTLV-III/LAV.
· Reliable in vitro and in vivo systems need to
be developed for the evaluation of vaccine im-
munogenicity safety and efficacy before commenc-
ing human trials.
· A program for clinical and field evaluation of
vaccine(s) needs to be established, including resolu-
tion of difficult aspects of design such as identifi
cat~on of target populations and the del~mition ot~
parameters of vaccine efficacy.
· Protocols need to be developed for the in
vitro and in vivo evaluation of anti-HTLV-
III/LAV immunoglobulin to explore its value in
passive Immunization.
Public Health Control Measures
In the absence of a vaccine and therapy,
prevention and control of HTLV-III/LAV infec-
tion depends largely upon effective approaches to
decrease sexual transmission, transmission among
IV drug users, and perinatal transmission from
infected mothers. A strategy to control and pre-
vent AIDS should involve voluntary counseling
and testing for persons at increased risk of
HTLV-III/LAV infection and imparting to in-
fected patients those Public Health Service recom
OCR for page 331
APPENDIX G 331
mendations concerning personal behaviors that
must be observed if spread of the virus is to be
halted. Throughout this section, serological testing
is intended to be voluntary, conducted with confi-
dentiality, and accompanied by appropriate pretest
and post-test counseling.
Public health activities directed toward the con-
trol and prevention of AIDS have required signifi-
cant funding and staffing at national, State, and
local levels. The projected increases in AIDS and
HTLV-III/LAV infection over the next 5 years
will pose substantial continuing demands for re-
sources for these efforts.
The recommendations of the conference partici-
pants concerning public health measures focused
on five areas.
1. Information base.
· Information is needed to better determine the
size of the population at greatest risk in the United
States, particularly the numbers of homosexual
men, bisexual men, IV drug abusers, and hetero-
sexuals who have multiple partners.
· Better information is needed on the number of
persons infected with HTLV-III/LAV. Extensive
and repeated seroepidemiologic surveys are needed
~ determine the incidence and prevalence or
. . ~
infection by age, race, ethn~clty, sex, geographic
area, and sexual preference. States should be
encouraged to obtain and report data on incidence
and prevalence to CDC for publication.
· The Public Health Service should encourage
and assist in the evaluation and comparison of all
interventions for prevention and control of AIDS
and HTLV-III/LAV infection.
· PHS should continue to support key epidemi-
ologic studies.
· The United States should continue to play a
role in understanding and assisting efforts to
control the disease worldwide, particularly in areas
with seemingly different epidemiologic patterns.
2. Information and education. National infor-
mation and education campaigns on AIDS and
HTLV-III/LAV infection should be targeted to
individuals and groups whose behavior places them
at high risk for AIDS, other sexually active adults,
adolescents, preadolescents, and health care pro
. . ~ · ~ .
viders. A major target or mass mrormat~on
_
education programs is the currently umnIectea
population, to assure that those persons know how
to protect themselves. An additional purpose is to
persuade infected persons to take appropriate steps
to safeguard their own health and to avoid
infecting others.
· PHS should explore the advantages of using
paid radio, TV, and printed media advertising as
well as public service announcements to inform the
public on AIDS and HTLV-III/LAV infection.
· PHS, State and local health departments,
State and local boards of education. colleges.
universities, and other organizations should sup-
port and encourage comprehensive health educa-
tion that includes information about AIDS and
HTLV-III/LAV infection.
· With the assistance of appropriate organiza-
tions, programs should be implemented to provide
culturally sensitive, meaningful information and
education to blacks and Hispanics, including ho-
mosexuals, IV drug abusers, blood donors, women
both at risk; themselves and also at risk for
transmitting infection perinatally, and to other
segments of the public.
· Health care providers need current informa
tion and training on the diagnosis, psychosocial
counseling, and management of HTLV-III/LAV
infected persons.
3 Prevention of IV drug abuse transmission. IV
,' ~
drug abusers serve as the major reservoir for
transmission ot mtectlon to heterosexual adults
and their infants. as well as among themselves. As
a group, they are not well organized, often poorly
educated, and tend to have less interaction with
the health care delivery system than other groups
who participate in high-risk behaviors. Efforts to
change drug abuse behavior must proceed with the
understanding that addictive behavior is not often
changed without specific drug treatment.
