207
HIV EPIDEMIC* WILLIAM ROPER, M.D. Director U.S. Centers for Disease Control
Atlanta, Georgia
I am honored to be here today to help commemorate the contributions of Dr. David Axelrod, whose absence from public health we all feel so keenly. Under Dr. Axelrod, the State of New York Department of Health has provided extraordinary leadership during the first decade of the HIV epidemic in many areas, including research, surveillance, and prevention, as well as health care and other services. Leaders with courage and compassion like Dr. Axelrod are sorely neededand often sorely tried-by this epidemic of HIV infection. As we mark the 10th anniversary this year of the first published report of what we now know was AIDS, we recognize that the toll of AIDS will continue to challenge the best efforts of those of us in public health for perhaps decades to come. The number of AIDS cases and deaths increases each year, from 133 deaths in 1981, to more than 26,000 deaths in 1990-a 195-fold increase in deaths in less than a decade. And New York has borne a very large share of this loss. In 1981, exactly half of the nation's reported AIDS deaths-67-were residents of New York. Last year, New York AIDS deaths totalled nearly 5,000, almost one-fifth of the nation's total for 1990 of 26,000 deaths. According to our projections, the cumulative number of deaths from AIDS in the United States may exceed 300,000 by the end of 1993. CDC estimates that approximately 1 million people are currently infected with HIV in this country alone, which represents approximately 1 in 100 adult males and 1 in 600 adult females. In 1989 AIDS was the second leading cause of death among U.S. men 2544 years of age, causing 14 percent of all deaths among men in this age group-surpassing heart disease, cancer, suicide, and homicide-in fact, all causes except unintentional injuries. For men in these prime years of life in New York City, AIDS is the leading cause of death. Presented as part of a symposium, Dr. David Axelrod and the Health of the Public: Looking Ahead, cosponsored by the New York State Department of Health, the New York Academy of Medicine, and the Josiah Macy, Jr. Foundation October 23, 1991. *
Vol. 68, No. 2, March-April 1992
208
208
W. L. ROPER
In 1991, based on current trends, AIDS will likely be among the top five leading causes of death for women aged 15-44. For black women 15-44 years of age in New Jersey and New York, AIDS has been the leading cause of death for several years. The high incidence of AIDS among young people indicates that many of these individuals became infected as teenagers. Adolescents are increasingly vulnerable-surveys indicate that the majority of teenagers in the United States have engaged in sexual intercourse, with the average age of first sexual experience among U.S. adolescents being 16. In 1989 21 percent of high school students said they had already engaged in sex with four or more partners. Keep in mind that this survey was conducted among high school students, and the data do not reflect information on those outside the school system, who might be considered to be at even higher risk. CDC data indicate that 50 percent of U.S. adolescent females who were diagnosed with AIDS in 1990 contracted the virus through heterosexual contact. Moreover, recent serosurveillance data indicate that HIV infection is equally prevalent among young women and men between the ages of 16 and 22 who apply to the Job Corps program. I find all of these statistics alarming, as I know you do. Those of you in New York have been painfully aware of these numbers and trends. We owe much to Dr. Axelrod's foresight early in the epidemic in identifying just what the important issues concerning AIDS were. New York State was an early leader in implementing seroprevalence studies in various population groups, including anonymous testing of newborns for HIV antibody. This latter study, originally developed in Massachusetts to determine the seroprevalence of HIV among childbearing women, has measured the HIV antibody status of infants in more than 1 million consecutive births in New York State since 1987. Based on information from these surveys as well as other sources, prevention programs based on the testing and counseling of women of reproductive age were launched in New York State. Shortly thereafter, these epidemiological surveys were expanded to monitor the seroprevalence of HIV among childbearing women nationwide. The survey, begun in most states between 1988 and 1989, provides data on more than 2 million women per year. These data are important in developing, targeting, and evaluating education and prevention programs for women and infants at risk of HIV infection. New York State also has been a leader in other prevention efforts. By successfully combining federal and state resources allocated for HIV and Bull. N.Y. Acad. Med.
