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Comments on the AIDS Pandemic
[Background information for the diver regarding AIDS]

Reflecting back on our experiences with AIDS during the past 15 years, there are many lessons to be learned.  In some respects the experience has been analogous to the spin-off from the U.S. space effort, mobilizing dormant federal agencies to encourage advances in clinical, therapeutic, social and viral research which would not have occurred otherwise.  In other respects it has been a public health disaster, allowing one of the world's most devastating epidemics to get out of hand.

Any chance to control AIDS when the first case was reported in 1981 was lost when our public health service was taken by surprise, having no idea what was causing the disease complex destroying the immune systems of otherwise healthy young men thereby allowing opportunistic infections and cancers.  When the virus causing the illness was identified two years later as a retrovirus, too late for basic public health control, the highly contagious, fatal illness had been allowed to proceed unchecked.  Now a pandemic, it affects some 8-10 million adults, 1 million children and the World Health Organization estimates that it may reach 40 million people by the year 2000.

How could this have happened in an era with such a strong history of successful epidemiological control of major diseases?  Some feel that we had the ability to contain this disease from the outset but failed to do so because of definitions of the disease applied by the CDC.  Even after it was identified as a retrovirus and named "human immune virus", a patient had to have certain opportunistic infections before a diagnosis of AIDS could be made.  It was not until 1992 that the CDC expanded it's definition of AIDS to include those people with a CD4 cell count below 200, dramatically increasing the number of people who could be treated for AIDS by about 40 percent.

Even after the cause AIDS was determined no widespread control measures were instituted.  These control measures have had a long history of success, stopping such diseases as yellow fever, small pox, cholera, tuberculosis, polio and controlling the sexually transmitted diseases,, syphilis and gonorrhea.  Using good public health measures, some of these illnesses were controlled even before their causes were known.  Why were health agencies loathe to apply appropriate measures to stem an epidemic that can only be described as a 20th century plague?

A thoughtful person might feel that the underlying cause of this omission was complacency brought on by an era of antibiotics, vaccines and immune sera.  Possibly thinking that this was just another ordinary virus, they might have felt that they could rely on our pharmaceutical industry for a "magic bullet’ cure. on the other hand, quarantine was unthinkable, if not impossible, because of the population initially involved.  Initially a disease of the gay community, accounting for over half of the AIDS cases in 1990, significant lobbying pressure from this extremely well organized and vocal group prevented adequate case control and contact follow-up.  Institution of appropriate blood testing was not allowed in the schools and workplace because of the fear of discrimination.
Fear of discrimination resulting from a positive HIV test has until recently blocked testing of emergency room and other hospital patients.  Without a written informed consent to do the testing, hospital administrators have been reluctant to do routine testing for the AIDS virus.  Because of this lack, hospital personnel have been exposed to grave danger from having to operate upon and treat patients of unknown HIV status.  The same has been true of donor testing of blood with untested, tainted blood causing many cases of AIDS in the early years of the epidemic.  Tragic HIV infections have occurred in professional personnel because of this "politically correct" lack of information.

A whole new cottage industry has been developed in the process of dealing with this new disease.  In the operating room, new techniques have been developed to protect the surgeon and other personnel.  Impervious masks and shields, disposable gowns, and needle proof gloves have been developed.  In unprecedented action, possibly responding to pressure from activist groups, the FDA has speeded up it's review process of approving drugs possibly effective against the HIV viral agent and infections brought on by a weakened immune system.  Important drugs have been released which can delay the onset of AIDS in the HIV positive patient.  Other "spin-off" drugs, have been developed which are effective against complicating infections associated with AIDS; cytomegalovirus, pneumocystis, Kaposi’s sarcoma, major fungal infections, and severe anemia.
Recent efforts directed toward prevention of this mostly sex- transmitted disease have been admirable.  Intensive educational programs have been directed toward the young and sexually active, flooding them with information about "safe sex", condom use and abstinence.  Needle exchange programs have been successful to a degree in reducing the addicts exposure to HIV.  Extensive lobbying by surgeon's and hospital groups has gradually relieved some of the restrictions on widespread HIV testing.  However, because of the social and economic ramifications of a positive HIV test, little has been done in the area of broad-based testing of the populace.