· A systematically increased capacity for treat-
ing IV drug abusers is needed. Until adequate
capacity is available, persons in need of treatment
should be prioritized. Decisions may vary by
locality, but highest priority should be given to
those presently on waiting lists for treatment.
· All treatment and prevention approaches
should include information and counseling on
sexual and perinatal transmission of HTLV-
III/LAV, availability of family planning services,
and availability of voluntary serological testing for
HTLV-III/LAV.
· Until treatment capacity is adequate for per-
sons who continue to abuse IV drugs, studies are
needed to evaluate the efficacy and feasibility of
promoting safer use of drug paraphernalia (for
example, increased availability of sterile needles or
OCR for page 332
332 APPENDIX G
"works") and education regarding use of sterile
needles and sharing of needles.
4. Prevention of sexual transmission. Sexual
contact will remain the primary mode of
HTLV-III/LAV infection for the foreseeable fu-
ture, with greater increase in the proportion of
heterosexual transmission over the next 5 years.
A central goal of local disease control programs
should be to reach the greatest number of
HTLV-III/LAV infected persons with testing and
counseling (provision of pretest and post-test infor-
mation, including psychological support) about
their infections and methods to reduce the likeli-
hood of transmission to others, in order to change
high-risk sexual behaviors. At present, only a small
proportion of the already infected population has
been reached.
Several methods may help achieve this goal,
although they may have differing efficacies in
various settings and populations. These include
encouragement of voluntary serological screening,
self referral of sexual and drug abuse contacts,
notification and counseling of contacts by health
authorities, and targeted educational programs.
· Serological testing of persons whose behavior
places them at risk should be encouraged and
made widely available. In all communities, appro-
priate medical care encompasses offering counsel-
ing and testing to all persons at risk, including
persons with a sexually transmitted disease, IV
drug abusers, and persons seen in private practice
who engage in high-risk behaviors. (Anonymous
testing should be available as an option.)
· Self-referral of an infected person's sexual and
needle-sharing contacts should be encouraged. In
some areas or populations, additional contact
notification activities may be offered to infected
persons by the health agency.
· Research is needed on the efficacy of counsel-
ing or knowledge of personal serological status or
both in modifying sexual and needle-sharing
behavior to reduce or eliminate the risk of trans
mission.
· For persons who know that they are infected
with HTLV-III/LAV yet continue to practice
high-risk sexual or needle-sharing activities, tempo-
rarv invc)luntarv isolation shc)uld he considered an
option only In rare Instances and alter due
process. Enforced isolation is not a practical way
to minimize spread of the infection, since infected
persons probably remain infectious for life. Educa-
tion, counseling, and social services-including
'PHS estimates that the direct health
care costs of persons with AIDS will
be between $8 arid $16 billion in 1991.
The $8 billion figure is based on the
projection of 71,000AIDS patient*
alive in 1991 and 74,000 new cases by
then. '
drug treatment-are the main interventions for
dealing with this problem and are appropriately
applied to recalcitrant infected persons and their
potential consenting partners. Uninfected persons
must avoid behavior which would permit infection
from persons who know or do not know they are
infected.
5. Prevention of transmissibility by blood and
blood products. The risk of transmission of
HTLV-III/LAV by transfusion of blood and
blood products is extremely low, due to deferral of
high-risk donors, serological screening of donated
blood and plasma, and the heat and chemical
treatment of clotting factor concentrates. Nonethe-
less, some additional measures are appropriate to
further reduce this low risk.
· Increase the effectiveness of deferral by all
persons at increased risk of HTLV-III/LAV infec-
tion by:
-Collecting demographic and other data from
donors found to have confirmed HTLV-III anti-
body. This will require some type of case reporting
and subsequent interviews, but it is essential to the
continued evolution of the high-risk donor deferral
strategy;
-Improving communications to potential do-
nors about self-deferral, taking into consideration
their language skills and literacy;
-Exploring the usefulness of providing means
at the time of donation for blood donors, who do
not self-exclude but who have remaining doubts
about their suitability, to designate that their
donated unit not be used for transfusion;
-Implementing the use of a signed donor
consent form in all blood banks that clearly
indicates the absence of specific risk factors for
transmission of infections;
· Continue to require that blood and plasma
establishments maintain deferral lists of donors
who have repeatedly reactive ELISA tests.
