[Music]
Ah ha! It says right here you can get AIDS from kissing.
I was right. I was right, see right it
down right it down. All right now look at this,
this is the President's report. This says that
you cannot get AIDS from kissing except for from deep
kissing. But it doesn't define what deep kissing is.
Well what's deep kissing? You want to try it?
No one is prepared to define deep kissing,
not even Webster. So you went into
the office. And what did she say?
Okay. She says oh wait wait first I went
in and I said I'm getting my test for AIDS,
my blood test. And she made me fill
out all these forms first and then she looks at
me and she goes you have nothing to worry about.
The way she just said that I was like
I wasn't aware you can tell from looking. You
had written across your face. You know right,
You don't have to be a drug
user or a homosexual to contract the AIDS virus.
Anyone can catch AIDS. [Music]
Good afternoon. A disease that hardly anyone had even heard
of five years ago now is killing tens of thousands
of people. The disease of course is AIDS.
And as much as we've heard about AIDS lately,
there are still a lot of misconceptions and misinformation about
the disease, the cause, the transmission and the
hope for a cure with this teleconference today
the Virginia cooperative extension service is trying to clear up
a lot of the misinformation from now until about 2.30.
We'll be hearing from several doctors and educators about
various aspects of the AIDS virus. First, we'll
hear from Virginia tech biochemistry professors Joyce Clark and
Thomas Sitz on the transmission symptoms and global scope of
the AIDS virus. Clark is a master's graduate of
Cambridge and a PhD graduate of the University of California.
Sitz as a PhD graduate of Tech with post doctoral
training at Baylor. The two help to develop and teach
a one semester course on AIDS first offered this
past fall at Virginia Tech. Next, we'll hear
from Dr. Charles Schleupner from the Veterans Administration Hospital and
Salem Virginia. He'll be discussing the testing for the
AIDS virus. Next Steve Shepherd will discuss AIDS prevention
and counselling. Shepherd is regional AIDS coordinator for the
Virginia State Health Department. He'll be talking with Joanne
Underwood, a student health services worker at Virginia Tech.
And after that Dr. Janet Taper Virginia Tech extension
nutrition and food specialist will discuss family support for AIDS
patients. Taper is a graduate of McGill University and
Virginia Tech. She works with the Tidewater Virginia AIDS
crisis Task Force and is developing two manuals on nutritional
support for AIDS patients. She'll be talking with Joyce
Simmons, a member of that task force. Then
to wrap up the first part of our teleconference Dr.
Richard Keeling of the University of Virginia. We'll talk
about AIDS on college campuses. Keeling is a graduate
of Tufts Medical School and is director of
UVA's Department of Student health. After
Dr. Keeling will take a break reconvening at 3:30
for a live hour long discussion with our presenters.
We'll take your questions on our toll free telephone line
at that time. First up doctors Joyce Clark and
Thomas Sitz to talk about the AIDS virus, it's
transmission symptoms and global spread. While the two have studied
the disease thoroughly, they don't like the title of
expert because they feel with AIDS there may not yet
be any true experts. This in part explains why
different, knowledgeable people say different things about AIDS.
Their intent here is introduction and background to tell you
what we do know about the disease and to remind
you how much yet there is to be learned.
So now Dr. Thomas, Thomas Sitz and Joyce Clark
AIDS is an epidemic affecting all parts of the earth.
A disease with such global proportions is properly called
a pandemic because men, women and children are dying
of AIDS around the world everywhere AIDS is transmitted by
three main routes by sexual intercourse. Both homosexual and
heterosexual through infected blood and from mother to child either
before during or after birth and in the mother's milk.
When we look at the worldwide spread of AIDS,
three distinct patterns emerge. Pattern one is found
in North and South America, Western Europe Australia and
New Zealand Sexual transmission is primarily homosexual, but heterosexual
transmission is increasing transmission by blood occurs primarily through IV
drug abuse. Although transfusions of infected
blood have also occurred because relatively few women are infected
at the present time, it is uncommon for Children
to be born with AIDS. Pattern two is found
in the countries of Central Africa and most countries of
the Caribbean Here, sexual transmission is predominantly heterosexual,
with men and women being equally infected. As might
be expected. A large number of Children are infected
transmission by blood occurs primarily through the transfusion of infected
blood and the re use of needles in medical practice
Pattern three covers the Middle East, Eastern Europe,
North Africa and Asia. In these parts of the
world, the incidence of AIDS is relatively low.
The disease is found mainly in those persons who have
had sex with infected foreigners. According to published reports,
60% of the world's cases have occurred in the
United States, 12% in Western Europe and Australia and
12% in Central Africa. Although this area is thought
to be under reporting, The remaining 6% have occurred
in the rest of the world. Yeah, the
difference in the three patterns that we've seen, pattern
one pattern tune, pattern three may have arisen because
of differences in the way the virus has introduced into
the population and when it was introduced, for example
, in the United States, the virus was first
introduced into the homosexual population And probably was amplified there
through the sexual revolution of the 1970s. By contrast,
in africa, it was introduced first into the
heterosexual population. So you have these two compact trusting
patterns, pattern one and planning to if AIDS had
first been recognized in Africa rather than the United States,
the myth of it being a homosexual disease would
not have arisen. Pattern to heterosexual transmission may become
the dominant pattern in the world. For example,
in the caribbean, which has a high incidence of
AIDS, the early cases were primarily in homosexual and
bisexual men. As the epidemic progress, the partner
transmission became heterosexual. We're seeing this start in the
United States as the virus moves out of the homosexual
population into the ivy drug abusing population and into the
general population. In the remainder of this unit,
we're going to be talking about a number of cases
of AIDS or the AIDS caseloads. And I think
it's important to understand that when we're looking at the
pattern of AIDS cases today, we're really looking at
the past with the AIDS virus. Unlike other viruses,
there's a long incubation period between when you're infected
and when you start to show symptoms of AIDS,
it's about eight years. And for this reason,
the pattern of age that we're seeing today really reflects
a part of transmission 7, 8, 9 years
ago. So if we want to know what the
pattern yesterday, we really need to know the pattern
of infection. Global AIDS surveillance is carried out by
the World Health Organization or who As of February 1989
, countries have reported a total of 140,000 AIDS cases
since reporting began. Who estimates that this world total
is under reported with an actual case load of 300,000
to 420,000. Who estimates that there will be 400,000
new cases of AIDS during 1989 and 1990. These
new cases will outnumber the total number that has occurred
during the entire history of the AIDS pandemic. Who
estimates estimates because we do not have a world survey
That 10 million persons are infected worldwide but not yet
showing symptoms in the United States. The actual number
of AIDS cases is known more accurately. The center
for disease control in Atlanta Georgia has kept statistics on
AIDS since 1981. Yet even these numbers maybe 20%
underestimated because of under reporting and delays. The CDC
publishes a monthly surveillance report, which is available in
many libraries. This graph plots the total number of
AIDS cases in the United States from 1981 to 1989
to show the progression of the disease. These are
not the new cases for each year, but the
total accumulated cases at the end of that year.
As of the week of February 13, there have
been a total of 86,157 cases of AIDS reported in
the United States. Aids has been reported in every
state. In the Union, 24% of all cases
have been reported in New York, 20% in California.
As the pandemic progresses, the percentage of cases
in other states will increase. The geographic distribution is
informative, but other distributions may be even more helpful
. A breakdown by age race and gender groups can
help us understand the true impact of AIDS on our
society. 80% of the AIDS cases in the United
States occur between the ages of 20 and 50.
This is in stark contrast to other slowly progressive diseases
such as cancer, which mainly affects the elderly.
Of the 21% with AIDS. In the 20-29 age
group, many may have been infected as teenagers.
Approximately 90% of cases in the United States are in
men and 10% in women. Year by year the
percentage of women with AIDS is increasing. Women typically
get AIDS through I. V. Drug abuse and
sexual intercourse. Sexual relations now accounts for 30% of
AIDS in women, compared with only 11% in 1985.
The size of the various risk categories is changing.
In 1987, of all AIDS cases contracted the
disease by male homosexual sex 1988 This group was reduced
to 55%. In contrast, I. V.
drug abuse increased as a transmission route from 18% in
1987 to 25%. In 1988, the heterosexual category
is small but growing Heterosexuals now account for 5% of
all AIDS cases, compared to 1%. In 1986
, AIDS has spread into the general population by Heterosexual
Sex, increasing from 41 cases per month in 1986
to 133 per month. In 1988, AIDS in
Children is especially tragic. Children born with AIDS usually
die within 2-3 years To date. 1400 Children under
13 have been diagnosed with AIDS. In the United
States, 78% were infected through birth. The number
of Children born with AIDS is expected to increase to
20,000 by the end of 1991. Recent data from
New York, the state with the highest percentage of
AIDS cases indicate that one in 62 babies in New
York City is born infected with the AIDS virus.