SYMPOSIUM
SYMPOSIUM
209
AIDS, the New York State AIDS Institute supports 14 community health centers which provide HIV care and prevention services to HIV-infected patients. And through the development of a strong cooperative relationship between the Division of Substance Abuse Services and the AIDS Institute, HIV counseling, testing, referral, and partner notification services have been implemented in 14 drug treatment facilities statewide. New York has initiated a number of innovative features of the Medicaid reimbursement program as it relates to AIDS, but I'll leave that discussion to my colleague Nancy Gary, of HCFA. I will mention, however, that these measures have helped provide an incentive for individuals to seek earlier testing and, in doing so, to increase opportunities for early treatment. I have discussed some of the areas in which New York has taken a lead in shaping national policy; I would like now to take a few minutes to talk with you about one of the most controversial AIDS issues facing us today-and one I think many of you are concerned about. On July 12 of this year, new CDC guidelines were released on preventing HIV and HBV transmission to patients during invasive medical and dental procedures. Questions are being raised concerning these guidelines. These concerns are advanced by individuals and groups whose full understanding and collaboration are essential to protecting public health. I think it would be useful to briefly summarize the key points of our
guidelines: * The risk of transmission of HIV and HBV infection from a health care worker to a patient during exposure-prone invasive procedures is very low, but it is real. * We strongly urge all health care workers to adhere to universal precautions as a primary safeguard; however, people who perform exposureprone invasive procedures should also know their HIV and HBV status and, if infected, should discontinue these procedures unless they seek counsel from a panel of experts on whether or not they should continue. Someone who is HIV seropositive should not continue to perform these procedures without such counsel. Informed consent of the patient is important if the health care worker continues to perform these exposureprone invasive procedures. The questions being raised in connection with these public policy guidelines focus on three central issues: (1) Are the recommendations scientifically based? (2) What and how should we tell the public? (3) How do we deal with the consequences of the guidelines? Vol. 68, No. 2, March-April 1992
210
210
W. L. ROPER
First, what can be said about their scientific basis? It is scientifically established that the HIV virus which causes AIDS is a bloodborne pathogen. As such it potentially can be transmitted during any procedure which presents the possibility of accidental mingling of viruscontaminated blood between patient and practitioner. This danger is not merely hypothetical; it has demonstrably occurred in the transmission of the infection from one dentist to five patients. This was not an event that was totally unanticipated; we had indeed addressed this possibility as early as 1986 when we published recommendations for HIVinfected health care workers who perform invasive procedures. Although universal precautions are very important, they do not provide 100% protection from infections as we are reminded by the experience with hepatitis B, where infection has continued to be transmitted from surgeons to patients in certain invasive procedures. It is clear that certain procedures cannot be made totally safe, and it's not simply a problem with the worker's technique. Gloves do not prevent injuries with sharp instruments. And, of course, in the case of hepatitis B, the ultimate solution is health care workers who have been fully immunized. But, argue as we may that the risk of transmission of bloodborne pathogens is low, the risk is nonetheless real. It cannot be wished away. We have based the July 12 guidelines on the science of the transmission of bloodborne diseases, including hepatitis B. But we will continue to have an open mind and to seek your and others' input on this issue. As we gather new information, we will review these guidelines. We want to be certain that our recommendations reflect the best science available-now and in the future. We resolve to continue this process-we will have a major public meeting on November 4 to discuss exposure-prone procedures, and we invite those of you who are interested to come and help us with this important endeavor. One final point about the science of these guidelines. Lately, I've heard a number of people raise questions about the Florida dental case and espouse one or another theory for precisely how the virus was transmitted in this practice. The fact is we do not know and probably never will know the exact mechanism of HIV transmission in this dentist's office. In this instance, our past experience with hepatitis B provides a sound basis for these current guidelines. The second issue we must address is what to tell the American public about their risk of infection related to invasive procedures. In general, we are discussing this problem as a very low risk, but one that can be further reduced. Bull. N.Y. Acad. Med.
