FOREWORD

This is a report from the Surgeon General of the U.S. Public Health Service on AIDS. Acquired Immune Deficiency Syndrome is an epidemic that has already killed thousands of people, mostly young, productive Americans. In addition to illness, disability, and death, AIDS has brought fear to the hearts of most Americans -- fear of disease and fear of the unknown. Initial reporting of AIDS occurred in the United States, but AIDS and the spread of the AIDS virus is an international problem. This report focuses on prevention that could be applied in all countries.

My report will inform you about AIDS, how it is transmitted, the relative risks of infection and how to prevent it. It will help you understand your fears. Fear can be useful when it helps people avoid behavior that puts them at risk for AIDS. On the other hand, unreasonable fear can be as crippling as the disease itself. If you are participating in activities that could expose you to the AIDS virus, this report could save your life.

In preparing this report, I consulted with the best medical and scientific experts this country can offer. I met with leaders of organizations concerned with health, education, and other aspects of our society to gain their views of the problems associated with AIDS. The information in this report is current and timely.

This report was written personally by me to provide the necessary understanding of AIDS.

The vast majority of Americans are against illicit drugs. As a health officer I am opposed to the use of illicit drugs. As a practicing physician for more than 40 years, I have seen the devastation that follows the use of illicit drugs -- addiction, poor health, family disruption, emotional disturbances and death. I applaud the President's initiative to rid this nation of the curse of illicit drug use and addiction. The success of his initiative is critical to the health of the American people and will also help reduce the number of persons exposed to the AIDS virus.

Some Americans have difficulties in dealing with the subjects of sex, sexual practices, and alternate lifestyles. Many Americans are opposed to homosexuality, promiscuity of any kind, and prostitution. This report must deal with all of these issues, but does so with the intent that information and education can change individual behavior, since this is the primary way to stop the epidemic of AIDS. This report deals with the positive and negative consequences of activities and behaviors from a health and medical point of view.

Adolescents and pre-adolescents are those whose behavior we wish to especially influence because of their vulnerability when they are exploring their own sexuality (heterosexual and homosexual) and perhaps experimenting with drugs. Teenagers often consider themselves immortal, and these young people may be putting themselves at great risk.

Education about AIDS should start in early elementary school and at home so that children can grow up knowing the behavior to avoid to protect themselves from exposure to the AIDS virus. The threat of AIDS can provide an opportunity for parents to instill in their children their own moral and ethical standards.

Those of us who are parents, educators and community leaders, indeed all adults, cannot disregard this responsibility to educate our young. The need is critical and the price of neglect is high. The lives of our young people depend on our fulfilling our responsibility.

AIDS is an infectious disease It is contagious, but it cannot be spread in the same manner as a common cold or measles or chicken pox. It is contagious in the same way that sexually transmitted diseases, such as syphilis and gonorrhea, are contagious. AIDS can also be spread through the sharing of intravenous drug needles and syringes used for injecting illicit drugs.

AIDS is >not< spread by common everyday contact but by sexual contact. (penis- vagina, penis-rectum, mouth-rectum, mouth-vagina, mouth-penis). Yet there is great misunderstanding resulting in unfounded fear that AIDS can be spread by casual non-sexual contact. The first cases of AIDS were reported in this country in 1981. We would know by now if AIDS were passed by casual, non- sexual contact.

Today those practicing high risk behavior who become infected with the AIDS virus are found mainly among homosexual and bisexual men and male and female intravenous drug users. Heterosexual transmission is expected to account for an increasing proportion of those who become infected with the AIDS virus in the future.

At the beginning of the AIDS epidemic many Americans had little sympathy for people with AIDS. The feeling was that somehow people from certain groups "deserved" their illness. Let us put those feelings behind us. We are fighting a disease, not people. Those who are already afflicted are sick people and need our care as do all sick patients. The country must face this epidemic as a unified society. We must prevent the spread of AIDS while at the same time preserving our humanity and intimacy.

AIDS is a life-threatening disease and a major public health issue. Its impact on our society is and will continue to be devastating. By the end of 1991, an estimated 270,000 cases of AIDS will have occurred with 179,000 deaths within the decade since the disease was first recognized. In the year 1991, an estimated 145,000 patients with AIDS will need health and supportive services at a total cost of between $8 and $16 billion. However, AIDS is preventable. It can be controlled by changes in personal behavior. It is the responsibility of every citizen to be informed about AIDS and to exercise the appropriate preventive measures. This report will tell you how.

