Now, there's new recommendations from the Centers for Disease Control that we take care of and screen people for HIV antibody and to provide early prophylaxis against PCP and other drugs. In our particular clinical situation, although these recommendations are made, our clinic takes care only of people who are symptomatic that have symptomatic disease and we don't have the resources at the proper time to actually meet the needs that have been promulgated by the Centers for Disease Control. I think a few things that we need to do. I think we need to have greater access to drug treatment, programs for heroin and cocaine, I think that we need user-friendly sites for education and counseling and preventing HIV infection. One example that was in last week's "Morbidity and Mortality Weekly Report" was project trust, which we launched in Boston about a year and a half ago which has been a very, very successful site for bringing intravenous drug users, their sexual partners, into the health care system. I think we need community based clinics and hospitals to provide primary care for intravenous drug users, their sexual partners, their needle sharing contacts, and their family, because, in this particular population, it becomes a family disease. I think particularly the community based organizations could provide screening programs, education, and counseling, make decisions about prophylaxis and maintaining the large portion of these people who have asymptomatic HIV infection. Then I think there needs to be a linkup with centers or clinics that are able to provide more advance services such as the clinics that we have at the City Hospital. I think that closer ties are needed between drug treatment programs and medical services. Many of the programs have acted independently in the past. I think this could be accomplished by linking funds for drug treatment with the primary care and medical care of the individual. There's a variety of models that have been tried and I think many of these could be successful. I think there needs to be greater access to clinical trials. We need to expand the sites. We need new sites that are particularly designed to take care of the needs of the population that are now becoming infected with the virus. I think we need funds for more systematic counseling, education, and prevention programs, for intravenous drug users who come in contact with the health care system, that is, the in-patient clinics, the family planning clinics, the sexually transmitted disease clinics, and all the clinics where they actually maintain contact with the system, that we need to use those for the prevention and education programs that we don't have the funds for at the present time. Finally, I think we need more money for shelters and medical programs for the homeless since this population is growing and although we have these resources at the present time, they're inadequately funded and are unable to meet the needs of the growing epidemic in Boston. I think what's been said earlier I would like to echo, basically, I think it's the time to invest now, particularly in this population; I think it's been demonstrated that these individuals when they're provided with the proper services can be compliant with the health care systems, can enter clinical trials and it's an issue of whether we want to invest now or not invest now and pay a larger sum of money later to actually care for this population. Thank you very much. [The prepared statement of Dr. Craven follows:] ISSUES IN THE CARE OF INTRAVENOUS DRUG USERS, WOMEN AND MINORITIES, WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION Donald E. Craven, M.D. Presented to the Human Resources and Intergovernmental Subcommittee of the Committee on Government Operations Rayburn House Office Building July 28, 1989 "There is no area in which there is so much mystery, so much misunderstanding and so many differences of opinion as the area of narcotics." John F. Kennedy, 1962 Several wars on drugs have been declared with few victories. In March 1985, the House Select Committee on Narcotics Abuse and Control report called drug abuse the number one health problem in the United States and stated that: "More that 20 million Americans use marijuana regularly, approximately 8 million to 20 million are cocaine users, about 500,000 are heroin addicts, one million are regular users of hallucinogens and six million people abuse prescription drugs." These statistics are extraordinary, and do not reflect abuses of alcohol, anabolic steroids, or "crack". In less that a decade, AIDS has become the number one public health concern in the United States and has had a greater impact on our health care system than virtually any other infectious disease in history. The long incubation period, chronicity of disease and lack of an effective vaccine make this epidemic unique and difficult to control. The AIDS epidemic has highlighted our failure to adequately address the issues of sexuality, sexually transmitted diseases, and