AIDS and public health.

After briefly stating the significance of acquired immunodeficiency syndrome (AIDS) for public health, this paper considers programs or proposals to control the spread of AIDS in the following eight general areas: (a) education; (b) distribution of sterile needles; (c) screening and treatment of blood, blood products, and other tissues; (d) voluntary and mandatory screening of persons for evidence of infection; (e) reporting; (f) contact tracing; (g) isolation and other restrictions on freedom of movement or association; and (h) physical marking of persons with AIDS. Significant moral issues within each of these areas are discussed, and the overall justifiability of various proposals is examined.     

Trends in transfusion-associated acquired immune deficiency syndrome in the United States, 1982 through 1991

To evaluate the efficacy of measures for preventing the transmission of human immunodeficiency virus (HIV) by blood transfusion, trends in transfusion-associated cases of acquired immune deficiency syndrome (AIDS) reported through June 1992 were analyzed. By year of transfusion, cases rose from 56 in 1978 to 714 in 1984, dropped sharply to 288 in 1985 when screening of donated blood for HIV antibody began, and fell below 20 per year from 1986 through 1991. Reinvestigation of a sample of cases suggested that only one-fourth of those attributed in the trends analysis to post-1985 United States transfusions actually were due to that source. By year of AIDS diagnosis, cases climbed from 14 in 1982 to 824 in 1987 and subsequently remained relatively level. Of cases diagnosed in 1991 with known transfusion dates, almost all resulted from transfusions received before 1986. Cases in persons aged > or = 65 years at diagnosis fell steeply after 1987, while those in persons aged 45 to 64 years leveled and those in persons aged 25 to 44 years continued to increase; this caused the median age to decrease from 59 in 1986 to 47 in 1991. Thus, screening and other measures have almost completely prevented transmission, but, because of infections acquired before screening began, many cases continue to be diagnosed among increasingly younger persons.     

Prevalence of antibodies to human immunodeficiency virus type 1 among blood donors prior to screening. The Transfusion Safety Study/NHLBI Donor Repository

The Transfusion Safety Study (TSS) and the National Heart, Lung, and Blood Institute (NHLBI) established a repository of approximately 200,000 sera from blood donors in late 1984 and early 1985. Collections were made in the four metropolitan areas with the highest prevalence of AIDS. Retrospective testing showed an overall anti-HIV-1 prevalence of 16 cases per 10,000 donations. In this study, the predictive value of a negative initial enzyme-linked immunoassay was estimated from both quality control specimens and the rescreening of 13,461 sera to be greater than 99.99 percent with respect to technical error. Among anti-HIV-1-positive persons, there was a 1.3- to 1.5-fold excess of first-time donors. The anti-HIV-1 prevalence among donors showed that infection was more common among young men than suggested by national reporting of AIDS cases. Anti-HIV-1 prevalence varied among the four metropolitan areas less than did reported AIDS cases, but, by 1987, the differences in the latter had decreased. Anti-HIV-1 prevalence in collection areas outside of the four major cities differed much more widely than that among the cities themselves. The TSS/NHLBI Donor Repository will remain available for the indefinite future for further evaluation of screening procedures for HIV-1 and other viruses for which transfusion is found to be an important route of transmission.     

Identification of HIV-infected transfusion recipients: the utility of crossreferencing previous donor records with AIDS case reports

An expanded "look-back" program has been developed, in which patients who may have been exposed to HIV through blood transfusion were identified via three triggers: the blood that they received was donated by persons who 1) have subsequently been reported to local health departments as meeting the diagnostic criteria for AIDS, 2) have donated since the introduction of anti-HIV screening and tested positive, or 3) have been found to be infected during investigation of reported transfusion-associated HIV infections. In comparing triggers, cross-referencing the list of patients reported to have AIDS (AIDS case list) proved to be the most efficient approach for identifying HIV-infected donors and transfusion recipients. Of the 7973 AIDS patients reported in eight Northern California counties as of December 1988, 316 (4.0%) were determined to have donated at Irwin Memorial Blood Centers between 1977 and 1985. Despite the logarithmic increase in reported cases of AIDS in the San Francisco Bay area over the last 5 years, the rate of detection of previous donors from AIDS case lists remained between 3.3 and 5.4 percent. These persons accounted for 69 percent of the identified infected donors, and their identification led to notification of 60 percent of potentially exposed recipients and 51 percent of known infected recipients. The crossreferencing of AIDS case listings with blood bank records was equally efficient for regions with low and high AIDS prevalence. National adoption of AIDS case list crossreferencing is recommended as an effective means of identifying previously unidentified infected recipients in an effort to limit the secondary spread of HIV infection.     