What what does the future hold? We want to
be able to predict the progression of the epidemic so
we can plan so we can plan to care for
those who are dying, care for those who need
medical attention. So we can maybe mitigate the social
and economic impact of this epidemic or pandemic is in
the world sense. What do we need? We
need to be able to model the epidemic mathematically and
statistically as we've done for other epidemics. To make
those models, we need accurate data and the most
urgent data we need is data on serial prevalence.
That is how many people are infected with the AIDS
virus but are not yet showing symptoms because it's these
people who are infected now who will be developing full
blown AIDS In the 1990s. To get that data,
we need to do masks testing for infection.
We have to do it randomly. We have to
do it in such a way that we guard the
civil rights and protect the civil rights of the persons
concerned. The C. D. C. has
made a short term prediction that the total number of
AIDS cases will increase to 300,000 by the end of
1991. The future of the epidemic in the United
States will be determined not only by its spread among
homosexuals and I. V. Drug abusers but also
by its growth in the heterosexual population. The key
factor for this group will be the number of sexual
partners. It is especially important to educate the group
that is highly sexually active teenagers. Mhm. The
cause of AIDS was discovered in 1983 by Dr.
Montagnier and his associates at the Pasteur Institute in Paris.
Their discovery occurred just two years after AIDS was
recognized as a new disease In 1984. The virus
was also isolated and cultured by the research group of
Dr. Gallo at the National Institutes of Health in
Bethesda Maryland. The virus is now known universally as
the human immunodeficiency virus or HIV. It was known
previously as H. T. L. V.
Three and V. In the six years since the
virus was isolated, scientists have learned a great deal
about HIV through the application of such disciplines as molecular
biology and immunology. For example, the development of
sophisticated tissue culture techniques has been critical for further understanding
tissue cultures allow scientists to grow the virus in cells
outside the body. Tissue culture techniques are shown here
in a biochemistry laboratory at Virginia Tech. The virus
itself is extremely small, its diameter is about 100
nm, much smaller than a bacterium and most viruses,
it can be seen only with an electron microscope.
A model of the virus has been built up
by groups of scientists working with electron microscopes. There
are three important parts of the virus that help in
understanding how it functions glycoprotein, the lipid membrane and
the virus's genetic material. RNA. A. These
glycoprotein knobs on the surface of the virus are crucial
to the infection process. They contain structures that bind
specifically onto a cell's outer membrane. The target of
the AIDS virus is mainly T four lymphocytes and macrophages
. Key cells of the human immune system, the
outer surface of the virus is a lipid membrane very
similar to the cells that it infects. This lipid
membrane prevents the virus from drying out when it is
outside the body. What happens to the virus when
it's outside the body? For example, when infected
blood is spilled or when maybe semen is spilt on
skin? Does the virus die immediately? We may
have read or heard that it explode? It's very
fragile. Well, it certainly doesn't explode and it's
not as fragile as we once thought. The survival
of the virus in Floyd's outside the body has been
of course, great concern to scientists. We're working
with concentrated solution to the virus is of course of
concern to health workers were going to come into contact
with spills of body fluids. The stability of survival
of the virus outside of the body was investigated in
1986 and the results of that investigation published in this
publication of The Journal of the American Medical Association,
April, 11, 255. And it's by Lionel
Resnick and his group and they also investigate how the
virus can be killed on neutralized. Researchers used a
highly concentrated preparation of the virus to determine how long
it could survive. Under three conditions at room temperature
at 56 C about the temperature of hot tap water
and as a dried solution. The results were as
follows. The virus survived 15 days at room temperature
, three hours at 56 C And three days as
a dried solution. Although the virus can survive for
some time outside the body, it is easily neutralized
or killed by such common items as household bleach,
detergents and alcohol. All of these substances disrupt the
lipid membrane. As the research shows, heat is
also effective in destroying the viral proteins. The World
Health Organization has prepared a document describing procedures for sterilization
by heat and disinfection with chemicals instructions for obtaining this
document will be given at the end of this program
. The third important part of the virus is its
genetic material which is found at its center or core
. Unlike plant and animal cells whose genetic material is
DNA. The AIDS virus uses ribonucleic acid or RNA
for reproduction. The second essential ingredient for reproducing the
virus is an enzyme reverse transcriptase. These two features
RNA as genetic material and reverse transcriptase classify HIV as
a retrovirus. HIV is also classified as a lentil
virus. Letter means slow. Aids is characterized by
a long latent period between infection by the virus and
the appearance of symptoms Typose seven years for men and
eight years for women. These three components, glycoprotein
, the lipid membrane and the virus's genetic material.
RNA. A play key roles in the life cycle
of the virus. Like all viruses. HIV depends
on a host cell for replication in the first stage
of infection, the viral membrane fuses with the cell
membrane and it's R. N. A. And
enzyme reverse transcriptase are released into the cell. Once
inside the cell, the enzyme transforms the viral RNA
into DNA, I don't know mm. The DNA
then migrates to the nucleus of the cell, where
it becomes part of the host cells, D.
N. A. And is known as pro viral
DNA. The long latent period begins at this point
and the pro viral DNA can lie quietly as part
of the host cell's genetic material for several years.
If the host cell is stimulated into activity by another
pathogens such as a flu virus, then the pro
viral D. N. A. Is also stimulated
. It recreates viral RNA. A. Which then
forms new viral particles and migrates back to the surface
of the cell. What happens next is shown dramatically
in this electron micrografx of an infected T. four
cell huge numbers of viruses are shown budding off the
cell surface where they enter the bloodstream and begin to
infect new cells. We may have been infected with
other viruses such as the flu virus, measles virus
, cold virus. We don't succumb to these infections
were protected by our immune system. We recover.
Why is the AIDS virus different this for a time
was an enigma. Just how how it evades the
immune system. Now we've just seen a typical life
cycle of a retrovirus. The AIDS virus is a
retrovirus and that life cycle can partially explain how the
virus evades the immune system. If you remember,
the viral genetic material becomes part of the host genetic
material within the cell. In effect the virus is
hidden in the cell from the surveillance of the immune
system. But there are other ways the AIDS virus
is highly psychopathic. That means it's got a very
strong ability to kill the cells it infects in this
way is different from other. Retroviruses tend not to
be a psychopathic. We can't fully explain this,
but part of the reason lies and it having a
more complex genetic material. It has extra genes that
somehow make it more lethal to the cells it infects
. So it destroys the cells of the immune system
and particularly thinking about this t fall lymphocyte which is
its principal target and which is a central cell in
the immune system. So it destroys the immune system
right? A third aspect which contributes to this evasion
of the immune system, is that it changes rapidly
. It mutates As many as 17 different strains of
the AIDS virus has been isolated from one individual.
These strains differ slightly in the structure of the outer
glycoprotein. Cult AIDS virus is mutating faster than the
flu virus. We all know that the flu virus
is changing fast but the AIDS virus is mutating about
five times more rapidly than the influenza virus. In
other words Is changed as much in 10 years as
the influenza virus has changed in 50 years. What
are the consequences of this rapid mutation? Well,
it means for one thing that the antibodies that we
produce that normally protect us against pathogens. For example
, of the viruses cannot recognize these variants of the
AIDS virus so they're rendered ineffective. It also means
that some of these AIDS variants may be more psychopathic
. We're not sure of that. Okay, the
rapid mutation of the AIDS virus is one of the
major obstacles in developing a vaccine. The basis of
the vaccine is to elicit antibodies, protect you against
a particular pathogen. In the case of the AIDS
virus, the vaccine would have to protect us against
many different strains, non strains and strange to be
developed and this is one of the major reasons why
researchers in the field are very pessimistic about vaccine development
. They certainly don't predict a vaccine. The vaccine
will be developed before the end of this century and
maybe maybe not after that at this point, it
might be helpful to summarize the complex information presented thus
far. The human immunodeficiency virus, or HIV,
was discovered as the cause of AIDS in 1983.
It infects and destroys important cells of the immune system
, specifically T4 cells and macrophages. It can survive
outside the body but it is readily destroyed by bleach
, alcohol, detergents and heat. HIV is a
retrovirus, meaning its genetic material is RNA. Rather
than DNA. It is also a lentil virus,
which means it lies dormant for years before it acts
after entering the host cell. It's RNA transforms into
pro viral DNA by means of the enzyme reverse transcriptase
. This DNA then hides in the genetic material of
the host cell's nucleus until it is stimulated to replicate
itself and spread from the host cell. It mutates
frequently so that it is not detected by the hosts
antibodies. Once a person is infected with the AIDS
virus, how is the immune system damaged and eventually
wiped out? T four lymphocytes are of critical importance
to the immune system. They are also one of
the main targets of the AIDS virus. This graph
shows a typical time course for the depletion of T
four cells in an infected patient Over a seven-year period
, the infected persons T- four cells are gradually reduced
to dangerously low levels. Scientists have discovered three ways
that these cells are killed. As shown in this
electron micrografx, the virus buds off the surface of
the host cell when it is stimulated or turned on
the budding activity itself can kill the host cell.
