Ten years of AIDS: AIDS has changed medicine and the way it is practised Catherine A. Hankins, MD, FRCPC H as the AIDS epidemic changed the face of medicine in Canada? As we mark the 10th anniversary of the reporting of the first AIDS case in Canada, this question is clearly rhetorical. We may nonetheless hold quite different views on what the changes have been and whether they have had a salutary effect on the evolution of medical practice in Canada. One obvious change that HIV/AIDS has brought to daily practice is the implementation of

universal precautions for infection control in occupational settings. Gone are the days of labelling specimens, patient files and hospital doors with blood-precaution stickers if the patient was known to be a hepatitis B antigen carrier. Recognition that there is a period - it can last several weeks following exposure to the virus during which an HIV-infected patient's blood and body fluids may be highly infectious but still HIVantibody negative led to the realization that, from a practical standpoint, testing could not be an effective control measure to prevent nosocomial transmission. We also became aware of the potential for blood-borne transmission of other known - HTLV- 1 and HTLV-2 - and unknown retroviral infections. As a result, the universalprecautions policy was adopted. Its full economic impact has yet to be felt, but today hospitals, clinics and physicians strive to treat all Catherine Hankins is a public health epidemiologist at the Centre for AIDS Studies, Montreal General Hospital, and associate professor in the Department ofEpidemiology and Biostatistics, McGill University, Montreal. F'EBRUARY 1, 1992

patients as if they were infected with a blood-borne agent. There are anecdotal indications that HIV/AIDS may be having an effect on the career decisions of prospective medical students and on the specialty choices made by interns. The clinical diversity and the medical challenges that HIV disease provides are being counterbalanced by fears of occupationally acquired HIV infection, even though risks are currently very low for physicians involved in invasive procedures in Canada. It remains to be seen whether a real shortage of physicians trained to treat AIDS patients will occur because of these fears. In the charged atmosphere of the current debate over HIV antibody testing of physicians and surgeons, the patient-doctor relationship is again under scrutiny. Although thousands of patients have been treated by infected physicians and dentists without HIV transmission occurring, and only one dentist has transmitted HIV infection to his patients, the issue of trust and of physician competence is in question. As this subject receives more and more attention in coming months, it is likely that a more general approach to assessing the physical, mental and psychologic capacity of physicians to practise - whether the physicians are HIV infected or not will evolve. There is no doubt that in just 10 years HIV/AIDS has changed the way that knowledge is shared between physicians and their patients. Many Canadians living with HIV infection have close ties to local community groups and to cross-border and underground

sources of information. They may follow closely both local and international media stories concerning HIV/AIDS treatments, and physicians frequently find themselves learning of new developments through their patients. For some doctors, highly knowledgeable patients may constitute a clear threat to their professional self-image; for others, they may provide the opportunity for a richer, more interactive and stimulating relationship between physician and patient than was previously experienced. The HIV/AIDS epidemic has brought a new perspective to the issue of informed consent, especially with respect to investigative testing. Canada adopted World Health Organization guidelines for HIV antibody testing - the three "C" conditions of counselling (pre- and post-test), consent (informed) and confidentiality (concerning the results and the fact that the patient's blood had been tested). Some physicians are angry that explicit informed consent is needed to conduct an HIV antibody test - they question the advisability of treating HIV tests differently from other diagnostic tests. In the long run, however, Canadian physicians have become more particular about seeking informed consent for a host of tests for which blanket consent had become the rule. This development has positive implications for patient participation in the diagnostic process, as well as potential cost implications for the health care system as physicians become more aware of the need to justify the choice of diagnostic tests to their patients. This practice may CAN MED ASSOC J 1992; 146 (3)