Time from diagnosis of acquired immune deficiency syndrome (AIDS) to death among persons with blood-borne AIDS in Italy

The objective of the study reported here was to analyze survival time and factors associated with more rapid death among persons with acquired immune deficiency syndrome (AIDS) in Italy who acquired human immunodeficiency virus (HIV) infection through the transfusion of blood (n = 115) or blood components (n = 111). Subjects included all persons with AIDS all reported to the Italian AIDS Registry. The Kaplan-Meier method was used to estimate both the median survival time from the date of AIDS diagnosis to the date of death and the median survival time stratified by age at diagnosis, time of diagnosis, and AIDS-indicator disease. The Cox proportional-hazard model was used to assess factors independently associated with death. The prognosis for persons with blood-borne AIDS in Italy remains poor: overall median survival time was estimated to be 9.2 months, with no significant differences between hemophiliacs and transfusion recipients (p = 0.91). The median survival time for subject > 60 years old was 6.0 months, which is a significantly shorter time than that for younger subjects (p < 0.001). Subjects diagnosed prior to 1988 had a median survival time of 8.2 months, which is a significantly shorter time than that for subjects diagnosed after 1987 (p < 0.03). Subjects neurologically affected by AIDS had a median survival time of 4.1 months, which is a significantly shorter time than that for subjects diagnosed with any other disease (p = 0.03). Such factors were independently associated with more rapid death.     

The Georgia Rural-Based Nurse Model: Primary Care for Persons with HIV/AIDS

Abstract The need for specialized HIV education for nurses working in rural areas will increase as the incidence of HIV infection increases in rural areas. Public health nurses provide a viable alternative to providers in acute care facilities and will continue to be the primary care providers for persons with HIV/AIDS in rural areas. While approaches to HIV/AIDS education should include clinical treatment as the core, clinical knowledge alone will not promote the development of caring communities. The Rural-Based Nurse Model provides a comprehensive curriculum that addresses the many complex issues associated with the care of persons with HIV/AIDS. Additionally, participants are linked with care providers who serve clients across the continuum of HIV disease. Through meaningful educational opportunities and provider networking, this program has the potential for improving the quality of care in rural areas for persons with HIV/AIDS. HIV/AIDS education programs will require individualized community strategies that consider existing resources and barriers. However, the Rural-Based Nurse Model provides a formula for HIV/AIDS education that can be easily adapted to other settings.     

AIDS and Homosexuality: A Longitudinal Study of Knowledge and Attitude Change Among Rural Nurses

With no effective medical treatment or vaccine for acquired immunodeficiency syndrome (AIDS) available now or in the near future, nursing can make the most difference by providing emotional support and physical care for people with AIDS and their families. One of the least understood areas in providing such care is the feelings nurses have toward persons with AIDS, especially in rural areas. This study measured changes in knowledge and attitude toward AIDS and homosexuality before, immediately after, and three months after an all-day AIDS workshop for nurses. The program provided current knowledge about transmission of the human immune virus and risk behaviors, and addressed personal feelings regarding fear of caring for persons with AIDS as well as negative feelings associated with homosexuality. Results revealed significant positive changes in knowledge and attitudes three months later. Participants also became significantly less fearful and more willing to care for persons with AIDS. Feelings of fearfulness and willingness to care for people with AIDS were associated not with knowledge differences but with differences in attitudes toward the disease and homosexuality. Therefore, this program's affective component was more closely associated with precursors to behavior change than was cognitive education. As the education needs of rural and community nurses increase, programs specific to them must continue to be developed and studied. Future research must also explore and evaluate actual nursing care of AIDS patients in relation to education program objectives.     

