PREPARED STATEMENT BY C. EVERETT KOOP, M.D., SC.D. SURGEON GENERAL U.S. PUBLIC HEALTH SERVICE AND DEPUTY ASSISTANT SECRETARY FOR HEALTH DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED BEFORE THE HOUSE SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT OF THE HOUSE COMMITTEE ON ENERGY AND COMMERCE Foun, FEBRUARY 19, 1988. “7 © MR. CHAIRMAN, | WELCOME THIS OPPORTUNITY TO APPEAR BEFORE YOU AND DISCUSS THE CRITICAL PUBLIC HEALTH ISSUES CONCERNING AIDS AND HIV INFECTION. FIRST | WOULD LIKE TO SAY THAT SINCE OCTOBER 1986 WHEN | RELEASED THE SURGEON GENERAL’S REPORT ON AIDS, THIS COUNTRY HAS DONE MUCH THAT WE CAN BE PROUD OF. THE NEWS MEDIA, PRINT AND ELECTRONIC, HAVE RENDERED TREMENDOUS SERVICE IN GETTING OUT CLEAR INFORMATION TO THE PUBLIC. THE ENTERTAINMENT MEDIA HAVE ALSO PUT OUT THE AIDS MESSAGE IN WAYS THAT CAN CHANGE BEHAVIOR AND SAVE LIVES. THE ADMINISTRATION AND THE CONGRESS HAVE GIVEN HIGH PRIORITY AND GREATLY INCREASED RESOURCES FOR THE FIGHT AGAINST AIDS AND HIV INFECTION. THE RESEARCH AND HEALTH CARE COMMUNITIES ARE WORKING HARD ON THESE PROBLEMS. IT !S | THE HIGHEST LEVEL OF ACTIVITY AND COMMITMENT TO A PUBLIC HEALTH PROBLEM THAT | HAVE SEEN IN MY LIFETIME. THERE IS A PUBLIC AWARENESS OF THIS HEALTH ISSUE AND A STRONG DESIRE TO TAKE PERSONAL AND PUBLIC ACTION. BUT THERE !S MUCH MORE TO BE DONE AND MANY ISSUES WHICH WE MUST ENJOIN IF WE ARE TO CONTAIN THE SPREAD OF HIV INFECTION. LET ME. SHARE A FEW ISSUES OF SPECIAL CONCERN. RECENT ARTICLES HAVE STATED THAT THERE IS NO DANGER OF HETEROSEXUAL TRANSMISSION FROM “NORMAL VAGINAL INTERCOURSE”. ALTHOUGH HOMOSEXUAL AND IV DRUG ACTIVITY ARE THE ROOTS BY WHICH MOST CASES ARE TRANSMITTED, IT IS JUST NOT TRUE THAT THERE IS NO DANGER FROM NORMAL VAGINAL INTERCOURSE. WHAT IS UNKNOWN IS THE LEVEL OF DANGER; BUT THERE IS ALWAYS A DANGER WHENEVER PEOPLE ENGAGE IN CASUAL SEX OUTSIDE THE MARRIAGE RELATIONSHIP, EVEN IF THEIR PROMISCUITY IS HETEROSEXUAL. TO DATE THERE HAVE BEEN 2,092 CASES OF REPORTED HETEROSEXUAL TRANSMISSION OUT OF A TOTAL OF 52,249 ADULT CASES OF AIDS (ABOUT 4%). IF YOU EXCLUDE THE FOREIGN-BORN, THE FIGURE DROPS TO 2.3% AND MOST OF THAT IS IN SEXUAL PARTNERS OF IV DRUG ABUSERS. THE CENTERS FOR DISEASE CONTROL (CDC) ESTIMATES THAT BY 1991 HETEROSEXUAL TRANSMISSION WILL ACCOUNT FOR 5% OF THE TOTAL ADULT CASELOAD. WE KNOW FROM THE INFECTED SPOUSES OF PERSONS WITH HEMOPHILIA THAT HIV CAN BE SPREAD THROUGH “NORMAL VAGINAL INTERCOURSE”. WHAT CONCERNS ME IS THE POTENTIAL FOR A MORE RAPID SPREAD OF HIV INFECTION INTO THE GENERAL POPULATION. ,BUT FOR THE GREAT MAJORITY OF AMERICANS, THOSE WHO RISK INFECTION ARE INDIVIDUALS WHO PLACE THEMSELVES AT RISK BECAUSE OF EXTRAMARITAL OR HOMOSEXUAL INTERCOURSE OR IV DRUG ABUSE, NOT NORMAL INTERCOURSE WITHIN THE BONDS OF MARRIAGE. OF COURSE, IN THOSE CASES WHERE A SPOUSE IS ALREADY INFECTED, INFECTION CAN TAKE PLACE IN MARRIAGE. BUT, THANKFULLY, PEOPLE WHO POSTPONE INTERCOURSE UNTIL MARRIAGE, AND WHO MAINTAIN A MUTUALLY FAITHFUL