SYMPOSIUM
SYMPOSIUM
211 211
One of the criticisms of CDC and the guidelines is that we have been driven not by science, but by politics. I firmly believe that sound public health policy is a merging of the best of science and the best of public policy. In public health we don't have the luxury of making abstract, ivory-tower pronouncements. Whether in setting environmental policy, in informing parents about the risks of immunization, dealing with hazards for workers, or assessing the risks of coronary surgery in particular hospitals, we must inform the public about both the benefits and the risks of different actions, and trust the public to make the right decisions. In this instance, we are informing the public about a very low risk, but one that can be made yet lower. Third, how do we deal with the consequences of the guidelines? I know that these guidelines will have a very significant impact on some health care workers. We need to search for compassionate ways as a society to help those colleagues who are adversely affected by these guidelines and to protect their rights. As many of you know, the Department of Health and Human Services has actively intervened to prevent a hospital in this state from discriminating against an HIV-infected employee. I want to reemphasize that the great majority of health care workers will be assisted by these recommendations, by the reassurances they contain about no risk beyond exposure-prone procedures, and by our strong opposition to mandatory testing. Many of you and others have expressed concern about how this will affect health care services for people who are infected with HIV. No one has complete answers to this deep-seated problem and it's one we are committed to working with you on. I believe strongly in the principle that health care workers have a responsibility to care for all patients, including those who are HIV infected. Where do we go from here? While we must acknowledge that there is not universal agreement on this issue, it is important to keep our differences of opinion in perspective. Together we can and must address many other issues in the HIV epidemic-issues which affect many more persons than in the health care setting. CDC and New York State will continue to address concerns expressed by health care workers and patients about HIV transmission, but we cannot let this issue and subsequent debate cause us to lose sight of the far greater public health problem of HIV infection. I recognize that the impact of HIV infection has been greater for New York than virtually any other state and that you have consequently had to face the reality of this epidemic to a far greater extent than many of the rest of us. David Axelrod and the State of New York have met this challenge. The Vol. 68, No. 2, March-April 1992
212 212
W. L. ROPER
nation has learned from you. And I believe we can learn from Dr. Axelrod that, even if a position is not popular, we must be courageous in supporting what we believe to be right. As HIV infection and AIDS continue to challenge our best efforts on the national as well as the state level, may we continue the constructive dialogue that has led to some of our most innovative and effective collaborative efforts. Thank you for your attention.
Bull. N.Y. Acad. Med.
HIV EPIDEMIC* WILLIAM ROPER, M.D. Director U.S. Centers for Disease Control
Atlanta, Georgia
I am honored to be here today to help commemorate the contributions of Dr. David Axelrod, whose absence from public health we all feel so keenly. Under Dr. Axelrod, the State of New York Department of Health has provided extraordinary leadership during the first decade of the HIV epidemic in many areas, including research, surveillance, and prevention, as well as health care and other services. Leaders with courage and compassion like Dr. Axelrod are sorely neededand often sorely tried-by this epidemic of HIV infection. As we mark the 10th anniversary this year of the first published report of what we now know was AIDS, we recognize that the toll of AIDS will continue to challenge the best efforts of those of us in public health for perhaps decades to come. The number of AIDS cases and deaths increases each year, from 133 deaths in 1981, to more than 26,000 deaths in 1990-a 195-fold increase in deaths in less than a decade. And New York has borne a very large share of this loss. In 1981, exactly half of the nation's reported AIDS deaths-67-were residents of New York. Last year, New York AIDS deaths totalled nearly 5,000, almost one-fifth of the nation's total for 1990 of 26,000 deaths. According to our projections, the cumulative number of deaths from AIDS in the United States may exceed 300,000 by the end of 1993. CDC estimates that approximately 1 million people are currently infected with HIV in this country alone, which represents approximately 1 in 100 adult males and 1 in 600 adult females. In 1989 AIDS was the second leading cause of death among U.S. men 2544 years of age, causing 14 percent of all deaths among men in this age group-surpassing heart disease, cancer, suicide, and homicide-in fact, all causes except unintentional injuries. For men in these prime years of life in New York City, AIDS is the leading cause of death. Presented as part of a symposium, Dr. David Axelrod and the Health of the Public: Looking Ahead, cosponsored by the New York State Department of Health, the New York Academy of Medicine, and the Josiah Macy, Jr. Foundation October 23, 1991. *
Vol. 68, No. 2, March-April 1992
208
208
W. L. ROPER