How Caring for Persons with HIV/AIDS Affects Rural Nurses

Prior research findings about caregiving for persons with HIV/AIDS indicate that caregiving impacts nurses in three separate domains: personal self as a nurse in practice; interactions with the nurse's family members, friends, and colleagues; and interactions with persons with HIV/AIDS. However the impact caregiving for persons with HIV/AIDS has on rural nurses has not been extensively explored. A qualitative study of rural registered nurses' experiences of caring for persons with HIV/AIDS was conducted to determine how caregiving affects registered nurses in rural areas. Content analysis was used to analyze rural registered nurses' written comments about their experiences of caring for persons with HIV/AIDS. Themes identified from the nurses' accounts of instances of caregiving were the perceived risk of acquiring the virus, a lack of concern about HIV/AIDS, and a need for ongoing continued education about the care of persons with HIV/AIDS.     

浙江省金华市无偿献血人群艾滋病病毒感染现状分析

目的 了解浙江省金华市无偿献血者人类免疫缺陷病毒(human immunodeficiency virus,HIV)感染的状况及流行特征,以确定低危献血人群,降低输血传播HIV的风险。 方法 对2006年1月至2012年7月266 844例无偿献血者利用酶联免疫吸附试验进行抗-HIV检测,结果采用免疫蛋白印迹(WB)确证,并对抗-HIV确证阳性者进行流行病学调查与统计分析。 结果 抗-HIV抗体初筛阳性共406例,WB法确证阳性29例,阳性率为0.01%,不确定5例,其余确证为阴性。经流行病学调查,异性传播19例,占65.5%。同性传播9例,占31%。 结论 结合本地区献血人群的HIV感染状况、流行特征,应从无偿献血招募、体检咨询工作方面采取积极有效的措施,需加强与社会互动,开展对献血者艾滋病相关知识的宣教,从而达到保证血液质量与安全。     

Measures to decrease the risk of acquired immunodeficiency syndrome transmission by blood transfusion. Evidence of volunteer blood donor cooperation

We studied whether volunteers giving blood to the Greater New York Blood Program (GNYBP) cooperated with procedures implementing public health recommendations intended to decrease the risk of acquired immunodeficiency syndrome (AIDS) transmission by blood transfusion. Predonation medical screening was expanded to exclude donors who might be ill with AIDS. To exclude possible asymptomatic carriers of the disease, members of groups at increased risk of AIDS were asked either not to give blood or to give it for laboratory studies. A confidential questionnaire, administered to all donors after medical screening, provided the vehicle for donors to advise the GNYBP whether their donation was for laboratory studies or for patient transfusion. We found that the number of male donors decreased; AIDS-related questions in medical history led to a 2 percent increase in donor rejections; 97 percent of donors said their blood could be used for transfusions; 1.4 percent said their blood could be used for laboratory studies only; and 1.6 percent did not respond. Only units designated for transfusion were released to hospitals. People who indicated that their donation was for laboratory studies had a higher prevalence of markers for hepatitis B virus and of antibodies to cytomegalovirus. White cell counts and helper/suppressor T lymphocyte ratios were not significantly different in the two groups. We conclude that volunteer donors have cooperated with the established procedures. None of the laboratory assays identified blood units donated by individuals who, based on information about AIDS high-risk groups, designated their donation for laboratory studies.     