The spread of AIDS can and must be stopped.

(signed) C. Everett Koop, M.D., Sc.D. Surgeon General

AIDS

AIDS CAUSED BY VIRUS

The letters A-I-D-S stand for Acquired Immune Deficiency Syndrome. When a person is sick with AIDS, he/she is in the final stages of a series of health problems caused by a virus (germ) that can be passed from one person to another chiefly during sexual contact or through the sharing of intravenous drug needles and syringes used for "shooting" drugs. Scientists have named the AIDS virus HIV or HTLV-III or LAV. These abbreviations stand for information denoting a virus that attacks white blood cells (T-Lymphocytes) in the human blood. Throughout this publication, we will call the virus, the "AIDS virus." The AIDS virus attacks a person's immune system and damages his/her ability to fight other disease. Without a functioning immune system to ward off other germs, he/she now becomes vulnerable to becoming infected by bacteria, protozoa, fungi, and other viruses and malignancies, which may cause life- threatening illness, such as pneumonia, meningitis, and cancer.

NO KNOWN CURE

There is presently no cure for AIDS. There is presently no vaccine to prevent AIDS.

VIRUS INVADES BLOOD STREAM

When the AIDS virus enters the blood stream, it begins to attack certain white blood cells (T-Lymphocytes). Substances called antibodies are produced by the body. These antibodies can be detected in the blood by a simple test, usually two weeks to three months after infection. Even before the antibody test is positive, the victim can pass the virus to others by methods that will be explained.

Once an individual is infected, there are several possibilities. Some people may remain well but even so they are able to infect others. Others may develop a disease that is less serious than AIDS referred to as AIDS Related Complex (ARC). In some people the protective immune system may be destroyed by the virus and then other germs (bacteria, protozoa, fungi and other viruses) and cancers that ordinarily would would never get a foothold cause "opportunistic diseases . . . " using the >opportunity< of lowered resistance to infect and destroy. Some of the most common are >Pneumosystis carnii< pneumonia and tuberculosis. Individuals infected with the AIDS virus may also develop certain types of cancers such as Kaposi's sarcoma. These infected people have classic AIDS. Evidence shows that the AIDS virus may also attack the nervous system, causing damage to the brain.

SIGNS AND SYMPTOMS

NO SIGNS

Some people remain apparently well after infection with the AIDS virus. They may have no physically apparent symptoms of illness. However, if proper precautions are not used with sexual contacts and/or intravenous drug use, these infected individuals can spread the virus to other. Anyone who thinks he or she is infected or involved in high risk behaviors should not donate his/her blood, organs, tissues, or sperm because they now contain the AIDS virus.

ARC

AIDS-Related Complex (ARC) is a condition caused by the AIDS virus in which the patient tests positive for AIDS infection and has a specific set of clinical symptoms. However, ARC patients' symptoms are often less severe than those with the disease we call classic AIDS. Signs and symptoms of ARC may include loss of appetite, weight loss, fever, night sweats, skin rashes, diarrhea, tiredness, lack of resistance to infection, or swollen lymph nodes. These are also signs and symptoms of many other diseases and a physician should be consulted.

AIDS

Only a qualified health professional can diagnose AIDS, which is the result of a natural progress of infection by the AIDS virus. AIDS destroys the body's immune (defense) system and allows otherwise controllable infections to invade the body and cause additional diseases. These opportunistic diseases would not otherwise gain a foothold in the body. These oppoRtunistic diseases may eventually cause death.

Some symptoms and signs of AIDS and the "opportunistic infections" may include a persistent cough and fever associated with shortness of breath or difficult breathing and may be the symptoms of >Pneumocystis carnii< pneumonia. Multiple purplish blotches and bumps on the skin may be a sign of Kaposi's sarcoma. The AIDS virus in all infected people is essentially the same; the reactions of individuals may differ.

LONG TERM

The AIDS virus may also attack the nervous system and cause delayed damage to the brain. This damage may take years to develop and the symptoms may show up as memory loss, indifference, loss of coordination, partial paralysis, or mental disorder. These symptoms may occur alone, or with other symptoms mentioned earlier.

