Facing the Health-Policy Challenge of HIV Infection

Article excerpt

Infection with the human immunodeficiency virus (HIV) was unknown prior to 1981. Today it is becoming one of the major challenges facing health-care policymakers throughout the world.

HIV disease has a latency period averaging ten years. This means that the full effect of current infection has not been reached in terms of clinical cases of the later stage of disease - acquired immunodeficiency syndrome (AIDS). The National Commission on AIDS (NCA) estimates that one million people in the United States are currently infected with HIV and yet show no clinical signs of disease. Officials of the government have estimated that 40,000 to 80,000 new infections are occurring each year. AIDS is currently the sixth leading potential cause of years of life lost for individuals under sixty-five years of age. Just when the focus in disease prevention was on chronic, noninfectious diseases, HIV infection came along to remind health policymakers that infectious disease can still be a plague for modem society.

HIV: Subcultural Epidemics, but a Problem for All. HIV infection has highlighted our subcultural nature from multiple perspectives - ethnic, behavioral, gender, and religious. Moreover, the societal ramifications of the disease, with its attendant politics, have greatly influenced decision making in health policy. Certainly, there are reasons for focusing on the subcultural nature of the disease. Specific strategies of prevention and/or treatment may be more relevant to certain groups than to others. Noting disease clusters may also help to target expenditures more cost-effectively. Unfortunately the subcultural focus also has a negative side. It has served to make some groups feel that HIV infection is a disease to which they are immune, and it has added to the hate focused on subcultures perceived as being "responsible" for the disease.

HIV currently affects U.S. ethnic minorities disproportionately. As of July 1992, 29 percent of adult and 53 percent of pediatric sufferers of AIDS were black. At the same time, 16 percent of adult cases and 24 percent of pediatric cases were reported in the Hispanic population. A problem for ethnic minorities is the potential for HIV infection to be used as justification for further discrimination. Reports also indicate that the HIV epidemic may be exacerbating racial tensions and heightening minority fears.

Behavioral minorities such as homosexuals, bisexuals, prisoners, and users of intravenous drugs have also been severely affected in the early years of the HIV epidemic. Debate over society's responsibilities toward these groups complicated prevention and treatment efforts. Men who reported having had sexual intercourse with other men accounted for 58 percent of the AIDS cases reported as of July 1992. Gay organizations have been active in fighting HIV and have been effective in encouraging safe practices of sex. There are still gay subgroups that seem to be a challenge in terms of efforts at prevention. According to the NCA, these are young gay males, gay men of color, homosexual or bisexual men who do not identify with the message of gay organizations, and lesbians.

The illegal nature of drug use has complicated initiatives to prevent HIV. When efforts to stop illegal use of drugs fail, it is critical for makers of health policy to decide when alternatives such as needle-exchange programs are justified in the name of public health. While the debate over appropriate governmental antidrug strategies continues, the illegal use of drugs and associated sex continue to be a significant source of HIV infection. Currently about one-fourth of adult AIDS cases are directly related to injecting drug use, and more than 50 percent of pediatric cases of AIDS are associated with adult use of injected drugs.

Prisoners are another behavioral minority who are bearing a heavy burden in dealing with HIV infection. In March 1991, the NCA issued a report on HIV infection in correctional institutions. …