HIV Related Health Care......page 7 the population of the United States. This feature of the NIAID AIDS clinical trials program persists because the academic institutions which conduct these studies are the same facilities which do not traditionally care for the poor, ethnic/racial minorities, or the drug addicted. Not only does this represent less benefit for the economically disenfranchised, but it also represents less than de sirable science. There is considerable precedence in the history and current practice of medicine, that pharmaceuticals which demonstrate benefits in certain populations, may lack efficacy if utilized in other populations. Most protocols of experimental AIDS drugs are being investigated in white homosexual/bisexual populations, while epidemiologic trends demonstrate steadily decreasing rates of disease in this population concurrent with persistent increasing HIV disease rates among ethnic/racial minorities and IV drug abusers. Finally, but not least of the obstacles is the issue of health care financing. In many areas of this country, especially in New York City, we have witnessed a rise in HIV-related funding at the expense of the support of other causes of morbidity and mortality. For example, funding for sexually transmitted diseases in many health departments has been shifted to finance HIV-related initiatives. Many community health care clinics are perplexed at the signals they are receiving from the Health Resources and Services Administration (HRSA). These facilities are being encouraged to provide more HIVSignificant related primary care; yet they are not provided any additional funding. Should these facilities increase their emphasis on HIV-related HIV Related Health Care......page 8 services and pay less attention to diabetes, cancer prevention and hypertension - other diseases also accounting for excess morbidity and mortality for the poor of America? It has been abundantly clear for some time that our current system of public and private (including health insurance) reimbursement continues to drive many health professionals to choose more lucrative medical care medical specialties at the expense of primary car careers. The decrease in primary care practitioners further encourages the utilization of more costly hospital-based clinics and emergency room care. As long as HIV-related primary continues to be concentrated in hospitals and in the practices of medical specialists, the health care costs will continue to spiral upwards. Clearly, greater emphasis on primary medical care (such as with prophylactic aerosolized pentamidine, AZT, and various immunizations) reimbursement and on the providers of primary medical care is at least part of the solution. As a final chapter to the health care finance issue, I am compelled to bring attention to the inefficiency that often plagues block grant and cooperative agreements between agencies of the Health and Human Services Department and state and city health departments. les While recognizing the principals and the distinct advantages of the federalism approach, there are often inordinate delays in receiving services funded by the federal government, yet administered by state and local health departments. If I might suggest, it may benefit this country if the U.S. Congress would consider evaluating the cost HIV Related Health Care......page 9 in dollars and lives of the inefficiencies of providing the limited health care dollars only through state and local health departments. In summary, the HIV epidemic has exposed previous inequities and inefficiencies in health care delivery today. These obstacles to the provision of HIV-related services includes the decreasing numbers of primary medical care providers, the continuing emphasis on costly inhospital or hospital-based tertiary care services and the continuing lack of adequate primary care facilities. These problems are felt most deeply by the poor and ethnic/racial minorities. As it relates to AIDS, this state of affairs also threatens the performance of various drugs under investigation for HIV infection/disease. Good research requires that the ingredients of adequate health care and social services are firmly in place. Mr. Chairman, please again accept my thanks for this opportunity to speak. While the issues we must address are monumental, I truly believe the knowledge and expertise exists to surmount these obstacles. It appears to me to be a matter of national resolve. This hearing represents another valuable step as we in this country attempt to determine the issues and approaches to very real dilemmas. AIDS & PUBLIC POLICY 1988;3:5-15 Intravenous Drug Abuse and AIDS in Minorities Lawrence S. Brown, Jr., and Beny J. Primm Introduction At the threshold of the last decade of the twentieth century, AIDS presents formidable challenges for nearly every aspect of society. Few issues have equaled the call to action commanded by the AIDS epidemic. While still incomplete in the minds of many, the response to this clear threat to the public health has been at a level not previously experienced by the medical and scientific communities. Yet, despite significant advances in understanding AIDS, somber morbidity and mortality statistics remain as reminders of the human toll associated with this epidemic. This devastation appears particularly acute among those portions of the US population already overrepresented in morbidity and mortality statistics of cancer, cardio- and cerebrovascular diseases, diabetes, and chemical dependency.' As Hopkins so poignantly articulated, AIDS represents the seventh Horseman of the Apocalypse for American ethnic/racial minorities. Currently, prevention and health education hold the greatest hope for combating AIDS. Thus, efforts directed at known modes of infection may serve as important foci for intervention and as valuable fuel for health prevention. This has special public health significance for blacks and Hispanics. To this end, this paper will explore the role of intravenous drug abuse in the disproportionate prevalence of AIDS and human immunodeficiency virus (HIV) infection in black and Hispanic populations. We will also review some current and proposed efforts to reduce intravenous drug abuse-related HIV transmission. Finally, some proposals for future considerations and directions will be offered. Prior to beginning this discussion, two very important issues demand immediate attention. While the focus of this review will be on blacks and Hispanics, it should not be inferred that Asians, Pacific Islanders, and Native Americans do not experience excess HIV-related morbidity and mortality. While the relative risks of AIDS are smaller in these populations than among blacks and Hispanics, these other groups would also benefit from an understanding of the pivotal role that intravenous drug abuse plays in the AIDS epidemic. Nor should it be assumed that other known routes of HIV infection are