In 1991, based on current trends, AIDS will likely be among the top five leading causes of death for women aged 15-44. For black women 15-44 years of age in New Jersey and New York, AIDS has been the leading cause of death for several years. The high incidence of AIDS among young people indicates that many of these individuals became infected as teenagers. Adolescents are increasingly vulnerable-surveys indicate that the majority of teenagers in the United States have engaged in sexual intercourse, with the average age of first sexual experience among U.S. adolescents being 16. In 1989 21 percent of high school students said they had already engaged in sex with four or more partners. Keep in mind that this survey was conducted among high school students, and the data do not reflect information on those outside the school system, who might be considered to be at even higher risk. CDC data indicate that 50 percent of U.S. adolescent females who were diagnosed with AIDS in 1990 contracted the virus through heterosexual contact. Moreover, recent serosurveillance data indicate that HIV infection is equally prevalent among young women and men between the ages of 16 and 22 who apply to the Job Corps program. I find all of these statistics alarming, as I know you do. Those of you in New York have been painfully aware of these numbers and trends. We owe much to Dr. Axelrod's foresight early in the epidemic in identifying just what the important issues concerning AIDS were. New York State was an early leader in implementing seroprevalence studies in various population groups, including anonymous testing of newborns for HIV antibody. This latter study, originally developed in Massachusetts to determine the seroprevalence of HIV among childbearing women, has measured the HIV antibody status of infants in more than 1 million consecutive births in New York State since 1987. Based on information from these surveys as well as other sources, prevention programs based on the testing and counseling of women of reproductive age were launched in New York State. Shortly thereafter, these epidemiological surveys were expanded to monitor the seroprevalence of HIV among childbearing women nationwide. The survey, begun in most states between 1988 and 1989, provides data on more than 2 million women per year. These data are important in developing, targeting, and evaluating education and prevention programs for women and infants at risk of HIV infection. New York State also has been a leader in other prevention efforts. By successfully combining federal and state resources allocated for HIV and Bull. N.Y. Acad. Med.
SYMPOSIUM
SYMPOSIUM
209
AIDS, the New York State AIDS Institute supports 14 community health centers which provide HIV care and prevention services to HIV-infected patients. And through the development of a strong cooperative relationship between the Division of Substance Abuse Services and the AIDS Institute, HIV counseling, testing, referral, and partner notification services have been implemented in 14 drug treatment facilities statewide. New York has initiated a number of innovative features of the Medicaid reimbursement program as it relates to AIDS, but I'll leave that discussion to my colleague Nancy Gary, of HCFA. I will mention, however, that these measures have helped provide an incentive for individuals to seek earlier testing and, in doing so, to increase opportunities for early treatment. I have discussed some of the areas in which New York has taken a lead in shaping national policy; I would like now to take a few minutes to talk with you about one of the most controversial AIDS issues facing us today-and one I think many of you are concerned about. On July 12 of this year, new CDC guidelines were released on preventing HIV and HBV transmission to patients during invasive medical and dental procedures. Questions are being raised concerning these guidelines. These concerns are advanced by individuals and groups whose full understanding and collaboration are essential to protecting public health. I think it would be useful to briefly summarize the key points of our
guidelines: * The risk of transmission of HIV and HBV infection from a health care worker to a patient during exposure-prone invasive procedures is very low, but it is real. * We strongly urge all health care workers to adhere to universal precautions as a primary safeguard; however, people who perform exposureprone invasive procedures should also know their HIV and HBV status and, if infected, should discontinue these procedures unless they seek counsel from a panel of experts on whether or not they should continue. Someone who is HIV seropositive should not continue to perform these procedures without such counsel. Informed consent of the patient is important if the health care worker continues to perform these exposureprone invasive procedures. The questions being raised in connection with these public policy guidelines focus on three central issues: (1) Are the recommendations scientifically based? (2) What and how should we tell the public? (3) How do we deal with the consequences of the guidelines? Vol. 68, No. 2, March-April 1992
210
210
W. L. ROPER