the plague of drug abuse. There has been tremendous progress in controlling the spread of HIV in gay men, but the challenge for intravenous drug users (IVDU) and minorities will be more formidable, require more creativity, as well as federal, state, city, and private resources. Failure to meet the challenge of AIDS in IVDU could have catastrophic ecomomic, political, and psychologic effects. The changing epidemiology of HIV in the IVDU population requires a redistribution of present resources, new strategies, and new programs for education, prevention, and medical care. Boston City Hospital, where I am a clinician, is a municipal hospital that cares for a large portion IVDU as well as many poor and uninsured patients in Boston. This presentation will discuss some of our clinical programs, with special emphasis on the care of IVDU, women and minorities who are infected with HIV. Changing Epidemiology of AIDS: Over the past five years there has been a dramatic upsurge in the number of AIDS cases in IVDU, women, children, and minorities. IVDU now account for more that 27% of the AIDS cases in the United States, more that 50% of the cases in women, and greater than 75% of the cases in children. Blacks and Hispanics, many of whom have IVDU as a risk behavior have suffered a disproportionate share of the burden of AIDS. The cumulative incidence of AIDS/100,000 is highest among blacks (83.8) and Hispanics (73.0) compared to whites (26.3). In addition, fatality rates for AIDS cases in New York City have been highest for IVDU, women and blacks. Rates of human immunodeficiency virus (HIV) infection may change rapidly in IVDU as demonstrated by changes in seroprevalence rates and AIDS cases. In New York City, intravenous drug use is now the most common cause of new AIDS cases, and similar increases in this risk group has been noted in other cities such as Boston. Drug users may spread HIV by sharing contaminated drug injection paraphernalia, by sexual intercourse, or perinatally. IVDU men and women are a bridge for increased heterosexual transmission, and the fertility of DU women increase the the risk for vertical transmission to the child. in essence the whole family may become infected with HIV. Rates of perinatal transmission range from 20% to 40%, but even if a child is not infected, it is likely that one or both parents may become sick and die of HIV infection by the time the child is 10 years of age. The AIDS epidemic is moving rapidly into innercity minority communities. These communities are already burdened with poverty, high infant mortality, teenage pregnancy, crime, homelessness, prostitution, and drug-related problems. Education and prevention strategies for HIV have been limited by the lack of advocacy groups and an organizational structure. To reach these populations will require a community based effort and strategies for outreach and continued contact with persons who seek help. Certainly, drug treatment and prevention programs are of paramount importance. With the current treatments for HIV and the use of prophylactic drugs against opportunistic infections has changed the character of HIV disease as well. Patients will be less likely to present with Pneumocystis carinii pneumonia and more likely to be hospitalized with diseases such as dementia, that may require more chronic care and different placement after hospitalization. All of these issues must be considered for future care. Differences in the Medical Presentation of IVDU: The question is often asked whether the changing epidemiology of HIV has changed the clinical presentation of the disease. The clinical syndromes of IVDU with HIV are similar to gay men with a few notable exceptions. IVDU have fewer patients with Kaposi's sarcoma, and more patients with bacterial pneumonia, bacteremia, and tuberculosis (TB). The increased spread of TB is of concern because of its contagiousness by the airborne route. Although the rate of TB was declining in the early 1980's, the numbers of cases in young black males living in the inner city has increased dramatically since 1985. This is due in part to the spread of HIV into minority communities as well as the immunosuppressive effects of HIV. About 33% of the new cases of active TB in New York City and Miami also have evidence of HIV infection. Therefore, screening, as well as effective use of chemoprophylaxis is needed for IVDU in drug treatment programs, and minorities attending primary care clinics. Likewise, TB clinics are an important area to raise issues of HIV infection. Sexually transmitted diseases are also more common in IVDU. Some IVDU women support their drug habit through prostitution which may also increase the risk of acquiring or spreading HIV. Rates of gonorrhoea, syphilis and chlamydia have increased in metropolitan areas, and certain sexaully transmitted diseases may facilitate the transmission of HIV. Clinics for sexually transmitted diseases are important places for education, counselling, and prevention programs for HIV. |