THE PRESENT SITUATION

The number of people estimated to be infected with the AIDS virus in the United States is about 1.5 million. All of these individuals are assumed to be capable of spreading the virus sexually (heterosexually or homosexuality) or by sharing needles and syringes or other implements for intravenous drug use. Of these, an estimated 100,000 to 200,000 will come down with AIDS Related Complex (ARC). It is difficult to predict the number who will develop ARC or AIDS because symptoms sometimes take as long as nine years to show up. With our present knowledge, scientists predict that 20 to 30 percent of those infected with the AIDS virus will develop an illness that fits an accepted definition of AIDS within five years. The number of persons known to have AIDS in the United States to date is over 25,000; of these, about half have died of the disease. Since there is no cure, the others are expected to also eventually die from their disease.

The majority of infected antibody positive individuals who carry the AIDS virus show no disease symptoms and may not come down with the disease for many years, if ever.

NO RISK FROM CASUAL CONTACT

There is no known risk of non-sexual infection in most of the situations we encounter in our daily lives. We know that family members living with individuals who have the AIDS virus do not become infected except through sexual contact. There is no evidence of transmission (spread) of AIDS virus by everyday contact even though these family members shared food, towels, cups, razors, even toothbrushes and kissed each other.

HEALTH WORKERS

We know even more about health care workers exposed to AIDS patients. About 2,500 health workers who were caring for AIDS patients when they were sickest have been carefully studied and tested for infection with the AIDS virus. These doctors, nurses and other health care givers have been exposed to the AIDS patients' blood, stool and other body fluids. Approximately 750 of these health workers reported possible additional exposure by direct contact with a patient's body fluid through spills or being accidentally stuck with a needle. Upon testing these 750, only 3 who had accidentally stuck themselves with a needle had a positive antibody test for exposure to the AIDS virus. Because health workers had much more contact with patients and their body fluids than would be expected from common everyday contact, it is clear that the AIDS virus is not transmitted by casual contact.

CONTROL OF CERTAIN BEHAVIORS CAN STOP FURTHER SPREAD OF AIDS

Knowing the facts about AIDS can prevent the spread of the disease. Education of those who risk infecting themselves of infecting other people is the only way we can stop the spread of AIDS. People must be responsible about their sexual behavior and must avoid the use of illicit intravenous drugs and needle sharing. We will describe the types of behavior that lead to infection by the AIDS virus and the personal measure that must be taken for effective protection. If we are to stop the AIDS epidemic, we all must understand the disease --its cause, its nature, and its prevention. >Precautions must be taken.< The AIDS virus infects persons who expose themselves to known risk behavior, such as certain types of homosexual and heterosexual activities or sharing intravenous drug equipment.

RISKS

Although the initial discovery was in the homosexual community, AIDS is not a disease only of homosexuals. AIDS is found in heterosexual people as well. AIDS is not a black or white disease. AIDS is not just a male disease. AIDS is found in women; it is found in children. In the future AIDS will probably increase and spread among people who are not homosexual or intravenous drug abusers in the same manner as other sexually transmitted diseases like syphilis and gonorrhea.

SEX BETWEEN MEN

Men who have sexual relations with other men are especially at risk. About 70 percent of AIDS victims throughout the country are male homosexuals and bisexuals. This percentage probably will decline as heterosexual transmission increases. >Infection results from a sexual relationship with an infected person.<

MULTIPLE PARTNERS

The risk of infection increases according to the number of sexual partners one has, >male or female<. The more partners you have, the greater the risk of becoming infected with the AIDS virus.

HOW EXPOSED

Although the AIDS virus is found in several body fluids, a person acquires the virus during sexual contact with an infected person's blood or semen and possibly vaginal secretions. The virus then enters a person's blood stream through their rectum, vagina or penis.

Small (unseen by the naked eye) tears in the surface lining of the vagina or rectum may occur during insertion of the penis, fingers, or other objects, thus opening an avenue for entrance of the virus directly into the blood stream; therefore, the AIDS virus can be passed from penis to rectum and vagina and vice versa without a visible tear in the tissue or the presence of blood.

PREVENTION OF SEXUAL TRANSMISSION -- KNOW YOUR PARTNER

Couples who maintain mutually faithful monogamous relationships (only one continuing sexual partner) are protected from AIDS through sexual transmission. If you have been faithful for at least five years and your partner has been faithful too, neither of you is at risk. If you have not been faithful, then you and your partner are at risk. If your partner has not been faithful, then your partner is at risk which also puts you at risk. This is true for both heterosexual and homosexual couples. Unless it is possible to know with >absolute certainty,< that neither you nor your sexual partner is not carrying the virus of AIDS, you must use protective behavior. >Absolute certainty< means not only that you and your partner have maintained a mutually faithful monogamous sexual relationship, but it means that neither you nor your partner has used illegal intravenous drugs.

