The impact of AIDS on state and local health departments: issues and a few answers

Health benefits and risks of reporting HIV-infected individuals by name

With more treatment options emerging for human immunodeficiency virus (HIV) infection, the policy of reporting HIV-infected individuals by name merits reevaluation. This paper reviews the benefits and risks of name reporting of persons infected with HIV. Public health departments have linked name reporting with medical referrals, risk reduction counseling, and partner notification programs. Yet some studies indicate that people are less likely to be tested for HIV infection when name reporting is implemented. Whether name reporting actually improves individual or public health, therefore justifying the increased risk of loss of confidentiality and possibly reduced testing rates, remains unknown. The lack of health outcome data on name reporting allows beliefs rather than facts to dominate debate about this policy. Before this practice is more widely adopted, a determination should be made as to whether the potential benefits of name reporting outweigh the risks.

The risk of domestic violence and women with HIV infection: implications for partner notification, public policy, and the law

Partner notification has emerged as an important strategy in the fight against acquired immunodeficiency syndrome (AIDS), and states have now adopted a plethora of laws that encourage or mandate notification, often without the patient's consent. As human immunodeficiency virus (HIV) infection continues to spread among women, the future development of AIDS control strategies and public health laws must be shaped by concern for the safety and autonomy of patients who face a risk of domestic violence. Three distinct recommendations flow from this premise. First, all HIV-infected women should be assessed for the risk of domestic violence and offered appropriate interventions. Second, where a risk of abuse is indicated, partners should never be notified without the patient's consent. State laws that presently permit involuntary notification should be repealed or amended. Third, laws that punish a patient's refusal to notify partners should also be modified or repealed.

Ethical dilemmas in HIV infection: what have we learned?

The acquired immunodeficiency syndrome (AIDS) has raised perplexing ethical and public policy dilemmas. Early in the epidemic, closing of bathhouses, testing blood donors for human immunodeficiency virus (HIV) infection, and notifying seropositive blood donors evoked passionate controversies. Current dilemmas include testing and using promising new treatments, notifying partners of seropositive persons, and, most recently, restricting the clinical activities of seropositive health,care workers who perform invasive procedures.

These dilemmas about HIV infection involve scientific judgments, cultural norms, and social values. In the HIV epidemic, public rhetoric and political pressure have been prominent. On the one hand, some persons have launched moralistic crusades against homosexuals and injection drug users. For these persons, AIDS symbolizes the breakdown of traditional family values and the social order. On the other hand, some advocates for persons with HIV infection have used confrontational tactics such as sit-ins and disruptive demonstrations.

AIDS prevention in low-incidence areas

AIDS has been largely described as a problem of major urban areas. However, states in which there is a low incidence of AIDS are dealing with issues from somewhat different perspectives than high-incidence states. The terms "low incidence" and "high incidence" can be misleading: If one state compares its AIDS cases to another state, the comparison may indeed show a comparatively low incidence of AIDS. However, if the comparison is made with other diseases within the same state, a quite different picture may emerge. In low-incidence states, some individuals infected with human immunodeficiency virus (HIV) may seek medical care from physicians who have more experience in treating AIDS cases, both because of a perception of better medical care and less stigmatization. Although the numbers may be relatively small, the number of HIV/AIDS patients seeking care in large metropolitan areas may add to the health care burden already being seen in some parts of the country.

Psychological defenses and control of AIDS

The well known psychological defenses of avoidance, repression, and denial against the knowledge that one has, or might have, a fatal disease used by a high percentage of individuals, must be considered in control programs for the human immunodeficiency virus (HIV). Current programs of education, voluntary testing, and counseling do not consider this defense mechanism and may therefore provide inadequate control. Compulsory HIV testing programs and development of an "HIV Parole" system may be needed if the current HIV epidemic worsens.

Partner notification in the control of human immunodeficiency virus infection

Partner notification should be standard public health practice in the control of human immunodeficiency virus (HIV) infection. A universal partner notification program for the United States is affordable, operationally manageable, and can effectively reach high-risk persons. Such a focused approach personalizes the epidemic and probably enhances the efficacy of risk reduction messages. Confidentiality protections are attainable. Voluntary partner notification is acceptable to our constituents; while counseling is "mandatory," testing is optional. Evidence of partner notification's usefulness as a case prevention tool should be a by-product of program outcomes and not a prerequisite for its implementation.

What do we really know about AIDS control?

For the near term, control of the AIDS epidemic depends entirely upon altering the human behavior which results in HIV transmission. How best to achieve the required changes has been controversial with approaches ranging from education/information only, to a vast array of largely unproven voluntary behavior modification techniques, to mandatory testing and restrictive measures. Given the complexity of human behavior and the reality of a still uncontrolled epidemic, at least among poor urban drug using minorities, there is a legitimate role for most approaches and any promising behavior modification strategy deserves evaluation. However, because voluntarism will not work for some individuals, society still must choose between effective public health law--including restrictive measures--now, and a much larger reservoir of HIV infection and more deaths from AIDS for many generations to come.

A vigilância epidemiológica e a infecção pelo HIV

Este artigo discute três métodos de obtenção da informação necessária à vigilância epidemiológica da AIDS: Inquéritos soroepidemiológicos em grupos populacionais determinados, utilização de serviços-sentinela e notificação compulsória dos soropositivos. De acordo com a experiência da equipe do Programa de Prevenção e Controle da AIDS da Secretaria Estatual de Saúde do Rio de Janeiro, quase toda a informação existente atualmente baseia-se na notificação de casos confirmados da doença. No sentido de monitorar os níveis e tendências da infecção pelo HIV, este trabalho sugere a utilização dos três métodos de vigilância discutidos, garantindo a maior efetividade do programa de prevenção e controle de AIDS.