There are other methods by which the virus can kill
T- four lymphocytes. One way is that infected cell
confused with many other non infected cells. This will
form a large complex a few cells which will then
die. And another method to is that the uh
there's another cell type in the body called the killer
cell. That can be targeted to kill infected T
four lymphocytes. And these killer cells can also target
and kill uninfected T four lymphocytes. What this results
in in is a depletion of T. four population
T4 lymphocyte population of the body and this land leads
this severe depletion the immune system that's observed. Yeah
The macrophages, another blood cell type that can be
infected with HIV Macrophages are also important in the immune
system. But unlike T. four cells they are
not killed by the virus, the macrophages thought to
be responsible for transmitting the virus to the brain.
About two thirds of AIDS patients have some level of
brain damage visible on autopsy, a condition called AIDS
dementia. In addition to the blood and brain cells
, cells in the colon and bone marrow may also
be infected by HIV infected colon cells often cause diarrhea
. In AIDS patients, infected bone marrow cells can
cause severe anemia. Mhm. The discussion so far
has focused on the virus itself. What is the
nature of the disease called AIDS? How do the
signs and symptoms of AIDS affect the definition of the
disease? Mm They're currently two different ways of viewing
the disease. You have the CC surveillance definition for
AIDS and then you have the walter reed staging system
. Now, the CDP CDC surveillance definition is dependent
upon a patient getting sick with some symptoms of AIDS
, going to a position and then the position diagnosing
the disease and reporting it for the Center for Disease
Control. The walter reed staging system is very similar
to the type of staging staging that's used in treating
cancer patients and is more indicative of a progression disease
, from infection to various symptoms and following to death
. In the C. D. C. Definition
of flow chart is used by a physician to classify
persons as having or not having AIDS according to their
sets of symptoms. The following two examples would both
be reported to the CDC, A person syrup positive
for an AIDS test with a weight loss greater than
10% of baseline body weight and a chronic weakness and
documented fever. These symptoms are typical of a condition
that was previously called AIDS related complex or arc.
The second case example is more severe, a negative
AIDS test and Pneumocystis Carini pneumonia, the so called
AIDS pneumonia. Certain symptoms such as this type of
pneumonia are sufficient to automatically classify a person as having
AIDS. The AIDS test can be negative because the
patient may not be able to produce enough antibodies to
be detected by the test. The walter reed staging
system focuses on the progression of the disease. Following
infection. This graph was used earlier to show the
eventual decline of T. four cells in the immune
system of a typical infected person. We now superimpose
the six stages of the disease progression on it.
An infected person is classified into one of these six
stages, depending on their depletion of T4 cells,
type of opportunistic infection and other criteria. This system
begins at initial infection. Stage one with no symptoms
. Stage two symptoms include chronic swollen lymph glands.
In stage three and 4, the immune system deteriorates
, but it is not clinically obvious. Stage five
is characterised by various skin and mucous membrane infections and
other immune defects. In stage six, the infection
becomes systemic and the entire body is affected. The
question becomes what percentage of infected persons develop symptoms of
AIDS? Data from robert Redfield at walter reed indicate
that all infected persons may eventually develop symptoms of AIDS
. As the walter reed staging system implies, AIDS
may be viewed as a continuous progression from infection through
various stages of sickness to death. The message is
clear the AIDS virus is lethal. It should be
clear by now that there is no cure for AIDS
. The drugs that are now available like ACT and
the ones that will probably be approved in the near
future will slow down the progression of the disease.
The drugs under consideration Work in one of 2 ways
either directly impact on the AIDS virus itself by slowing
down the progression disease or they treat the various opportunistic
infections that these AIDS patients develop. Okay, scientists
who examine the life cycle of H. I.
V. C. Several obvious places to attack the
virus with drugs. For example the only approved drug
inhibits the enzyme reverse transcriptase. As described earlier.
This enzyme converts the viral RNA into DNA after it
has entered the cell. Other drugs similar to egg
are now undergoing clinical trials. Hopefully they will be
approved soon and will make treatment more effective. Scientists
are also developing ways to block the virus from infecting
new cells. They are attempting to use the C
. D. For protein which the virus uses as
a marker to target and bind to new cells.
Many approaches are being developed to prevent the AIDS virus
from destroying the immune system. At present, the
hope is to slow the progression of the disease until
AIDS patients can live almost normal lifespans. A second
major area of development is to treat the opportunistic infections
that develop after AIDS has weakened the immune system.
These diseases, various fungal viral and bacterial infections are
the eventual killers of AIDS victims. New drugs and
more aggressive treatments are being developed and tested to control
these infections. Yeah, the transmission of the AIDS
virus is the subject of overwhelming concern to all of
us. The tragic case of the burke family,
first described in a special issue of the journal Scientific
american, graphically illustrates some of the major routes of
transmission. It also shows how AIDS may not be
transmitted. The father, a hemophiliac, contracted the
AIDS virus through a transfusion of infected blood. He
then unknowingly infected, his wife who also became pregnant
. She gave birth to the baby boy who was
also infected. The father and son are now dead
and the mother has some symptoms of infection. The
daughter who was born before the mother became infected is
healthy and free of infection. The lesson is clear
, casual contact. The type of contact to which
the daughter was exposed does not transmit the virus,
as mentioned previously. The major routes of transmission in
the United States are sexual transmission, infected blood transmitted
by I. V. Drug abuse and from mother
to child before during or after birth. Other transmission
routes have also been documented blood transfusions. Laboratory workers
using highly concentrated solutions of the virus and clinical workers
splashed with infected blood. Also, persons are at
risk who share needles for steroid injections, tattooing or
ear piercing with unsterilized equipment and so forth. The
determination of transmission routes is a subject of some controversy
among scientists and medical personnel. Scientists used two basic
methods to determine various transmission routes. We have biological
types of evidence and epidemiological data. Biological methods have
been hampered by the lack of a good animal model
. For example, like a laboratory rat epidemiological methods
, Look at the distribution of the AIDS virus in
a particular human population or survey a particular population.
Let's look at some different possible routes of transmission.
We've heard a lot about the possibility of mosquitoes transmitting
the virus. There is a definite epidemiological data that
says mosquitoes do not transmit the AIDS virus and we
also have biological data that would tend to support that
. So we can at this point in time say
that mosquito transmission of AIDS if it occurs an extremely
rare or nonexistent phenomenon. Now, if we look
at another route of transmission, like intimate kissing,
which we hear a lot about. Also we can't
get epidemiological evidence because most people that engage in sex
also engage in intimate kissing so we can't discriminate that
through epidemiology. But there is some biological data,
even though we don't have an animal model, we
can isolate the AIDS virus from saliva and blood is
also isolated from saliva, suggesting that perhaps might be
a possible route of transmission from a practical standpoint.
The evidence is clear on the subject of transmission,
direct exposure to body fluids containing the AIDS virus or
infected cells is the only known method of transmission.
This rule can serve as a guide for future behavior
. It should be clear at this time that the
AIDS virus is lethal that AIDS is a fatal disease
. Drugs or vaccines will not cure or prevent this
epidemic. Aids can only be prevented through education and
changes in our behavior. That was dr choice clark
and Thomas Sitz talking about the AIDS virus. Next
we'll hear from dr Charles Schleupner with the Veterans Administration
Hospital in Salem Virginia. He'll be talking about testing
for the AIDS virus. What I would hope to
do with you today is to review the application of
HIV antibody testing in the general population and in selected
populations. To do this, we must first review
the serological response to HIV infection and then I would
like to discuss with you briefly the mechanisms for doing
the test, the results of the application of this
test that we've been able to evaluate so far in
the United States. And then briefly at the end
of the discussion, review the application of this test
to certain populations within the United States. So with
that introduction, I'd like first to point out that
this test is not likely to help us stamp out
AIDS, as some people would suggest, but rather
to help us understand better the epidemiology of this infection
and to assist patients in deciding whether changes in lifestyle
habit or what the future is going to bring for
them might be. There are three major approaches to
studying HIV infection in a patient or population group.