RELATIONSHIP THEREAFTER, ARE AT LITTLE RISK INDEED. THAT IS WHY | HAVE BEEN URGING YOUNG PEOPLE TO POSTPONE SEX UNTIL MARRIAGE, AND AFTERWARD TO REMAIN FAITHFUL TO THEIR MARRIAGE PARTNERS. AN INDICATION OF CASUAL SEXUAL ACTIVITY IS THAT REPORTED CASES OF INFECTIOUS SYPHILIS INCREASED BY APPROXIMATELY 30% FROM 1986 To 1987. THE GREATEST INCREASES WERE IN FLORIDA, NEW YORK CITY, AND CALIFORNIA (AREAS OF HIGH HIV INCIDENCE), RELATIVE INCREASES WERE GREATEST FOR FEMALES AND HETEROSEXUAL MALES OF ALL RACIAL AND ETHNIC BACKGROUNDS. - 10 - 1 AM ALSO CONCERNED ABOUT NEEDLE SHARING AMONG IV DRUG ABUSERS. -A RECENT NATIONAL INSTITUTE ON DRUG ABUSE (NIDA) STUDY OF HEROIN ADDICTS ADMITTED TO METHADONE TREATMENT INDICATED THAT 93% HAD SHARED NEEDLES (MOST IN THE LAST YEAR) AND 26% REPORTED DAILY NEEDLE SHARING; ONLY 14% REPORTED CONDOM USE. THESE FIGURES HAVE ALARMING IMPLICATIONS, FOR BOTH IV DRUG USERS AND THEIR SEXUAL PARTNERS. IT IS CURRENTLY ESTIMATED THAT THERE ARE ABOUT 1.1 MILLION IV DRUG ADDICTS. - 11 - THE SOLUTIONS ARE NOT READILY OBVIOUS. IV DRUG ABUSERS LEAD DISJOINTED LIVES AND MANY OF THEM ARE FUNCTIONALLY ILLITERATE. IT IS CRITICAL THAT WE FIND THE RIGHT COMBINATION OF STRATEGIES TO GET PEOPLE OFF DRUGS AND AWAY FROM CONTAMINATED NEEDLES. | WOULD ALSO LIKE TO MAKE THE POINT THAT ONE OF THE COMPLEXITIES OF AIDS IS THAT IT IS AN EPIDEMIC, CHARACTERIZED BY RELATED ISSUES, A NUMBER OF THEM SOCIAL (E.G. HOMOSEXUALITY, -12- IV DRUG ABUSE). WE MUST ADDRESS OUR STRATEGIES TO MEET THE SPECIFIC DIMENSION OF EACH ISSUE RELATED TO THE EPIDEMIC IF WE ARE TO CONTAIN HIV INFECTION, NATIONALLY AND INTERNATIONALLY. | WANT TO ADD A SPECIAL WORD OF PRAISE FOR THE PHYSICIANS, NURSES, TEACHERS, SOCIAL WORKERS, AND OTHERS, ESPECIALLY IN AREAS WITH THE HIGHEST CONCENTRATIONS OF AIDS CASES...SPECIFICALLY, THE CITIES OF NEW YORK, SAN FRANCISCO, AND LOS ANGELES. - 13 - OVER 40 PERCENT OF THE NATION'S AIDS CASELOAD HAS APPEARED IN JUST THESE THREE CITIES ALONE. AND THE RESPONSE BY THE GREAT MAJORITY OF HEALTH PROFESSIONALS IN THOSE CITIES HAS BEEN OUTSTANDING. HOWEVER, EVEN THERE -- AND IN MANY OTHER CITIES ACROSS THE COUNTRY -- WE ARE SEEING A NUMBER OF INSTANCES IN WHICH HEALTH PROFESSIONALS REFUSE NOT ONLY TO TREAT PERSONS WITH AIDS, BUT ALSO TURN AWAY PATIENTS ALLEGED TO BE FROM POPULATION GROUPS -14- IDENTIFIED WITH THOSE TWO HIGH-RISK BEHAVIORS: THAT IS, HOMOSEXUAL AND BISEXUAL MALES AND INTRAVENOUS DRUG ABUSERS. FOR GOVERNMENT, FOR THE PROFESSIONS INVOLVED, AND FOR AMERICANS GENERALLY, THIS KIND OF BEHAVIOR BY MINORITY MUST BE A CAUSE FOR CONCERN. OF COURSE, THE REASON MOST OFTEN GIVEN IS THAT AIDS IS CONTAGIOUS AND FATAL AND "I DON’T WANT TO GET IT.” -15- BUT THE PLAIN FACT IS THAT THE RISK OF CONTRACTING HiV FROM AN INFECTED PATIENT IS EXTREMELY SMALL AND VIRTUALLY ALWAYS PREVENTABLE. OF THE NEARLY 7 MILLION AMERICANS IN THE HEALTH PROFESSIONS, WE KNOW THAT FEWER THAN ONE DOZEN HAVE BECOME INFECTED WITH THE VIRUS WHILE DOING THEIR JOBS. - 16 - AND IN MOST