Screening potential blood donors at risk for human immunodeficiency virus

Even though all blood donated for transfusion is tested for the presence of human immunodeficiency virus (HIV) antibodies, there exists a period of time after infection by the virus before these antibodies can be detected. Blood donated during this window period is capable of transmitting the virus. Therefore, the blood of persons who are at risk for acquired immune deficiency syndrome (AIDS) should not enter the blood supply. Over a period of 4 months, 6573 potential blood donors who entered fixed and mobile blood collection sites in two cities were exposed to alternative interventions the aim of which was to exclude persons at risk for AIDS. We compared the interventions to one another and to existing materials in terms of the numbers of at-risk persons who did or did not donate for transfusion, the amount of attention paid to the materials, the scores on a comprehension test, and the self-reports by the subjects of attitudes towards the various interventions. At-risk donors who were asked direct AIDS risk behavior questions in addition to the current health history questions were more likely to be screened out than those who underwent alternative health history interviews (p less than 0.01). Potential donors paid more attention to the experimental brochures than to the experimental video or current materials (p less than 0.05). Comprehension scores were better for the new brochure and the video than for the current brochure (p less than 0.05). Donors were not offended by the experimental interventions.(ABSTRACT TRUNCATED AT 250 WORDS)     

The performance of blood pressure and other cardiovascular risk factors as screening tests for ischaemic heart disease and stroke

This paper summarises the main evidence and conclusions relating to using blood pressure measurement as a screening test to identify people who will develop ischaemic heart disease (IHD) or stroke, as recently published in a Health Technology Assessment report. While blood pressure is recognised as an important cause of stroke and IHD, and lowering blood pressure can substantially lower the risk of these diseases, the measurement of blood pressure is a poor screening test. It is not good in distinguishing those who will and will not develop these diseases. The poor screening performance is illustrated by the findings that in the largest cohort study, persons in the top 10% of the distribution of systolic blood pressure experienced only 21% of all IHD events and 28% of all strokes at a given age. Using several cardiovascular risk factors in combination does not add materially to the poor screening performance of blood pressure alone. Among persons in a specified age group, the 5% at highest risk experience 17% of all heart disease deaths with risk computation based on blood pressure alone, 22% when based on blood pressure and apolipoprotein B (or LDL cholesterol) in combination, and only 28% using these two, smoking and three other cardiovascular risk factors all in combination. Identifying patients at the time of hospital discharge following myocardial infarction or stroke is the most effective screening test to identify those who will die of cardiovascular disease. In patients with a history of myocardial infarction or stroke the cardiovascular death rate in the absence of treatment is about 5% per year, a risk that persists for at least 15 years. In the absence of treatment, about half of all deaths from heart disease in a population occur after hospital discharge following the first infarct. Among persons with no history of cardiovascular disease, age is a better screening test than the reversible risk factors, and the best policy is to offer treatment to all persons above a specified age such as 55 years.     

Epidemiologic comparison of human T-lymphotropic virus type I-infected blood donors from endemic and nonendemic regions over a 3-year period

BACKGROUND: Screening for human T-lymphotropic virus type I (HTLV-I) infection became systematic in 1989 in the French West Indies for blood from all donors and in France for blood from natives of endemic areas; in 1990, it was extended to blood from donors with at-risk sex partners and in July 1991 to blood from all donors. STUDY DESIGN AND METHODS: The epidemiologic characteristics of individuals found through the screening of donated blood to be HTLV-I infected were compared for an endemic region (Guadeloupe, French West Indies) and a nonendemic region (Paris area) over a 3-year period (1989 through 1991). RESULTS: In Guadeloupe, 131 HTLV-I-infected individuals were detected in the screening of 28,801 units; in the Paris area, 38 HTLV-I-infected donors were detected in the screening of 109,824 units. All Guadeloupean HTLV- I-infected donors were natives of endemic areas. Among the 38 Parisian HTLV-I-infected donors, 21 were natives of endemic areas, 10 were natives of endemic areas and had received transfusions, 2 were whites who had received transfusions, and 5 were whites who had had heterosexual contact with natives of endemic areas. The percentage of HTLV-I-infected individuals whose blood would have been excluded because of positivity for one or more markers for other viruses did not significantly change over the study period and did not significantly differ between regions (41%). Among the eight Parisian HTLV-I-infected blood donors detected after July 1991, six would not have been detected without the biologic screening. CONCLUSION: The generalization of biologic screening of HTLV-I-infected donated blood in France was useful for the prevention of HTLV-I and HTLV type II infections through transfusion.     