The first is an essay for antibodies to this virus
. We can use assay techniques which are screening and
this is the S. A technique called an enzyme
immuno S. A. Or E. I A
. Which has previously been called and Alyssa or enzyme
linked immuno assay. Then we also have confirmatory tests
for antibodies to HIV. These confirmatory tests, most
commonly referred to as the Western blot, but also
include an indirect immuno fluorescence test and an immuno precipitation
, I say. And then lastly, there are
a number of newer, more investigative and research techniques
which are also available competitive immuno assay and I g
. M say their various other tests that got us
a neutralizing antibody and most recently a test. It
was just approved within the last month. A latex
glued nation, I say, a screening I say
, which takes only five minutes. In addition to
essay for antibodies, we can also essay for the
viral antigen circulating in a patient's blood or directly culture
for the virus. These latter two techniques we're not
going to discuss in detail today but rather concentrate on
the detection of antibodies to HIV infection. HIV serology
, neurologic responses after infection are somewhat complex but very
analogous to the response to hepatitis B early during infection
. Within the first month we detect the presence of
the viral antigen which coincides with the rise and the
presence of the virus itself in the bloodstream. Following
this within the 2nd and 3rd months after infection,
the viral antigen declines in its concentration and together with
this we see a rise in antibodies both to this
viral antigen which is a core and again inside the
center of the virus called the P 24 antigen and
respectively the antibody to the P 24. And additionally
we see a rise in antibodies to the surface or
envelope protein of the virus. During or after illness
. The acute illness which may develop which is very
much like an infectious mononucleosis syndrome. The patient recovers
and both the antibody to the core protein and to
the envelope protein remain in some patients. And we're
not exactly sure how great a percentage it will be
, but only the future will tell. We find
that the antibody to the core protein declines. This
generally coincides with the development of either arc symptoms or
with AIDS. As the antibody to the core protein
declines. We again may see a rise in the
and again the core antigen may reappear in the bloodstream
. This core antigen detection, as I mentioned earlier
, is another technique which we have to evaluate the
patient's prognosis and also to evaluate therapy right? The
ass A. For antibody to HIV is performed today
with proteins derived from cell cultures which have been infected
with HIV. This E. I. A.
Has been applied since March of 1985 to the testing
of all blood specimens donated in the United States.
The initial results of blood testing at the Red Cross
centers throughout the country demonstrated that overall, approximately 25
individuals out of every 10 donors had positive blood test
results. This number varied from various regions in the
country, but the overall result was very similar.
Subsequent data have revealed that Donors in 1986 and 1987
. Subsequent to the initial evaluations have declined Very steadily
in terms of the numbers of patients who are positive
. To the point today that it's approximately 50% or
less of the original number of people who were positive
. Only about 13 patients who donate blood Today.
Out of every 10,000 donors are found to be positive
. This is due to efforts made by the Red
Cross to eliminate people who are in high risk groups
who come in to donate blood and this has been
quite effective. We have good data to demonstrate this
. Once an initial enzyme immuno essay is performed on
a patient from the physician's office or from the red
cross center, the test is found to be positive
. The EEA is then repeated on the same specimen
. If the idea is found to be positive again
, then a confirmatory test is performed, such as
a western block. The enzyme immuno assay uses proteins
, as I mentioned before from a cell culture.
That is again, Bush, if you will of
viral proteins, the confirmatory tests, the western bloc
attempts to separate these individual viral proteins by placing them
on a gel and undergoing a process called electrophoresis,
during which the proteins migrate at different rates through the
gel. When a current is applied. Thus,
if a person has a group of antibodies present in
their blood, they are confirmed by western blot as
being truly positive for antibody to HIV, thereby confirming
an initially positive E. A result various other scenarios
may develop where the antibody initially thought to be present
by enzyme in usa maybe negative by western blot.
And thus the various other confirmatory tests that I mentioned
, such as radio immuno precipitation or indirect immuno fluorescent
, are applied to the test to determine whether or
not a negative western blot in the circumstance of a
positive E. I. A. Is accurate or
not. The enzyme immune or the western blot,
Excuse me. Which is developed um is a test
that is fraught with potential inaccuracies because it is interpreted
by an individual observing the developed bands on a piece
of paper. These developed bands may be faint at
times and may also be subject to some inaccuracy that
just needs to be kept in mind when interpreting results
. Subsequent data, which have been developed by the
red cross Through 1987, looking at over 2.5 million
blood donors have demonstrated clearly that the enzyme immuno assay
is a very good test, but one which over
calls individuals who are positive. Like to review with
you briefly why this may occur. An example would
be the frequency of false positive tests as we call
them in a high risk population. For example,
if we screen 10,000 individuals who were in a high
risk population and 10% of those individuals were truly infected
, We would then find that about 1000 individuals out
of that 10,000 were infected with the virus by the
initial enzyme immuno assay. This is a typical scenario
in a city like san Francisco or new york where
we may have a large population group to be tested
with any tests such as the enzyme immuno assay.
There are, for technical reasons, people who are
said to be positive that is have the antibody when
they really do not have it. This number for
a group of 10,000 patients who are initially being screened
, it could be said to be approximately 27.
For example, in a hypothetical example, that number
would be fixed Whether or not the population were higher
low risk group. As long as we're as in
this case screening about 10,000 individuals. I think I
hope that the point is well made that the test
varies in its accuracy, then at least in its
positive predictive value for the population group tested being very
good for a high risk population and quite poor for
a low risk population. Again, the red cross
data that we've recently acquired demonstrate this fully, We
can recognize from a number of other publications as well
that low risk populations, We'll have a false a
positive predictive value of under 3%, whereas high risk
population may have a positive predictive value of even up
to 99%. If one were to apply this test
to low risk members of the population at large.
As has been suggested by some individuals, for example
, to a group of patients applying for marriage license
or a group of individuals being admitted to a hospital
setting. We can find that the estimates of the
cost of screening all of these individuals are quite high
proportionately to the number of individuals whom we would truly
find to be infected. For example, in the
state of Virginia Where we have over 130,000 marriage license
applicants per year, estimates can be as high as
costing$40 per individual who is truly infected. If
we were to screen all of these individuals during a
year's period, similar numbers would apply both within Virginia
and nationally. If we were to screen all individuals
who were applying for admission to a hospital. These
seem an ordinate expenses for the benefit of very few
people whom we would find to be truly effective with
that. I hope that I've made the point that
this test is a very good one for a high
risk population and for its initial intent of screening blood
and protecting the blood supply. It works very well
In the early 1900s when the test for Syphilis was
advocated to be applied to all individuals and particularly during
the war, to all military personnel to try to
protect individuals from acquisition and transmission of venereal disease syphilis
. In this case we apply this test subsequently for
many years to all individuals being admitted to a hospital
and a number of other circumstances. It's only in
the past few years that we've noted that this test
is clearly not warranted because the cost benefit ratio,
if you will is does not warrant continuation of it
. And we've discontinued this at many hospital settings throughout
the country. With this in mind, we can
suggest certain indications for the application of this test today
. Suggested indications include patients who present to physicians offices
with unexplained symptoms, which could be consistent with Arc
or AIDS. Additionally, women who are in potentially
high risk groups because of exposure to individuals who are
infected who are contemplating pregnancy or who are considering breast
feeding a child after the delivery of a child who
may be uninfected could likewise be examples of individuals who
could be screened individuals who are uncertain about their exposure
for a variety of reasons who need the reassurance that
their uninfected for personal reasons. Likewise, or individuals
for screening, and another argument for screening individuals who
are in high risk groups is that if they are
positive, they may as a result of learning that
they are and they have antibody indicating infection with the
virus. They may alter their lifestyle to prevent themselves
from becoming infected with other agents and from infecting other
individuals with the virus. Today, screening is being
applied to a variety of different populations, both on
a mandatory basis and with consent on a mandatory basis
. Obviously, as I've mentioned already, all blood
donors are being screened. The federal government has applied
this to prisoners with some value, though the policy
of screening all federal prisoners is now being questioned.
Military recruits and active duty personnel are being screened regularly
as well as foreign service officers and perhaps ironically aliens
seeking admission to the United States as immigrants are being
screened, I say ironically, since the United States
has some of the highest rates of infection on the
globe. In addition to the mandatory testing, contesting
with consent is being performed in STD clinics and also
in drug abuse clinics. Likewise, women coming to
family planning centers are being offered screening if they wish
it. Individuals planning marriage are being offered screening if
they wish it, but in no way should it
be? Or is it mandatory in most states?
Indeed, several states which had activated mandatory screening are
now rescinding this requirement. And likewise, hospital admissions
who were in high risk groups are being screened selectively
. I hope that this overview of HIV serological testing
has been helpful and perhaps later we'll have a chance
to discuss further questions which developed. Yeah, that
was dr Charles Schleupner of the Veterans Administration, next
to steve Shepherd, a regional AIDS coordinator for the
State of Virginia Health Department. He'll be talking with
Joanne Underwood, a student health services worker at Virginia
Tech about AIDS prevention and counseling. As an employee
here at the clinic where I see a lot of
college students were kind of interested in some of the
questions that they ask us and we thought maybe you
could help us with some of the answers. For
instance, what tests do most state health departments offer
to college students or to anyone for that matter?
Well, the standard tests on the Eliza and the
western bloc. Uh I would assume all health departments
use that test nationally. And what about confidential?
I've heard there two types confidential and anonymous kinds of
testing. What's the difference? Okay. Everything the
health department does, everything private physicians do is confidential
. That information is not given out except on the
signature of the of the patient or court order anonymous
testing that we do a lot with the HIV test
. Just means that we simply do not have the
patient's name. And then how do you know then
when you send that off what patient it is?
Well we coded. I mean we have a number
code or a letter in the number of code.
We give the patient part of that, and then
we write down so that when the patient comes back
, they have to bring that code with them in
order for us to look the test up. So
they have a certain number. Yes. Why do
you think counseling is needed? Some people ask me
, why do I need counseling? I'd just like
to have this test done. Well, if it
were a simple test, that would say yes,
you have AIDS? No, you don't have a
jess. You're infected. No, you're not.