OCR for page 333
APPENDIX G 333
· Continue to encourage development and use
of more sensitive serologic tests for HTLV-
III/LAV infection.
· Recommend that current recommendations for
HTLV-III antibody testing for donors of organs,
tissues, cells, and semen be made mandatory
· Encourage increased activities to eliminate
unnecessary transfusions.
Patient Care and Health Care Needs
Over the period 1986 to 1991, AIDS and
associated conditions will place an increasing bur-
den on the health care delivery system through an
increased number of patients and increased aggre-
gate costs of care. The burden will be shared by a
larger number of communities, including some
which will have a less complete capacity for
response. There will be increasing fragmentation
and less health care control of services provided if
more nonmedical, less traditional, and some uneth-
ical providers become involved.
PHS estimates that the direct health care costs
of persons with AIDS will be between $8 and $16
billion in 1991. (The $8 billion figure is based on
the projection of 71,000 AIDS patients alive in
1991 and 74,000 new cases by then. An additional
29,000 cases was added to account for the 20
percent underreporting or underascertainment of
cases. The cost for treating a patient with AIDS
used in the calculation was $46,000. For the higher
range, the $8 billion figure was doubled.) These
sums represents 1.2 to 2.4 percent of the expected
total U.S. personal health care expenditures in
1991 of about $650 billion. Because people with
AIDS are concentrated in certain urban centers,
however, these costs will be disproportionately
borne.
These estimates may be conservative by 10 to 50
percent because of the increased need fo. care for
the large population of patients with the other
conditions associated with HTLV-III/LAV infec-
tion and the significant nonmedical care costs
necessary for management of these illnesses. Devel-
opment of community-based health and social
services support systems can reduce costs and
enhance care during this 5-year period.
To improve care for AIDS patients, all sectors
of the health care delivery system should work
together to
· Develop a coordinated Federal, State, and
local response to manage the health services and
health financing crisis posed by the escalating
AIDS epidemic. This response must reflect the
pluralistic character of the American health care
system and must involve the coordinated participa-
tion of the public, private, and voluntary sectors,
as well as ambulatory, in-hospital, and long-term
care providers;
· Explore the feasibility and need for convening
a national, blue-ribbon commission representing
the necessary constituencies to canvass needs and
resources available and to make recommendations
regarding how each sector of our society can help
to fill financing and resource needs;
· Emphasize the needs of institutional and
community-based providers for training, continu-
ing education, and psychosocial support;
· Upon request, assist State and local govern-
ments and community-based organizations to as-
sess, develop, and implement comprehensive
service delivery systems of care for AIDS patients
in a cost-effective manner;
· Develop organized consortia of service deliv-
ery systems responsive to the care of AIDS
patients; such consortia should include all the
necessary components of care (that is, ambulatory,
hospital, mental health, and dental health services,
counseling, home health care, and hospice care.)
· Explore efforts to set up regionalized consor-
tia of services for AIDS patients;
· Utilize studies of the special health services
needs and barriers to prevention of HTLV-
III/LAV infection in blacks and Hispanics, and
best methods of information dissemination to
foster inclusion of culturally sensitive service deliv-
ery for children with AIDS, IV drugs abusers,
hemophiliacs, and minorities in all appropriate
metropolitan areas;
· Initiate demonstrations of the appropriate care
needed at different stages of the illness, costs of
services, and most cost effective provisions of
needed services, including Model Medical Waiver
programs; and
· Support health services research on AIDS that
emphasizes cost of services for different risk
groups, stages of illness, and treatment modalities
and assesses potential improvement of methods
and increased cost-effectiveness of care.
References ~
1. Public Hcallh Service plan for the prevĒnlion and control
of acquired immune deficiency syndrome (AIDS). Public
Health Rep 100: 453-455, September-October 1985.
2. Coffin, J., et al.: Human immunodeficiency viruses. [Let-
ter]. Science 232: 697, May 9, 1986.
3. Kinsey, A. C., Pomeroy, W. B., and Martin, C.
E.: Sexual behavior in the human male. W. B. Saunders,
Philadelphia, 1948.
Representative terms from entire chapter:
infected persons