First, what can be said about their scientific basis? It is scientifically established that the HIV virus which causes AIDS is a bloodborne pathogen. As such it potentially can be transmitted during any procedure which presents the possibility of accidental mingling of viruscontaminated blood between patient and practitioner. This danger is not merely hypothetical; it has demonstrably occurred in the transmission of the infection from one dentist to five patients. This was not an event that was totally unanticipated; we had indeed addressed this possibility as early as 1986 when we published recommendations for HIVinfected health care workers who perform invasive procedures. Although universal precautions are very important, they do not provide 100% protection from infections as we are reminded by the experience with hepatitis B, where infection has continued to be transmitted from surgeons to patients in certain invasive procedures. It is clear that certain procedures cannot be made totally safe, and it's not simply a problem with the worker's technique. Gloves do not prevent injuries with sharp instruments. And, of course, in the case of hepatitis B, the ultimate solution is health care workers who have been fully immunized. But, argue as we may that the risk of transmission of bloodborne pathogens is low, the risk is nonetheless real. It cannot be wished away. We have based the July 12 guidelines on the science of the transmission of bloodborne diseases, including hepatitis B. But we will continue to have an open mind and to seek your and others' input on this issue. As we gather new information, we will review these guidelines. We want to be certain that our recommendations reflect the best science available-now and in the future. We resolve to continue this process-we will have a major public meeting on November 4 to discuss exposure-prone procedures, and we invite those of you who are interested to come and help us with this important endeavor. One final point about the science of these guidelines. Lately, I've heard a number of people raise questions about the Florida dental case and espouse one or another theory for precisely how the virus was transmitted in this practice. The fact is we do not know and probably never will know the exact mechanism of HIV transmission in this dentist's office. In this instance, our past experience with hepatitis B provides a sound basis for these current guidelines. The second issue we must address is what to tell the American public about their risk of infection related to invasive procedures. In general, we are discussing this problem as a very low risk, but one that can be further reduced. Bull. N.Y. Acad. Med.
SYMPOSIUM
SYMPOSIUM
211 211
One of the criticisms of CDC and the guidelines is that we have been driven not by science, but by politics. I firmly believe that sound public health policy is a merging of the best of science and the best of public policy. In public health we don't have the luxury of making abstract, ivory-tower pronouncements. Whether in setting environmental policy, in informing parents about the risks of immunization, dealing with hazards for workers, or assessing the risks of coronary surgery in particular hospitals, we must inform the public about both the benefits and the risks of different actions, and trust the public to make the right decisions. In this instance, we are informing the public about a very low risk, but one that can be made yet lower. Third, how do we deal with the consequences of the guidelines? I know that these guidelines will have a very significant impact on some health care workers. We need to search for compassionate ways as a society to help those colleagues who are adversely affected by these guidelines and to protect their rights. As many of you know, the Department of Health and Human Services has actively intervened to prevent a hospital in this state from discriminating against an HIV-infected employee. I want to reemphasize that the great majority of health care workers will be assisted by these recommendations, by the reassurances they contain about no risk beyond exposure-prone procedures, and by our strong opposition to mandatory testing. Many of you and others have expressed concern about how this will affect health care services for people who are infected with HIV. No one has complete answers to this deep-seated problem and it's one we are committed to working with you on. I believe strongly in the principle that health care workers have a responsibility to care for all patients, including those who are HIV infected. Where do we go from here? While we must acknowledge that there is not universal agreement on this issue, it is important to keep our differences of opinion in perspective. Together we can and must address many other issues in the HIV epidemic-issues which affect many more persons than in the health care setting. CDC and New York State will continue to address concerns expressed by health care workers and patients about HIV transmission, but we cannot let this issue and subsequent debate cause us to lose sight of the far greater public health problem of HIV infection. I recognize that the impact of HIV infection has been greater for New York than virtually any other state and that you have consequently had to face the reality of this epidemic to a far greater extent than many of the rest of us. David Axelrod and the State of New York have met this challenge. The Vol. 68, No. 2, March-April 1992
212 212
W. L. ROPER
nation has learned from you. And I believe we can learn from Dr. Axelrod that, even if a position is not popular, we must be courageous in supporting what we believe to be right. As HIV infection and AIDS continue to challenge our best efforts on the national as well as the state level, may we continue the constructive dialogue that has led to some of our most innovative and effective collaborative efforts. Thank you for your attention.
Bull. N.Y. Acad. Med.