YOU CAN PROTECT YOURSELF FROM INFECTION

Some personal measures are adequate to safely protect yourself and others from infection by the AIDS virus and its complications. Among these are:

-- If you have been involved in any of the high risk sexual activities described above or have infected illicit intravenous drugs into your body, you should have a blood test to see if you have been infected with the AIDS virus.

-- If your test is positive or if you engage in high risk activities and choose not to have a test, you should tell your sexual partner. If you jointly decide to have sex, you must protect your partner by always using a rubber (condom) during (start to finish) sexual intercourse (vagina or rectum).

-- If your partner has a positive blood test showing that he/she has been infected with the AIDS virus or you suspect that he/she has been exposed by previous heterosexual or homosexual behavior or use of intravenous drugs with shared needles and syringes, a rubber (condom) should always be used during (start to finish) sexual intercourse (vagina or rectum)>

-- If you or your partner is at high risk, avoid mouth contact with the penis, vagina, or rectum.

-- Avoid all sexual activities which could cause cuts or tears in the linings of the rectum, vagina, or penis.

-- Single teen-age girls have been warned that pregnancy and contracting sexually transmitted diseases can be the result of only one act of sexual intercourse. They have been taught to say NO to sex! They have been taught to say NO to drugs! By saying No to sex and drugs, they can avoid AIDS which can >kill< them! The same is true for teenage boys who should also not have rectal intercourse with other males. It may result in AIDS.

-- Do not have sex with prostitutes. Infected male and female prostitutes are frequently also intravenous drug abusers; therefore, they may infect clients by sexual intercourse and other intravenous drug abusers by sharing their intravenous drug equipment. Female prostitutes also can infect their unborn babies.

INTRAVENOUS DRUG USERS

Drug abusers who inject drugs into their veins are another populations groups at high risk and with high rates of infection by the AIDS virus. Users of intravenous drugs make up 25 percent of the cases of AIDS throughout the country. The AIDS virus is carried in contaminated blood left in the needle, syringe, or other drug related implements and the virus is injected into the new victim by reusing dirty syringes and needles. Even the smallest amount of infected blood left in a used needle or syringe can contain live AIDS virus to be passed on to the next user of those dirty implements.

No one should shoot up drugs because addiction, poor health, family disruption, emotional disturbances and death could follow. However, many drug users are addicted to drugs and for one reason or another have not changed their behavior. For these people, the only way not to get AIDS is >to use a clean, previously unused< needle, syringe or any other implement necessary for the injection of the drug solution.

HEMOPHILIA

Some persons with hemophilia (a blood clotting disorder that makes them subject to bleeding) have been infected with the AIDS virus either through blood transfusion or the use of blood products that help their blood clot. Now that we know how to prepare safe blood products to aid clotting, this is unlikely to happen. This group represents a very small percentage of the cases of AIDS throughout the country.

BLOOD TRANSFUSION

Currently all blood donors are initially screened and blood is >not< accepted from high risk individuals. Blood that has been collected for use is tested for the presence of antibody to the AIDS virus. However, some people may have had a blood transfusion prior to March 1985 before we knew how to screen blood for safe transfusion and may have become infected with the AIDS virus. Fortunately there are not now a large number of these cases. With routine testing of blood products, the blood supply for transfusion is now safer than it has ever been with regard to AIDS.

Persons who have engaged in homosexual activities or have shot street drugs within the last 10 years should >never< donate blood.

MOTHER CAN INFECT NEWBORN

If a woman is infected with the AIDS virus and becomes pregnant, she is more likely to develop ARC or classic AIDS, and she can pass the AIDS virus to her unborn child. Approximately one-third of the babies born to AIDS-infected mothers will also be infected with the AIDS virus. Most of the infected babies will eventually develop the disease and die. Several of these babies have been both to wives of hemophiliac men by way of contaminated blood products. Some babies have also been born to women who became infected with the AIDS virus by bisexual partners who had the virus. Almost all babies with AIDS have been born to women who were intravenous drug users or the sexual partner of intravenous drug users who were infected with the AIDS virus. Most such babies can be expected.

Think carefully if you plan on becoming pregnant. If there is any chance that you may be in any high risk group or that you have had sex with someone in a high risk group, such as homosexual and bisexual males, drug abusers and their sexual partners, see your doctor.

