Testimony of David W. Fraser, M.D. on AIDS Education House Subcommittee on Human Resources and Intergovernmental Relations March 16, 1987 I am David W. Fraser, President of Swarthmore College, a physician and an epidemiologist. Today I am representing the National Academy of Sciences and the Institute of Medicine, on whose Committee on a National Strategy for AIDS I served last year. Next to the threat of nuclear war, AIDS is fast becoming the most important public health problem of the 20th century. That importance comes from three facts: 1) that it is likely to kill 179,000 people in the U.S. alone by 1991 and the epidemic could continue to expand in the decades afterwards; 2) that it affects especially young adults and, increasingly, children and 3) that, although we have no effective drugs to treat the underlying disease or vaccine to prevent it, we do know how to prevent the spread of the virus that causes it. The parallels with nuclear war go somewhat further. At one level we know how to prevent nuclear war too we could dismantle all nuclear weapons. But to get mankind to the point that that might be done is a very complicated matter, requiring concentrated and comprehensive planning and implementation. Education is the most promising tool that we now have for controlling the AIDS epidemic but up to now it has not been used with near the effectiveness that is called for. I shall try to lay out the case for a centrally coordinated, comprehensive education program to halt spread of the Fraser - AIDS education March 16, 1987 virus that causes AIDS, the Human Immunodeficiency Virus or HIV, via sexual intercourse, through intravenous (IV) drug use and from mother to infant. HIV is most commonly spread by sexual intercourse, specifically anal intercourse and vaginal intercourse. Like all sexually transmitted diseases, the chances of acquiring it go up as ones number of sexual partners goes up. And, the risk is related directly to the proportion of partners who are infected. - and other People who are intent on not catching HIV have several good strategies that they can follow. The surest is to remain in a monogamous relationship that has been so since 1977, or to abstain from anal or vaginal intercourse. But these strategies are not practical for many people and the number for whom this advice is not helpful constantly grows as each new generation becomes sexually active. For those people, using a condom during anal or vaginal intercourse is likely to be very effective. Barring a tear in the condom the HIV is most unlikely to be transmitted through it activity during love-making, including kissing and oral-genital intercourse, does not seem to spread the virus. For couples who become monogamous, the blood test for antibody to HIV may be very helpful in determining when it is safe to stop using a condom. Most people develop a positive serologic test for HIV within 6-8 weeks of becoming infected; on the outside seroconversion may take 6 months. So if both partners are seronegative 6 months after entering into a monogamous relationship, they are on pretty solid ground to assume that condoms are no longer needed so long as they have sex only with Fraser AIDS education 3 March 16, 1987 If a man is found to be seropositive, he should continue to use a condom during intercourse. If a woman is seropositive, her male partners should continue to use condoms. Those who reject monogamy or condoms may still be able to lower their risk of AIDS considerably by decreasing their number of sexual partners or by ensuring that the people with whom they do have sex are seronegative for HIV. it seems, I should like to emphasize that I am not offering different advice for heterosexual and homosexual people here. The risk of AIDS does not derive, from sexual orientation but rather from particular sexual acts, numbers of partners, and precautions taken or not taken. All sexually active people are at risk, although that risk will vary (and is varying) according to the frequency of the infection in the population from which one chooses sexual partner(s). Given that the risk of AIDS is great and growing and that ways to halt the sexual spread of HIV are pretty straight forward, it is essential that we find ways to alert people to their risk and inform them of ways that they can alter their sexual behavior to lower that risk markedly. Efforts to date have clearly been insufficient except in a few special situations like the gay population of San Francisco where intense educational efforts have been associated with marked changes in sexual behavior. One problem is the language that has been used to educate. The Surgeon General has quite appropriately called for blunter, more explicit information about specific Fraser AIDS education 4 March 16, 1987 sexual acts and specific precautions but advice continues too often to be vague. Warnings about "intimate sexual activity" or "exchange of bodily fluids" do not adequately differentiate between the potential riskiness of anal and vaginal intercourse and the apparent safety of, say, mutual masturbation. We have heard welcome, open talk about condoms in recent weeks but the utility of condoms needs to be more widely known and their use encouraged and accepted. The second most common way for HIV to spread is through the sharing of needles and syringes by intravenous drug users. Again, the mechanics of halting virus spread are simple. If drug users would not share equipment the virus in the blood would not be spread this way, although spread from infected drug users to their sexual partners would still be a matter of concern. The importance of educating drug users is especially great because of the wide differences that now exist in the rate of HIV infection among drug users in different cities in the U.S. Many people now at high risk of infection can be spared if effective educational efforts can be mounted quickly, and then sustained. Because of the complex psychological and social factors associated with intravenous drug use, simple dissemination of information is unlikely to be sufficient to curb spread of HIV in this population. Public health workers will need also to help addicts get off drugs, to assist them into more stable personal situations, and to help them take more responsibility for their actions. A great expansion of methadone maintenance programs may be Fraser - AIDS education 5 March 16, 1987 The third biggest educational need has to do with the risk of transmission of HIV from mother to her fetus or infant. Over 300 cases of AIDS have been reported in children, half of them under one year of age. Most of the infants are born to mothers who are intravenous drug users themselves, are sexual partners of drug users or bisexual men, or are from countries where the prevalence of HIV infection is higher in women than it now is in the United States. But as heterosexual spread of HIV becomes more common the number of women of childbearing age who are infected and could in turn pass HIV on to their children will increase. We must develop educational programs to identify women at high risk of HIV infection and, in conjunction with serologic testing as indicated, counsel them about risks to them and their children and alternatives open to them such as birth control or abortion. In focusing on these three groups in need of education, I do not mean to indicate that education is not needed elsewhere. Myths about AIDS need to be dispelled so that people who are infected are not treated inhumanely at work or at school by people who think (erroneously) that they might transmit the virus in such daily activities as shaking hands, sneezing, coughing or sharing of utensils--or even by embracing and kissing. But the emphasis must be on educating people about ways they can stop HIV transmission through sex, by sharing IV drug paraphernalia and from mother to child. We understand that the Centers for Disease Control has been given a mandate to oversee a national educational program about AIDS. Concentrating |