Diagnostic criteria for HIV/AIDS in Japan

In Japan, criteria for the diagnosis of HIV infection and AIDS have been revised in 1999. For the diagnosis of HIV infection, HIV-positivity has to be confirmed by western blot test or nucleic acid tests such as PCR for HIV when the results of screening tests for anti-HIV antibodies (ELISA) are positive. Diagnosis of AIDS can be made when HIV-infected persons show any one of 23 indicator diseases. Criteria for the diagnosis of these 23 diseases are described. The indicator disease most frequently seen in Japan is Pneumocystis carinii pneumonia followed by candidiasis, cytomegalovirus infection, tuberculosis and non-tuberculous mycobacteriosis in this order. The number of new cases of AIDS is still increasing every year.     

AIDS and AIDS-related conditions: screening for populations at risk

Since its onset, the acquired immunodeficiency syndrome (AIDS) epidemic has been associated with certain subgroups in the U.S. population. These include gay and bisexual men, intravenous drug users, hemophiliacs and blood product transfusion recipients. Members of these groups feeling either well or unwell may present themselves at clinics with a high level of anxiety regarding AIDS. Their needs for clinical evaluation of symptoms, education and reassurance, or further referral may be acute. The experience of the AIDS screening clinic at the AIDS/oncology clinic at San Francisco General Hospital has led to the development of protocols for nurse practitioners to use in screening members of AIDS risk groups, both the "worried well" and those who are symptomatic. This is a presentation of the clinic's screening history and physical examination criteria, including the markers of suspicion and algorithms of diagnostic studies that have been useful tools in the clinic.     

AIDS knowledge and beliefs related to blood donation in US adults: results from a national telephone survey

BACKGROUND: Misperceptions about the risk of contracting AIDS from donating blood may be preventing people from donating, while incorrect beliefs about AIDS screening tests or the appropriateness of donating with risk factors may place the blood supply at increased risk. STUDY DESIGN AND METHODS: Questions about AIDS transmission and testing and the acceptability of test seeking and donating with risk factors were asked in the National Community Health Survey, a telephone survey of 9859 US adults. Results were weighted to represent the US population. Demographic and donor status (current, lapsed, never) differences in knowledge and attitudes were examined using chi‐square and logistic regression. RESULTS: Nearly 25% of respondents thought it was somewhat or very likely that they could get AIDS from donating blood. Almost 80% knew that all blood donations are tested for AIDS, but only 65.5% knew about the test window period. A total of 33.5% felt that it was acceptable to use the blood center for AIDS testing, while 9.1% believed that it was okay for someone to donate even if they had AIDS risk behaviors; all had significant demographic and donor status differences. CONCLUSIONS: While there are many factors that prevent people from giving blood, the incorrect belief that it is possible to contract AIDS from donating is likely a barrier to donation. If blood centers dispelled this myth among those who have never donated, especially among minorities, it could be important for recruitment. In addition, our findings indicate that changes to education or recruitment could be needed to discourage test seeking and donations from risky donors.     

Disability in persons hospitalized with AIDS

This study documents the types and degree of disability seen in persons with AIDS at discharge from acute hospitalization. Based on 37 discharge evaluations using the Functional Independence Measure (FIM), 60% required human assistance in at least one of 18 FIM areas. Thirty-two percent required human assistance in five or more areas. Fifty-one and 38% required human assistance in stair climbing and ambulation, respectively. Feeding and bathing required assistance in about 33% and transferring to tub or shower in 25% of the sample. Increasing disability was associated with longer duration of AIDS diagnosis and increasing lengths of hospital stay (P less than 0.01 and P less than 0.05, respectively). There were individuals who remained nearly functionally independent up to 30 months after an AIDS defining event. The overall variability in function, however, was not significantly different between those with diagnoses less than and greater than 12 months. We conclude that significant physical disability exists in persons with AIDS at discharge from acute hospitalization. Consultation with and intervention by rehabilitation professionals may be helpful in the management of physical disability in this population and setting.     