Most researchers and clinicians feel that the best hope for control of the AIDS pandemic is a vaccine.  Several animal studies with vaccines may show theoretical promise in humans.  A preventive vaccine would be the ultimate goal, but a post-exposure shot might be helpful in boosting the immune response in the already infected individual.  Factors blocking the development of a good vaccine are associated with the variability of the virus from one patient to another (similar to the common cold), and the lack of a good animal model for study, (the chimpanzee gets the HIV virus but doesn't get AIDS).

Until an effective treatment is found AIDS patients can only continue to derive benefit from treatment of associated infections and to enlist help from family, friends, counselors and support groups.  Recently described "natural immunity" in multiply-infected West African prostitutes may be a clue as to a way to eventually stop the spread of the disease.  If this doesn't happen, one has visions of the human race evolving through a process of "natural selection" from those of us who are either monogamous or asexual -hopefully the former, if our race is to continue as the dominant animal on this planet.

Originally published in ‘Alabama Medicine’

HIV and Occupational Hazards:
What You Need to Know
From issue No. 242 (November, 1997 Special Edition) of Medical Sciences Bulletin
 Issue 242 Contents 

Since the discovery of AIDS in the early '80s, a great deal of progress has been made in our understanding of the transmission and prevention of HIV. Treatment options as well as educational measures have increased. Even though there is no cure for the disease, we are better able to control it than ever before.
There are many ways that someone can be exposed to the HIV virus. Of all the modes of transmission, perhaps, the most disheartening is through an occupation-associated event. The risk of contracting HIV while caring for an HIV-positive individual may make healthcare professionals self conscientious and compromise the level of care that they are able to provide.

To those who work in health care, occupational exposure to HIV and subsequent infection may be a continuous risk. But what is the extent of this risk? What factors determine its severity? And how can healthcare workers avoid or minimize accidental HIV infection? These are compelling public health questions researchers have tried to answer in a recently published study.
See Health Care Workers Exposed to Specific Occupational Factors are at Higher Risk for Developing HIV

The risk of HIV infection following percutaneous exposure is about 0.3%. The risk of contracting HIV infection following mucous exposure or exposure due to broken skin is estimated to be 0.09%. The risk of contracting HIV from dialysis patients is so low as to be almost unmeasurable. A health professional, caring for a dialysis individual, is at greater risk of contracting hepatitis B or C than HIV.

Perhaps the most common work-related injury that can place an individual at risk involves needle sticks. This injury accounts for about 33% of all work-related injuries and usually occurs while recapping the needle or because of careless needle disposal measures. In a study conducted by Ippolito and colleagues, it was determined that hollow-bore needles, disposable syringes, and hypodermic needles accounted for 59% of the injuries and winged steel needles accounted for 33% of the injuries. Of all these devices, disposable syringes had the lowest risk, while intravenous catheters had the highest risk. Through proper education and following good exposure guidelines, these injuries, as well as the risk for contracting the HIV virus can be easily eliminated.

There are many measures that can be taken to decrease the risk of contracting HIV at the workplace. Precautionary measures and careful technique can save many healthcare professionals from having long, sleepless nights. The fight against reducing the risk of HIV transmission through needles starts at home. Every individual that is involved with the care of an HIV-positive patient must practice universal precautions for the use and disposal of infectious materials.

Despite these measures, it is impossible to eliminate all accidents. For this reason, it is imperative to have a plan for those who are exposed. The Centers for Disease Control and Prevention (CDC) has made recommendations for post-exposure prophylaxis.

The safety of all healthcare professionals that are involved with HIV-positive patients is of great concern. Proper education, precautionary measures and careful technique can make the difference between accidental exposure and a safe work experience. In addition, a protocol for the steps that must be taken following exposure must be established. Hopefully these measures will place an individuals mind at ease and make them less likely to compromise the care of an HIV-positive patient because of fear of contracting HIV.

Ippolito G, De Carli G, Puro V, et al. Device-specific risk of needlestick injury in italian health care workers. JAMA 1994;272(8):607-10.

Thurn JR. HIV and occupational risk. Postgraduate Med. 1997;102(4):155-61.

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 Ernest S Campbell, MD, FACS

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