The counseling would be minimal for the patient's point of
view. We want them to understand what the test
will do and won't do. Uh from our point
of view, we want the patient to look at
their behavior. Are they at risk? Are they
putting themselves at risk for this disease or not?
And if they are to change it, So we
have a uh an agenda there that we want the
patient to understand what they're doing and not doing and
help them with uh deciding what changes they should make
And in their behavior you're saying in in about then
is when you start telling them which behaviors are more
risky. Sure. We talked and asked them what
what they do or to put themselves at risk,
why they want the test to begin with and then
and talk to them about that obviously sexual um activity
and uh I. V. Drug use or the
two main ways that the disease is spread. And
during that counseling the pre counseling you find those things
out. Do you ever turn anyone away from counseling
when they come to the health department? The decision
to have the test made? It should be the
patients and not ours. So after they talk to
you then they make the decision as to whether they
will be tested and do some of them go away
. Some of them most of don't most of them
come for the testing and you know after we talk
to them then they understand the procedure journal. They
have the test. There are some that realize that
they are not at risk and don't need the test
that their risk is so low when weighed against the
false positives which again are very low did they decide
not to have the test? So then then what
if it comes back and it is positive now you
have this number and the person comes in then there's
post counseling for all people or for just positive HIV
tests are supposed counseling for everyone. Everyone. If
they're positive they need to know what that means.
It does not mean they have AIDS. It means
they're infected with the virus. They have HIV infection
. They need to see a physician, they may
need to see a mental health counselor. Oh they
need to know what they can do to enhance their
chances of not developing AIDS. Uh and what symptoms
to look for and so forth. If they're negative
again, we need to go over what the risks
are, what they have done to put themselves at
risk and what they've decided not to do or to
do to help reduce that risk. Is there any
way to find out how this kind of testing affects
people? Do you know whether behavior has changed?
Do you have any evidence that post counseling helps change
behavior? I have read some about it. I
don't know that it changes it significantly in everyone,
but it is a part of the educational process.
Uh people are inundated with tv and uh you know
, newspapers and magazines about it. This is another
Part of that education. I don't expect that someone
who has spent 10 or 20 minutes or half an
hour with me is going to change their life,
but I do want them to know that uh exactly
what it is is put themselves, put them at
risk so that they can make a better judgment of
that. I know some people say, well education
doesn't work then why educate? But as an educator
, I can't believe that there have been changes in
some groups. There have been so sure gay males
have made major changes, not all gay males,
most gay males have made, you know, really
tremendous changes in the last several years. I was
thinking of a particular person who came in to see
us and he said he was going home to see
his girlfriend and now he was wanting testing. He
said I'd like to be tested because I'm going home
next week and I haven't really actually behave too well
up here had other partners but I really don't want
her to be exposed to anything. So how would
you counsel someone like that? Well, the first
thing I would do is commend him for thinking about
this. Uh the fact that he should have thought
about, you know, several months ago, I'll
bring up to the test is a test for antibody
a substance that your body makes in response to the
virus. It will take from 1 to 3 months
for antibodies to form. So the test will not
cover the last three months. Any activity this young
man has had in the last three months uh to
acquire the virus would not be covered by this test
or probably wouldn't be covered by this test. So
I don't know that he would get a lot of
information just you know from that. He would get
information prior to three months ago. If he had
contracted the virus up until three months ago, the
test would uh you know, let him know one
way or the other about that. Uh You know
, again this is an opportunity to talk to him
about all the sexually transmitted diseases, Chlamydia, syphilis
, gonorrhea. All of these things are sexually transmitted
. Uh The way you prevent all sexually transmitted diseases
is similar. Uh So I want him to think
about all of those things and make sure that he
doesn't bring those back to his partner at home.
We see a lot of the sexually transmitted diseases here
at our clinic. And then I think about it
. Should should we be telling all those people that
they are at risk for uh contracting the HIV virus
? And and do they need testing? Should we
be telling them to come to see you? I
think it's reasonable to bring the subject up to people
that are sexually transmitted that are sexually active people who
have sexually transmitted disease. If they have one,
then you know, that's the best place to look
for other sexually transmitted diseases since they're all spread the
same way and since the way to avoid them is
all the same, then then I think it's part
of a a general discussion on diseases. What if
what if one of our people came in and and
she found out that her boyfriend was also dating men
having sex with men. Would would you tell this
young woman that she should be tested? Oh I
definitely think so. I think all people at high
risk should get tested. Other people should weigh the
evidence and make a decision on that. But anybody
who is at risk, I think it is better
off knowing whether they're infected or not. Would you
get tested now and then uh three months later without
any contact or what? How do you suggest that
? Well I think you should be tested once and
and then three months after the last high risk activity
you had. So if the high risk activity was
yesterday then you will need to be tested once now
and then again in three months. Uh if you
had contact or needle sharing with someone who you knew
had the virus, I would even recommend 1 6
months uh from from yesterday uh but mostly shows up
in three. Yes. In the majority of people
, yes the immune system will function to produce antibodies
in three months. And people will know that.
I was thinking about that young man that's going home
to his girlfriend three now in three months. The
same idea testing now and in three months. Right
? But in the girl that you were telling about
who who's partner is bisexual as long as she is
going to have sex with him, uh There's no
good recommendation for her. It's academic when she finds
out she has it. If she's negative now it
doesn't mean he's negative because she could have sex with
him and simply have not gotten the virus yet.
A lot of people do they have a lot of
guys who do that. They'll send their girlfriend in
and you know if she's okay I'm okay. It
simply isn't the case. Women are more likely to
get tested. Is that what that means, do
you think? I think in general women are more
likely to go to physicians with any kind of problem
. Uh Men tend to hope that it goes away
all by itself. And that's why I uh you
know, there's a lot of uh asymptomatic or uh
diseases without symptoms that males carry, you know,
because they had symptoms and they say, well,
I hope it goes away. And indeed like the
gonorrhea and chlamydia. Sometimes the symptoms do go away
far earlier than the disease goes away. A young
woman came in and said to me that she had
had a rather radical operation. Now that's a different
situation. And and she had a lot of blood
and she was frightened. And so she wondered if
she could be tested. So I sent her down
to the health department to you. And is that
a reasonable? Well I think it's reasonable again people
have to weigh if they're gonna Transfusion more than 10
years ago. I wouldn't worry about it if they
got one after uh mid 85. I wouldn't worry
about it. Although it's possible ah to get blood
with the virus in it now. It's it's highly
unlikely. Not something I would think people would need
to worry about. But again you know if if
you got the blood uh while you were in san
Francisco or new york Then there's more reason to get
tested than she got the blood somewhere else. She
was in Washington I think. And it was like
14 points. So she really got so someone like
that I thought well that's when I should send to
you. I think that's reasonable. The only people
that might want might not want to test uh that
I've talked to that had transfusions are People who are
not sexually active, particularly people who are 70,
80 years old and do not have a sexual partner
since they don't have to worry about transmitting the disease
. All they have to worry about is themselves.
They may not want to know about that. Now
. Some students were telling me the blood mobiles here
this week at our school and some students are telling
me that once in a while someone goes through that
to see. Uh I hate to think that people
do that. But you know, I know that
they do. The problem with that is that like
I've said before, it takes 1-3 months for this
antibody to to show on the test. So anybody
who donates blood during the first three months could have
the virus and a negative test. So the negative
test makes them feel good. But the virus will
infect someone on transfusion and ruined a fan other family
. So not a wise thing to do. The
reason alternative test sites were formed in the first place
is so that people would have an alternative. That's
what it is. So that they would not have
to go to the red cross and be tested so
that they wanted to be tested. They could come
to these sites and be tested. So what does
the alternative test site mean? I Well, that's
it's an alternative originally to uh you know, the
Red Cross and the government uh started those in 1985
. The federal government put$12 million dollars into forming
these and there will be additional money into forming more
of them generally at alternative test sites. The testing
is anonymous. That's that's a little easier way to
do. Sure. We want high risk people to
have a place to go where they know that they
can be tested with the best test available. They
can be counseled uh and they know that the information
can't go further than that because we don't have their
name. Aids is reportable. A physician must report
a case of AIDS. But if someone has the
virus currently in this state, uh the option is
with the physician as to whether they want to report
it. If the physician wants help from the health
department on uh partner referral or counseling the patient about
the disease, then he can report that uh he
doesn't have to have. This varies from state to
state. So after this conversation, I want to
say one more thing. Prevention is probably the better
part of valor in this situation. What are your
words on prevention, joe? And this is one
of the most easily preventable of all diseases. The
majority of people who get this get it from sexual
transmission and from Abby drug use. People that don't
have sex won't get the disease. People who have
a one partner who doesn't go out on them won't
get the disease. People who use condoms will reduce
the risk of the disease. People who don't use
any of these are subjecting themselves to some risk.