Master scaling of perceived intensity of touch, cold and warmth.

A new approach is presented for scaling perceived intensity of touch, cold and warmth based on magnitude estimation. In this method named master scaling thenar is utilized as common reference area for scaling and calibrating perceived intensity. The master scaling is particularly well suited for clinical applications in which the stimulation in pain-affected body areas creates a complex perception (e.g., paradoxical heat for cold stimulation) and/or aberrant psychophysical functions for perceived intensity. The results from three different experiments showed that: (a) All patients and healthy subjects were able to scale adequately the perceived intensity of touch, cold, and warmth at unaffected body areas. (b) Thenar stimulations were shown to be adequate common references in the joint scaling of perceived intensity of other body areas in pain patients as well as healthy persons. (c) Individual thenar psychophysical functions can be used for screening patients and healthy persons with regard to their ability to scale perceived intensity of touch, cold and warmth. (d) Master scaled perceived intensity scales can be used for determining if various pain-unaffected body areas are normal or abnormal in patients and in healthy persons. (e) The interindividual variation in perceived intensity is considerably reduced after master scaling and approaches that of intraindividual variation as found in olfaction and hearing. Finally, empirically based thenar Master Functions of perceived intensity for touch, cold and warmth are proposed to be used in future sensory testing of patients, as well as of healthy persons.     

Strengths and weaknesses in methods for identifying the causative agent(s) of acquired immunodeficiency syndrome (AIDS)

Human immunodeficiency virus (HIV) is a cytoplasmic retrovirus which is transmitted via body fluids, especially through blood products and sexual contact, and is the causative agent of the acquired immunodeficiency syndrome (AIDS). Only about 5 to 10% of the patients infected with HIV contract AIDS; the great majority of infected people either develop a less aggressive condition (AIDS-related complex) or appear healthy. All persons infected with HIV may transmit the virus. In order to protect the national blood supply and to help in diagnosis, tests have been developed to identify infected persons. These include viral isolation techniques, enzyme-linked immunosorbent assay (ELISA), immunofluorescent assay (IFA), radioimmune precipitation (RIP) assay, Western blot, and, most recently, antigen identification and gene probes. Although the sensitivity and specificity among these methods varies, all are susceptible to false-positive and/or false-negative results. In order to understand the reasons for fragility in methodologies, it is necessary to appreciate several basic concepts related to the biochemistry, biology, pathophysiology, and genetic characteristics of HIV and related viruses. The purpose of this review is to present the strengths and weaknesses of each method, with emphasis on peculiar viral characteristics that lead to methodological defects or efficacies.     

The Mayo Three-Community Hypertension Control Program. III. Outcome in a community-based hypertension clinic.

As part of a broader community program to evaluate approaches to hypertension control, a Community Hypertension Clinic, staffed by two nurse practitioners, was set up in a rural community. Hypertensive persons were identified either by an initial central blood pressure screening or by a subsequent home screening. Slightly more than half of the hypertensive patients at initial screening, or 256 persons, elected to go to the Community Hypertension Clinic for second-stage screening, whereas the remainder elected to see their physicians or to do neither. After secondary screening at the Clinic, 120 patients eventually came under care and were managed by the nurse practitioners. After 2 years of follow-up, 57% of the Clinic patients had office-recorded diastolic blood pressures of less than 90 mm Hg. The Community Hypertension Clinic dropout rate was only 5% after 30 months of operation, for participants whose duration of follow-up ranged from 12 to 27 months (median 16 months), when a repeat home blood pressure screening examination was performed. Comparison of outcomes was thus possible between persons who attended the Community Hypertension Clinic and those who were referred to their physicians' offices. Persons with more severe hypertension most often elected to go to the Clinic, whereas patients with milder degrees of hypertension tended to go to their private physicians for follow-up or failed to make the recommended second-stage screening contact altogether. Greater declines in blood pressure were observed in the Clinic group.