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have started falling by the wayside when the need for the patient's financial approval to conduct tests was removed with the advent of universal medicare. AIDS has had a dramatic impact on the sexual lives of many Canadians, whether HIV infected or not. Medical students of the '70s were trained to inquire about sexual orientation when taking histories from unmarried men and to make general inquiries about sexual health. Physicians in the '80s and '90s have had to expand this sexual history-taking to systematically include all patients married or unmarried, male or female, adolescent or aged. Surveys of both adolescents and adults have shown that Canadians regard their physicians as the preferred source for information concerning AIDS and other sexually transmitted diseases. In the age of AIDS Canadian physicians have had to become comfortable talking about safer-sex choices with patients of varying ages from all walks of life. Discussions of the importance of adequate lubrication before penetration and of the risks associated with anal sex, for example, are now commonplace with sexually active patients, whether heterosexual, bisexual, or homosexual. Ten years ago few physicians were making a point of explicitly endorsing the use of condoms by demonstrating correct use and exploring with patients possible ways of proposing condom use to a sexual partner. Today, not only is this happening but also we are even making special efforts to advise patients taking oral contraceptives to use condoms for every sexual act in order to prevent sexually transmitted diseases including AIDS. The patient activism associated with HIV/AIDS has been unparalleled in the history of medicine. This politicization, which does not sit comfortably with us all, has had many positive spin382

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offs. One, the acceleration of regulatory processes for the approval of new drugs, has the potential to have a positive effect on all patients. There has been much debate about the importance of randomized controlled clinical trials and the concept of open arms and alternative clinical trial designs. The catastrophic condition of many AIDS patients has led to concerted pressure to streamline regulatory procedures while maintaining scientific rigour. The result has been increased availability and more timely access to new and promising drugs for patients with HIV/AIDS, changes that should benefit many Canadians with conditions other than HIV infection. Finally, and most significantly, HIV/AIDS has re-emphasized for all of us the importance of seeing health in its social context. It has become apparent to everyone that HIV/AIDS is not solely a medical problem. The psychologic, social, political and economic ramifications of this disease go far beyond the strictly clinical and epidemiologic aspects. HIV/AIDS is essentially a sexually transmittable disease that is potentially 100% preventable, and which may be 100% fatal. It has challenged our knowledge of human sexuality and found us wanting. It has unmasked the inequalities in relationships between the sexes that lead to HIV susceptibility in all cultures. And it has brought home to us once again the powerful link between poverty and disease, both in Canada and other Western countries and in the Third World. In Canada, where we place a lot of emphasis on human rights, the discrimination and prejudice experienced by patients with AIDS has laid bare the disquieting impact homophobia can have on many Canadians' ability to react with compassion and concern to those with HIV infection.

With the long incubation period of AIDS having delayed recognition of this epidemic, thereby preventing the early action normally needed to nip an epidemic in the bud, we are now in this for the very long haul: HIV/AIDS will be with us well into the 21 st century. For those already infected, coordinated treatment and care programs are needed; these include health-maintenance approaches for asymptomatic patients. The development of new therapies and continued trials of combined therapies may help turn HIV disease into a chronic illness. A greater emphasis on the psychosocial needs of patients with HIV/AIDS will be evident in the '90s; it will have to be accompanied by public-education strategies aimed at reducing discrimination and increasing acceptance. Aside from educational campaigns aimed at initiating and maintaining behavioural change to help slow transmission, the only hope that we can now hold out for bringing this epidemic under control worldwide will be a universal vaccination program for everyone. Aside from exemplary immunogenicity, the HIV vaccine that is eventually developed will have to be cheap and heat stable, and suitable for oral administration. This is a very tall order if we consider just the biological properties of this virus, let alone the economic cost, the political will and the organizational capacity that universal vaccination will re-

quire. In the meantime, we all have a role to play in helping patients to cope with this multifaceted disease and in assisting patients who are at risk of HIV infection to take the steps needed to prevent

infection. As an AIDS education poster so aptly puts it: "AIDS isn't over for anyone until it's over for everyone. "a LE ler FEVRIER 1992

Ten years of AIDS: AIDS has changed medicine and the way it is practised.

Ten years of AIDS: AIDS has changed medicine and the way it is practised Catherine A. Hankins, MD, FRCPC H as the AIDS epidemic changed the face of me...
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