Again, with needles. People who don't shoot up
won't get the disease. That way, people who
use clean needles won't get the disease. People who
share with someone that doesn't share with anybody else reduces
the risk, but then that they have to rely
on that other person and people who share needles with
other people are putting themselves at risk for the disease
. So if we had someone who hasn't taken care
of themselves, who have they have had a bit
of risky behavior, where would they find out about
where they should be tested? Okay. There's several
things one that they could call their local health department
, they could call the state hotline. If their
state had a hotline and if not this uh national
number 1 803 4 to AIDS, the operator at
this number will be able to tell them where to
call or even where to go and where the testing
could be found in their area. Yes. And
we're hearing people are hearing us all over the country
and if they want to ask you questions steve,
they could call in a little bit later in this
program. Certainly with questions. Thank you. Mhm
. Oh Peggy. I'm so happy you came home
. It was such a surprise. Yeah, I
just decided to come home. So how's jimmy?
Um mm He's okay And when's the wedding going to
be? I don't know. We might have to
change it Really. Why can I talk to you
? Of course you know jimmy and I went for
all those tests, the preliminary tests for our wedding
and stuff and we both decided to get an AIDS
test and we found out his results today and he
was tested HIV positive. What does that mean?
Peggy means he has the virus. I don't know
know what does it mean about you? My test
doesn't come back yet but if he's got it you've
got it right. Probably. Were you being careful
? We're engaged. Were you using a condom?
I plan on being with this guy for the rest
of my life. I don't think we thought about
conduct. Yeah. I plan on you being here
for the rest of my life. Jimmy took off
this morning when he found out. I don't even
know where he is. I came home because I
needed to talk to you. I need you to
be there for me. We've talked about some of
the facts and figures about AIDS. But that last
vignette touches on the enormous problem of trying to deal
with AIDS psychologically as well as physically to discuss AIDS
. And the family is Virginia tech, extension nutrition
and food specialist Janet Taper. She'll be talking with
Joyce. Simmons of the tidewater Virginia AIDS Crisis Task
Force. Families are often first line caregivers for those
who have AIDS. For the next few moments we
want to focus on those who live daily with AIDS
in their lives and in their homes. How do
they think? How do they feel, What do
they do or what can they do to deal with
the reality of illness and the probability of death when
it involves those whom they love most? No,
to friends or relatives of people with AIDS as no
two people with AIDS are alike. Each has to
deal with AIDS and his or her own individual way
. But there are some guides we want to look
with you then and how some families of persons with
AIDS feel and ways they have found to deal with
those feelings. And if we explore together feelings and
coping mechanisms a side of AIDS which drugs cannot treat
, perhaps we can help each other to deal with
some of those feelings constructively Joyce and I first began
to focus on these issues when an AIDS task force
with which she is involved raised just that question,
how do we provide practical support for families? Our
experience has been one of difficulty in finding available information
. And families want very practical information and when they
can't find that information, they tend to start feeling
helpless and isolated. I think that's very common.
I think all of us probably rushing about our lives
, have not the slightest inkling about what AIDS patients
and their families are dealing with. Of course there's
a tremendous feeling of isolation and if you look at
what we know about AIDS from the media, much
of it is about the disease itself, about probable
cause is possible, new methods of treatment, et
cetera. There's very little information available on how families
would cope on a day to day basis. And
I think that gap then does tend to increase that
feeling of isolation and make people feel that everybody else
is managing very nicely well. They're floundering with their
feelings. I think the experience of floundering with very
powerful emotions is common with these families. Barbara Peabody
, the author of a book sharing her experiences as
a mother of a child dying with AIDS refers to
families of AIDS patients as the word will. And
yet as you stated, these people feel isolated and
because of the isolated feelings, they tend to feel
that they're responding at normally or that they're the only
ones experiencing negative feelings, right? People will say
to you that they feel they're very unique in what
they're experiencing. And I think all of us need
to constantly remind ourselves that change in any form is
very difficult and certainly the death of one spouse,
one's lover, one's friends, one's child is extremely
difficult when a child dies before his or her parents
. As is so often the case with AIDS,
the whole order of the universe is violated. I
think everything that we believe about life and death is
put to the test um for these families, fear
of the future without a loved one is very difficult
, fearing that someone will die is almost as difficult
as if that person has already died. So fear
tension, stress, horror, terror all become everyday
companions for these families and many of them feel as
if they are living in a nightmare. And I
think if we can help them to understand that feeling
, those powerful emotions is not negative thinking, people
will say to you, they feel as if they
want to cry and scream for what seems like forever
. And crying and screaming may be necessary there to
feel whole again. But I I think we have
to help them to understand that that is all part
of a grieving process and it's very normal in this
particular situation, Janet in a situation like this where
there seems to be very little reason to hope.
How can we help these families? Hope is obviously
an essential part of the physical as well as the
emotional health of the patient and as well as out
of the family. And again, I think we
need to constantly remind ourselves of the individuality of each
of these situations and not get caught up in averages
and statistics. Every one of us has a different
set of genes, a different immune system, a
different will to live, a different urge to fight
things that can't be measured on charts and graphs.
And there's just the possibility of good days of comfortable
nights of shared experiences that are going to be real
beyond the statistics. And again, I think if
we can help families understand that it is the enjoyment
of life's gifts that constitutes being not the number of
days in which were given to enjoy those there are
safeguards against hopelessness, even in cases where hope may
seem to be very, very slim. I think
just being able to reassure families of your continuing love
and comfort that provides support and hope. Being able
to say to families, I'm here. Just just
presence provides tremendous reserves of of support and hope for
families and we need to do that in a way
that acknowledges the situation. That's right. I think
sometimes in offering hope, we tend to fall into
a trap of denial or false cheer. We feel
that in order to raise a person's spirit, we
almost have to hide from the truth so that as
soon as we sense despondency, we Russian with reassurances
that everything is going to be all right. And
when we do that, we deny the reality of
the situation. We deny the family member the chance
to express his or her feelings about the situation and
we may leave him feeling even more deserted than they
were before. So in a sense that we've abandoned
the person that we thought we were trying to help
. And I think all of us need to realize
that we may all share the same fears and anxieties
about the future and that to be able to express
those or share those with each other does not mean
that we're giving into hopelessness Janet. How can family
members respond to those outside of the family when they
sense or know that the relationship with other family members
and friends are changing? I think probably any family
that has dealt with AIDS has experienced the fact that
um, personal relationships, both within the family and
outside of the family will change. In general.
Friends will respond as they do in any other type
of crisis situation. Many of them will be able
to deal with the situation and will continue to offer
support, and some may find that they can't deal
with it at all and they will seem to drift
away from from the family's life. Um, generally
, that type of adverse reaction is due to ignorance
or fear, and recognizing that other people are ignorant
or are fearful, really does little to lessen the
pain that you may feel it being abandoned by individuals
who felt with your friends. But I think we
can only change attitudes among people if we continue to
be with them, if we continue to reach out
for them out to them, and that may be
difficult for families in the immediate situation. It may
only be at a much later time if at all
that they feel they can reach out to people who
they feel may have shunned them, but I think
there is a need to help your friends, help
you ask yourself have I withdrawn or have they drifted
away from me? If people don't call, maybe
give them a call and ask for some simple assistance
. Maybe they can run an errand, maybe they
can prepare a meal. Maybe they can just come
by and visit. And I think those simple acts
will draw people back into contact and help them feel
more helpful, more useful. A lot of times
, people just don't call because they feel they're bothering
you or you may have all the help you need
, that type of thing Janet What about the situation
where friends might really want to help? But family
members just can't seem to respond at that time.
Again, I mean, this is a situation where
family members may just feel stretched to the breaking point
, keeping their own lives going from day to day
. And it may be far too much to ask
, you know, that they're continually solicitous of other
people's feelings or trying to put other people at ease
. And I think in a situation like that where
you just don't feel ready to talk with someone or
to accept their offer of help. If you can
just say, you know, I really appreciate your
concern. I'm not ready to talk yet. That
at least suggests that there will come a time when
, when you will be ready to talk and it
leaves the door open Janet within the family unit.
These same situations will occur when family members just can't
seem to share a talk with one another. How
can we help families in situations like this? Obviously
AIDS is a blow to any family and to a
large extent how it is handled within the family is
going to depend on how the family has functioned as
a unit in the past. Oftentimes problems within a
family are the most difficult to deal with because you
can no longer go home to the shelter of your
family to escape your problems. It is there that
your problems have become most difficult and I guess I
would suggest that families try to maintain the family as
a unit for as long as possible and they can
do that without denying the seriousness of the situation.
And that type of approach is really necessary, I
think, for families to be able to cope on
a short term as well as a long term basis
because once family life becomes totally disrupted, it's much
more difficult to resume functioning as a unit again.