OF THOSE CASES, HIV EXPOSURE COULD HAVE BEEN PREVENTED, IF THE PERSON HAD FOLLOWED THE WORKPLACE GUIDELINES PUBLISHED BY THE CENTERS FOR DISEASE CONTROL MORE THAN 5 YEARS AGO. | CANNOT OVEREMPHASIZE: IT 1S ESSENTIAL THAT ALL WORKERS BE REQUIRED BY THEIR EMPLOYERS TO FOLLOW THESE CDC GUIDELINES AND THAT THEY BE PROVIDED WITH PROTECTIVE MATERIALS. -17- THE DECISION BY SOME HEALTH PROFESSIONALS TO DENY CARE TO HOMOSEXUALS, Iv -DRUG ABUSERS, OR OTHERS SUSPECTED OF CARRYING THE AIDS VIRUS IS; FHEREFORE; HISTORICALLY UNCHARACTERISTIC AND UNWORTHY OF ANYONE IN THE HEALTH OR SOCIAL SERVICE PROFESSIONS. IN 1988, THE FEDERAL GOVERNMENT WILL SPEND A TOTAL OF $1.465 BILLION ON AIDS, INCLUDING $375 MILLION THROUGH MEDICAID ON - 18 - AIDS TREATMENT; $931 MILLION ON AIDS RESEARCH AND EDUCATION; AND AN ADDITIONAL $159 MILLION ON TREATMENT AND PREVENTION EFFORTS. THE PRESIDENT’S FY 1989 BUDGET INCLUDES $2.026 BILLION FOR THESE EFFORTS, A 38% INCREASE OVER 1988. IN ADDITION, THERE ARE SOCIAL COSTS. SUCH AS LOST HUMAN CAPITAL, AND THESE ARE OFTEN TRANSLATED AS LOST WAGES AND PRODUCTIVITY. - 19 - BUT EVEN IF You PUT TO ONE SIDE THESE INDIRECT SOCIAL COSTS, WE WILL STILL FACE, IN ‘THE YEAR 1991, A NATIONAL BILL OF $3-TO-$5 BILLION FOR THE COST OF AIDS-RELATED CARE -- BOTH INPATIENT AND OUT-PATIENT, HOSPITAL AND HOSPICE. THESE 1991 COSTS WILL RESULT FROM THE CARE OF AN ESTIMATED 145,000 PERSONS WITH AIDS WHO WILL BE IN VARIOUS STAGES OF A TERMINAL ILLNESS. - 20 - THE COSTS ARE OVERWHELMING, AND ! DOUBT THAT THE AMERICAN PEOPLE HAVE COME TO TERMS WITH IT YET. CLEARLY, WE MUST DO A GREAT DEAL MORE TO DEVELOP ALTERNATIVE, LESS COSTLY, BUT HIGHLY EFFECTIVE WAYS TO CARE FOR AIDS PATIENTS. WE NEED TO DO THIS IN LIGHT OF THE SPECIFIC AIDS-RELATED DISEASES AND CONDITIONS WE KNOW ABOUT AND THE DIFFERENT STAGES THROUGH WHICH THEY PROGRESS. - 21 - THE CHALLENGE TODAY, IS TO GIVE THE COUNTRY A WAY OF CARING FOR AIDS PATIENTS WHILE PREVENTING AN ESCALATION OF COSTS. IN MY REMARKS | HAVE LIMITED MYSELF TO A FEW CRITICAL PUBLIC HEALTH ISSUES. THERE ARE MANY OTHERS AND THEY MUST ALL BE ADDRESSED IF WE ARE TO INTERRUPT THE CHAIN OF TRANSMISSION OF HIV AND SPARE OUR PEOPLE AND THE PEOPLE OF THE WORLD THE PAIN, SUFFERING AND DEATH OF - 22 - AIDS. WE NEED TO STOP IT IN A WAY THAT IS EFFECTIVE YET CONSISTENT WITH AMERICAN LAW AND TRADITION. WE CAN DO THIS JOB WITH THE HELP OF GOOD SCIENCE AND GOOD EDUCATION. WE CAN DO IT BY MAKING CERTAIN THAT THE AMERICAN PEOPLE HAVE A CLEAR UNDERSTANDING OF THE THREAT POSED TO THEM BY THIS DISEASE, AND THAT THEY ARE READY TO FIGHT BACK WITH THE BEST WEAPON AVAILABLE TO THEM: THEIR INTELLIGENT CHOICES ABOUT PERSONAL BEHAVIOR. AS THE ELECTED REPRESENTATIVES OF THE AMERICAN PEOPLE, YOU HAVE THE ABILITY TO - 23 - HELP THE PUBLIC HEALTH SERVICE MARKET GOOD DISEASE PREVENTION, GOOD SCIENCE AND GOOD | HEALTH CARE PRACTICES To THE PUBLIC. YOUR LEADERSHIP ROLE WITH REGARD TO AIDS HAS AND WILL SERVE THE BEST INTERESTS OF THE AMERICAN PEOPLE. THANK YOU.