trivial factors in the prevalence of AIDS in black and Hispanic populations. Risk behaviors associated with homosexuality and bisexuality are also important in the epidemiology of AIDS and HIV infection in ethnic/racial minorities. However, intravenous drug abuse poses a significantly greater public health challenge when one considers the prospect for heterosexual HIV transmission to the general population from intravenous drug abusers (IVDA). As will be shown shortly, this is especially true in inner city black and Hispanic communities. Scope of the Problem Of the 47,436 total AIDS cases and the 12,938 heterosexual adult/adolescent cases reported to the Centers for Disease Control (CDC) as of December 7, 1987, 25 percent and 62 percent, respectively, have been associated with drug abuse. The 59 percent case fatality rate of intravenous drug abuse-associated adult AIDS cases is in excess of the cumulative rate for all transmission categories. The significance of intravenous drug abuse in the development of AIDS in women and children is even more startling. Approximately 50 percent of adult female AIDS cases have a history of parenteral drug use. Another 30 percent of cases in women are attributed to heterosexual transmission. This last category largely reflects HIV transmission from male IVDAs to their female sexual partners.* Seventy-six percent of AIDS cases among children have been traced to parents with AIDS or at increased risk of AIDS.' Evidence of parenteral drug use by the mother or the sex partner of the mother has been revealed in the overwhelming majority of pediatric AIDS cases. Thus, IV Drug Abuse and Minorities intravenous drug abuse has had a considerable impact on the prevalence of AIDS among adult heterosexual men, women, and children. It might be assumed that this relationship would hold true in all regions of the country. In fact, the distribution of AIDS cases by transmission category varies according to geographic location. The geographic prevalence of intravenous drug abuse is a major factor in determining not only the aggregate total of AIDS cases but also the sexual distribution of AIDS and its prevalence in the pediatric age group. It might well be said that the US is in the midst of a number of AIDS epidemics. The features of each epidemic are predicated upon the geographic prevalence of HTVexposing behaviors around the country. AIDS is of particular importance to New Yorkers. Approximately 26 percent of the total number of reported cases, 32 percent of pediatric cases, and 47 percent of adult female cases of AIDS have occurred in New York State, principally in New York City, New York's disproportionately greater number of AIDS cases is generally attributed to its large community of substance abusers. Over 850,000 persons, or almost 6 percent of the state's population, are heavy substance abusers, with 258,000 of these calculated to be steady IVDAS. Nearly 200,000 of these IVDAs live in New York City, representing approximately one-half of the estimated 350,000 to 400,000 IVDAs nationwide." In New York City, where nearly one-quarter of the national AIDS case reports originate, intravenous drug abuse is linked to 32 percent of AIDS cases in adult men, 60 percent of cases in women, and 77 percent of pediatric AIDS cases." From another vantage point, approximately 82 percent of AIDS cases in IVDAS have occurred in the New York City metropolitan area." Data from New York City also appear to indicate that the natural history of the disease following diagnosis is related to the transmission category. In a cohort of 5,833 AIDS patients diagnosed before 1986, 8.6 percent of the patients among whom AIDS could be traced to homosexual behaviors had died at the time of diagnosis." In contrast, 15.2 percent of IVDAs in this cohort did not survive after diagnosis. The case fatality rates for male and female IVDAs with AIDS (59 and 61 percent, respectively) exceed the national average. As this demonstrates, intravenous drug abuse has particularly challenged New York City's ability to respond to the AIDS epidemic." As mentioned earlier, not all geographic areas have the level of parenteral drug abuse or intravenous drug abuse-associated AIDS witnessed in New York. The city provides an unfortunate lesson of what other regions might expect if they do not adequately address disorders linked to the abuse of injectable substances. When it comes to intravenous drug abuse, New York's window of opportunity for stemming the AIDS epidemic is considerably smaller than that of other geographic locations. While intravenous drug abuse has a significant impact on the prevalence of AIDS in the general population, its effect on AIDS-related morbidity and mortality among blacks and Hispanics is devastating. Several investigators have reported various HIV risk patterns and a disproportionately higher incidence of AIDS among blacks and Hispanics than among whites.215 Together, blacks and Hispanics account for 39 percent of the AIDS cases reported to the CDC, even though these ethnic/racial groups together comprise only 18 percent of the US population. These AIDS cases are distributed among the same transmission categories as cases among whites. There are, however, distinctive differences among ethnic/racial groups in the prevalence of various behavior patterns associated with HIV exposure. HIV transmission has been linked to homosexual/bisexual behaviors in 79 percent of AIDS cases among whites, 39 percent among blacks, and 48 percent among Hispanics. In comparison, intravenous drug abuse-associated AIDS cases comprise 6 percent of AIDS cases among whites, 35 percent among blacks, and 35 percent among Hispanics. Evaluating the remaining recognized routes of transmission, AIDS cases among whites tend to be linked to homosexual/ bisexual behaviors and transfusion-related infection. In contrast, AIDS cases in black and Hispanic populations are more likely to be associated with intravenous drug abuse or heterosexual contact with persons at increased risk of developing AIDS. Upon further review, these heterosexual contacts are largely IVDAS. A major issue in epidemiologic discussions is the extent to which differences in virus acquisition explain the disproportionate risk of AIDS in black and Hispanic populations. An evaluation of the racial distribution of AIDS cases in each of the acknowledged transmission categories sheds some light on this issue. Because nearly 95 percent of all AIDS cases have been homosexual/bisexual males and IVDAs and their heterosexual contacts, this evaluation will be limited to these transmission categories. Of the 34,498 AIDS cases associated with bisexual/homosexual behaviors, 73 percent are white, 15.8 percent are black, and 10.2 percent are Hispanic. In comparison, 11,643 intrave nous drug-associated AIDS cases are 335 percent white, 42.7 percent black, and 23.2 percent Hispanic. IVDAS account for 60 percent of the sexual partners in |