And I say that recognizing that illness and death obviously
blow holes in our lives that of course are going
to disrupt normal functioning. Uh, there are some
families that cannot communicate well with one another. And
and obviously a crisis situation is not any time to
be trying to readjust family patterns. And for some
families they may need to seek outside help. What
about the relationship with a family member that has AIDS
? We need to remember that the individual who does
have AIDS is dealing with the powerlessness probably to change
the reality of his or her situation. So that
individual is dealing with very conflicting and confusing emotions.
And oftentimes, family members will say to you that
that that they feel as if they're the target of
much anger and frustration on the part of the patient
. And although they recognize they are not the cause
of that anger, that doesn't make it any easier
for them to accept it. And although they feel
they should respond with compassion with patients, they may
want to respond in anger and sometimes exchanges in anger
will have value if that does help people to share
their feelings. I think one thing that's very important
is that the family member who has AIDS continue to
feel a necessary part of the family for as long
as possible and that families need to guard against rehearsing
how they will act when that family member dies if
they do die by excluding that individual from family activities
in the present, is that common? That can
be calm? And I mean, I think that's
something that we all do throughout our lives. We
tend to rehearse for events or prepare for events as
if they have already happened. And that just makes
it easier for us to assume roles when, when
they come to us. But I think we do
need to help families guard against that and not make
them feel guilty if they find themselves feeling emotionally out
of step. A lot of times, families will
find themselves missing someone who has not yet died and
and that's a natural feeling. But if they can
recognize that they are actually excluding the individual from routine
family activities, then if they can just try to
turn the routine back to normality as much as possible
. Often people with serious illnesses tend to withdraw from
family members when they need that support most. What
can we do to help families in this particular setting
? I think that the individual who does have AIDS
has the has the primary right to set the schedule
for when he or she is ready to talk with
with family members. And I think family members can
just show their support be present for that person,
um, encourage them perhaps um to share and they
can do that. You know, they say just
by being there, maybe try to recognize signs that
might indicate the person is ready to talk, but
maybe just doesn't know how to begin. Um I
think it's very important that family members are able to
share in that situation because it does make it easier
to deal with. And that means not just sharing
, you know, our love for each other,
our appreciation of each other, but also sharing fears
and confusion, conflicting emotions, et cetera. Sometimes
the responsibility for care of the AIDS patients falls on
one person and that person tends to feel quite a
bit of inner conflict because they tend to want to
be all things to all people. How can we
help he or she deal with balancing those set of
responsibilities. I think it's very important to help family
members realize the importance of taking care of themselves as
well. That the wellness of the person with AIDS
is going to depend upon the wellness of the caregiver
. And as you say, sometimes there is one
family member who feels that they have to do it
all. And if that person can sort of just
maybe step back and look at the tasks that have
to be performed and decide, are there some that
don't need to be done other things that someone else
can do? And often that person cannot cannot do
that for themselves and someone who is more objective maybe
needs to just help them examine tasks and say,
you know, this doesn't need to be done right
now. Families may need to look at bringing in
some outside help, whether that's professional nurses or homemakers
from public or private agencies, and they need them
to weigh the financial cost of doing that against the
emotional and the physical burdens of trying to shoulder the
load alone can't give us often say that they have
a feeling of guilt and selfishness when they need to
address their own needs. Is this normal? I
think that's very normal and in a crisis situation,
I think we all feel guilty about not being able
to give enough in this situation. People need to
understand that perhaps the time they take away from tending
to AIDS will strengthen them for the times that they
really need to deal with it. And people ought
not to feel guilty about doing that. People need
to recognize what are their capabilities? What are their
limitations? When people become extremely fatigued, extremely exhausted
, they may just despair. They may not be
able to deal with the situation at all. So
help family members realize that taking time away, getting
some rest themselves is something they need to do both
for themselves and for the person who has AIDS.
You mentioned that there are outside sources of help for
families. What are they and how can we encourage
families to take advantage of these? I think often
times for many families asking for outside help and accepting
help. It's very, very difficult because so many
people have been raised to believe that going alone is
a sign of strength, a sign of maturity.
Many people just don't know where to turn for help
. And I think one of the first sources to
which people might turn would be the health care team
. And I think it's very important that there is
a strong sense of trust, of report between the
individual, the family and the health care team.
I think families are not to be afraid to ask
medical questions of their health care team. Uh Those
people are there as a source of fact and they
can also be a source of information about other um
support and service organizations that might provide practical tips about
the disease. One of the, what are some
of the types of support groups that are available to
support families of patients with AIDS? There are several
sources within the community um, from which to draw
, I might suggest that if a family is a
member of a church or a synagogue, perhaps a
minister or a rabbi, a religious leader, perhaps
a member of the congregation could be a source of
support to families or again be a source of information
about other organizations. There are several support organizations that
have been established by uh individuals with AIDS and their
families, uh in order to share practical tips,
coping skills, etcetera, with other families going through
the same situation. And I think that marshaling of
people and resources is just a loving response to the
needs and fears of people. I think our first
visual then lists some of the organizations that are available
. And there is further information about each of these
organizations in the packet that has been handed out to
participants as well. I think probably um local AIDS
Task Forces could provide information on how families might access
these organizations. There are also books written by family
members of AIDS patients. Some of these might be
helpful to some of these families that find themselves in
the same situation. That's right. There are several
books which I think would be useful in our next
graphic lists, some of these. And although everything
expressed in these books is really a cry for help
in what the greatest crisis of family can experience the
death of a loved one. They do point the
way for families going through similar situations and they're all
books about love and hope uh in Clare Moffett's book
, she points out her son's feelings that AIDS was
a gift that removed barriers. And she says AIDS
was a catalyst that taught us how to love.
Claire Moffett eventually became one of the co founders of
the mothers for AIDS patients organization. Are there other
books that might provide practical information for families as well
as professionals? Several other sources are available. And
in this next graphic, we've listed several of these
. These books have been written basically directly to families
who are dealing with a situation on a day to
day basis. But much of the information that is
in these books would also be very, very useful
for healthcare professionals working with these families. What about
the young child, a younger person in the household
who's trying to cope with the family member who has
AIDS, what type of books are available for them
? There is not a lot of information available.
There is some. And our next graphic lists two
books which have been written to address the feelings of
younger persons adolescents. These two books are novels,
one deals with a sibling who has AIDS and the
other deals with a fellow high school student who has
AIDS and then how young adolescents would react to those
particular situations. Are there other resources that we might
mention? There are some videotapes and I think in
our last graphic, I've listed one of these and
this I think is a useful meditation tool, not
only for the AIDS patients but for the family as
well Janet many families are looking for information on healing
AIDS patients. Can we address that issue at this
time? Maybe just to say something about healing.
Jim Gary writes about the process of healing. In
the midst of this process we call dying and he
says that healing is not necessarily an end result.
Rather, healing is a way of living by which
we give definition to ourselves. Um healing regardless of
the success of the outcome as it is viewed by
others is the inner knowledge of our own ability to
deal with what we are experiencing. And if we
can stop focusing on the external aspects of healing and
maybe just pause and recognize and surpass our own fears
and judgments, we can come to realize that healing
is possible in every moment of our lives. So
that healing is not just limited to the physical body
, but rather even in the face of physical death
, healing of the human spirit is possible and that
produces wholeness of being. To wrap up the first
part of this teleconference. Before we take a break
, we have with us dr Richard Keeling of the
University of Virginia and we'll be talking with him as
president of the American College Health Association. So,
with that title in mind, let me let me
start out with the question of what is the status
of AIDS on our college campuses? What do we
know about it? Well, there are two different
things to talk about the first place. Cases of
AIDS itself and cases of AIDS itself on college campuses
have not been very common. One of the reasons
we don't see it very often may not be that
it isn't there AIDS itself is so stigmatized that a
lot of students who actually have had AIDS have probably
left school without telling us College Health Association this past
year. Did a survey. We could count about
500 students who could be identified as actually having had
AIDS. Much bigger than that, though, is
the issue of people who are infected who have the
virus and don't have AIDS itself yet. The iceberg
business we've talked about earlier on this conference and it's
certainly a major issue on college campuses. We expect
in the college setting, the vast majority of people
who have the virus will stay completely healthy until after
they graduate. They will therefore be kind of an
invisible population the size of that population. We begin
to get some ideas about the survey, currently being
conducted by the American College Health Association in the Public
Health Service tells us in the very preliminary results that
as many as three per 1000 college students may be
infected by the virus. If you extended that number
out pretty much evenly across the country, then in
a campus with 15 or 20,000 students, you'd expect
to have 45 50 60 students infected by the virus
. Once the study is all complete later this year
, april or may, then we'll know whether that
number is a little higher, a little low,
but at least it clearly establishes that the virus is
here. This is not a potential problem anymore.
It's one that actually already exists for us. Okay
, now, obviously, when you're talking about,
even though the numbers and you know, 60 per
20,000 students doesn't sound like much, you're talking about
a a lifestyle among students. That certainly puts some
sort of risk into those numbers. What can you
tell us about the risk on the college campuses as
far as is concerned in light of those numbers,
we're concerned about two major elements of risk for college
students, obviously mostly about sexual contact, secondarily about
shared needles to talk about both of them for a
moment. The area of sex, the public health
service, and others look at college campuses as almost
being pressure cookers in the sense of risk of sexually
transmitted disease because of specific behavior patterns. It's not
so much an issue of whether intercourse happens because that
does happen in the vast majority of college students are
sexually active. That's not really the issue. The
issue is how they approach that activity. And most
college students, although they know a lot about AIDS
, don't institute procedures effectively in their own lives to
protect themselves. So they don't do what they know
and they don't partly because of the old it can't
happen to me problem, but also because of some
other things. For example, alcohol and alcohol gets
connected to a lot of sexual activity on campus.
And no matter how good your intentions are, how
much negotiation you've done, if you get drunk,
things go out the window and you don't necessarily have
safer sex, you may not make good choices about
partners. Sexual assaults, comment on campuses. People
end up having sex without giving consent or negotiation.
A lot of people get to college having been pretty
protected from sex all the way through high school.
I don't have any good idea about how to deal
with their sexual feelings and negotiate. You throw all
of that together population that feels experimental and invincible throw
in some peer pressure, add the mixed messages of
advertising and all the things that happened that promotes sexual
activity. And you end up with this pressure cooker
. And that's where the risk is. The risk
of sexual activity on a campus will vary a little
in geographic location, vary a little by who you
are. But the major issue is we try to
emphasize with college students that who you are makes a
lot less difference than what you do and what you
do in the sense of unprotected intercourse in a college
setting may be relatively high risk just interrupted. Certainly
there's this feeling, I guess when you're 2021 that
nothing can happen to me, I'm on top of
the world sort of deal. Is that is that
one of the prevalent things that has to be fought
in this instance? Absolutely. It is. And
in a college student's life, it's usually been true
. There haven't been many tragedies. Typically, people
often have come from homes which cared for them well
and schools that prepare them well and they often have
not had serious health problems. Many of them have
not even had a grandparent die yet. They haven't
lost friends or colleagues. They haven't seen great tragedies
. And you know, it gets to the point
that people in that age group so seldom think about
their own mortality that you or I often think they're
being kind of morbid and erotic if they talk about
death and it's just not part of the age.
We're talking about other other factors of risk, the
other factor of risk on the campuses needles. And
we don't like to talk about that much at all
. Less than 1%. College and university students used
needles to inject recreational drugs, but there's another needle
sharing risk, it's much more important. And that
steroids stories get used by athletes and college students as
do professional athletes, sometimes inject anabolic steroids to build
welcome power. The problem is that 85 or more
percent of those steroids are illegitimately obtained, and if
they are illegitimately obtained, they often involve shared needles
, shared needle for steroids, the same as shared
needle for heroin and a shared needle to an athlete
may expose a woman who's a sexual partner who had
no idea that there was any risk at all to
her. So we have to think about needles as
well as sex, although predominantly among people in college
, we're talking about sexual risk of transmission just to
stay on that subject for a minute. Uh,
in terms of steroids we hear about steroids we hear
about in college campuses. Is it a big deal
? Actually, it is, we tend we tend
not to get very good information about it. If
you talk to athletic directors, coaches, trainers or
players they'll all tell you the same thing. Oh
yeah it's a big problem but not here and yeah
it happens but no no no not here. And
in fact it does happen every here that there is
there is a very important set of information from the
N. C. Double A. This past year
. They they steroid tested all athletes in postseason competition
in steroid sensitive sports, wrestling in some track and
field events. For example football. What they come
up with was that very few were positive in the
post conference test. But if you went back and
did the test without doing it in season two it
off season or if you don't tell the athletes are
going to test them then as many as a third
and even more test positive in steroid sensitive sports Survey
last year, in the journal of the American Medical
Association found that seven of male high school seniors have
used steroids. So what we're facing here is both
an epidemic that's significant in itself in terms of the
epidemic of steroid use and a very invisible one.
People don't want to see it, they don't want
to talk about it. And of course, the
whole climate sort of invites the sharing of needles,
keeping it under under your head, sort of deal
right. And it's also connected to the it can't
happen to me, nothing can go wrong. Everybody
else is doing it. There's peer pressure, their
desire for success. Increasingly, athletes have become more
clever about this process. So the drug testing may
not pick them up what what's being done institutionally about
AIDS and college campuses, both in terms of individual
institutions and in terms of, say, the american
college Health Association or other kind of blanket groups.
In terms of this, There's a lot being done
. The College Health Association has tried to provide leadership
. And what we've emphasized is that at the college
level, talking to students, information is not what's
needed anymore. We don't really need to go to
college students and talk AIDS 101. They have a
pretty basic structure that may be a little blurry on
the fringes, but their basic information level about AIDS
is not bad. What we need to talk to
them about is behavior. That is why don't you
do what? You know? And that means talking
to them about negotiation about very explicit details about sexual
activity. It means eliminating alcohol. Talking about condoms
, talking about how to make that happen in their
lives. I talked to a professor here at tech
once about the use of condoms, for example,
and his survey indicated that women are more likely to
bring up the subject than men. Have you found
that to be the case in terms of colleges?
Certainly is the case. Women in general have been
less reticent to deal with this issue. When you
have a talk about AIDS on a campus, 85%
of the audience will be women. Even if it's
a 50 50 male female campus, A lot of
men feel that talking about AIDS are going to hear
about it labels you as gay. A lot of
men are very aversive to any possibility of that and
they just don't want to be in that group.
So they often won't go, they won't bring up
the subject. They're afraid if they bring up a
condom, that a woman will say, why is
it on your mind or what have you done that
makes this an important issue for you? They also
frankly often timid about condoms because they're afraid of being
inept. Although we hear a lot about the macho
business if it won't feel as good, a lot
of the reasons that men are afraid of condoms is
that they don't want to fumble around, they're afraid
that things won't go well, that something will change
, the tone will be different, that maybe things
won't happen at the same pace and a condom is
too big an interruption. Well, starting with that
specific issue and getting more general, our attitudes changing
on college campuses. Then we have some evidence that
they are. There are surveys of what people do
, where you say, what have you been doing
? Self report stuff? And the self report surveys
give us at least a little hope that knowledge is
not bad, attitudes are improving behavior still trailing,
but it's better in some cases. At least we
have some other markers, like the rates of other
sexually transmissible diseases, which are better, at least
at some schools in some parts of the country.
And that suggests to us that among college students in
general, there may at least be the beginnings of
some recognition and behavior change among certain groups. There
is amazing changes. Gay men, for example,
on college campus have made tremendous differences and often have
now very low rates of sexually transmitted disease. But
the average college student who still thinks this is not
his problem typically is resistant to change. Do you
think we're getting an accurate record of the occurrence of
AIDS on college campuses? How much testing is there
going on? What are the numbers in terms of
what might actually be out there? A lot of
testing programs, there are mostly voluntary. So they
depend on students a trusting the health service or the
place the test is being done and be coming to
be tested. See the health service being able to
obtain the test result and tell the student not all
of those things can be assumed in a lot of
places. What we begin to know though is that
what we think is happening is probably the rock bottom
of what is actually happening. If we start talking
in terms of two or three per 1000 that ought
to be regarded as the bottom number, couple more
questions started out talking about the effect of alcohol for
example. And this whole situation with the big push
nationwide as far as raising drinking age is, is
that going to be a good sign in terms of
of the AIDS problem and recognition and dealing with the
problem on the campus? It's a good question.
I wish I had a good answer. I'm not
sure whether the raising of the alcohol age it's going
to make a lot of difference about any of the
alcohol associated problems. There's some very preliminary evidence about
drunk driving and speeding and other convictions, for example
, in connection with the raising of the drinking age
, which can be interpreted either way. I mean
, some people have interpreted it to say yes,
there's a benefit. Some people say it doesn't make
any difference. I think the same is true at
this point about alcohol programs connected the risky sexual behavior
. Clearly, we have to start looking at it
. We have to start tying behavior counseling into alcohol
as well as sex. If we're going to do
that though, we need to do it at the
level that it matters to students and talk realistically why
do you drink when you're going to have sex?
And instead of just sitting there acting like we don't
know why. We know why people do that.
It avoids responsibility. It avoids paying discomfort, ambivalence
. Nobody else can make a decision either. And
people have been using alcohol for those reasons for centuries
, especially among young people on college campuses. So
what we have to do is find substitutes for them
, work with them and say what would work as
well? Let's work to see How do we remove
your discomfort about sex without having to be drunk to
do it? All right. We've been talking with
dr Richard Keeling of the University of Virginia, president
of the American College Health Association. We're gonna take
a short break and be back at 3 30 with
all of our panelists who have been here today and
talk about, take your questions over the telephone,
as far as AIDS issues, we'll be back in
a little bit. Thank you, mm. Yeah
, mm. Mhm. Mhm. Yeah. Mhm
. Yeah. Mhm. Mhm. Yeah. Mhm 1809 01:45:01.289 --> A:middle L:90% . Mhm.