SUMMARY

AIDS affect certain groups of the population. Homosexual and bisexual males who have had sexual contact with other homosexual or bisexual males as well as those who "shoot" street drugs are at greatest risk of exposure, infection and eventual death. Sexual partners of these high risk individuals are at risk, as well as any children born to women who carry the virus. Heterosexual persons are increasingly at risk.

WHAT IS SAFE

MOST BEHAVIOR IS SAFE

Everyday living does not present any risk of infection. You >cannot< get AIDS from casual social contact. Casual social contact should not be confused with casual >sexual< contact which is a major cause of the spread of the AIDS virus. Casual >social< contact such as shaking hands, hugging, social kissing, crying, coughing or sneezing, will not transmit the AIDS virus. Nor has AIDS been contracted from swimming in pools or hot tubs or from eating in restaurants (even if a restaurant worker has AIDS or carries the AIDS virus). AIDS is not contracted from sharing bed linens, towels, cups, straws, dishes, or any other eating utensils. You cannot get AIDS from toilets, doorknobs, telephones, office machinery, or household furniture. You cannot get AIDS from body massages, masturbation or any non-sexual body contact.

DONATING BLOOD

Donating blood is >not< risky at all. YOU CANNOT GET AIDS BY DONATING BLOOD.

RECEIVING BLOOD

In the U.S. every blood donor is screened to exclude high risk persons and every blood donation is now tested for the presence of antibodies to the AIDS virus. Blood that shows exposure to the AIDS virus by the presence of antibodies is not used either for transfusion or for the manufacture of blood products. Blood banks are safe as current technology can make them. Because antibodies do not form immediately after exposure to the virus, a newly infected person may unknowingly donate blood after becoming infected but before his/her antibody test becomes positive. It is estimated that this might occur less than once in 100,000 transfusions.

There is no danger of AIDS virus infection from visiting a doctor, dentist, hospital, hairdresser or beautician. AIDS cannot be transmitted non-sexually from an infected person through a health or service provider to another person. Ordinary methods of disinfection for urine, stool and vomitus which are used for non-infected people are adequate for people who have AIDS or are carrying the AIDS virus.

You may have wondered why your dentist wears gloves and perhaps a mask when treating you. This does not mean that he has AIDS or that he thinks you do. He is protecting you and himself from hepatitis, common colds or flu.

There is no danger in visiting a patient with AIDS or caring for him or her. Normal hygienic practices, like wiping of body fluid spills with a solution of water and household bleach (1 part household bleach to 10 part water), will provide full protection.

CHILDREN IN SCHOOL

None of the identified cases of AIDS in the United States are known or are suspected to have been transmitted from one child to another in school, day care, or foster care setting. Transmission would necessitate exposure of open cuts to the blood or other body fluids of the infected child, a highly unlikely occurrence. Even then routine safety procedures for handling blood or other body fluids (which should be standard for all children in the school or day care setting) would be effective in preventing transmission from children with AIDS to other children in school.

Children with AIDS are highly susceptible to infections, such as chicken pox, from other children. Each child with AIDS should be examined by a doctor before attending school or before returning to school, day care or foster care setting after an illness. No blanket rules can be make for all school boards to cover all possible cases of children with AIDS and each case should be considered separately and individualized to the child and the setting, as would be done with any child with a special problem, such as cerebral palsy or asthma. A good team to make such decisions with the school board would be the child's parents, physician and a public health official.

INSECTS

There are no known cases of AIDS transmission by insects, such as mosquitoes.

PETS

Dogs, cats and domestic animals are not a source of infection from AIDS virus.

TEARS AND SALIVA

Although the AIDS virus has been found in tears and saliva, no instance of transmission from these body fluids has been reported.

AIDS COMES FROM SEXUAL CONTACTS WITH INFECTED PERSONS AND FROM THE SHARING OF SYRINGES AND NEEDLES. THERE IS NO DANGER OF INFECTION WITH AIDS VIRUS BY CASUAL SOCIAL CONTACT.

TESTING OF MILITARY PERSONNEL

You may wonder why the Department of Defense is currently testing its uniformed services personnel for presence of the AIDS virus antibody. The military feel this procedure is necessary because the uniformed services act as their own blood bank in a time of national emergency. They also need to protect new recruits (who unknowingly may be AIDS virus carriers) from receiving live virus vaccines. These vaccines could activate disease and be potentially life-threatening to the recruits.

WHAT IS CURRENTLY UNDERSTOOD

Although AIDS is still a mysterious disease in many ways, our scientists have learned a great deal about it. In five years we know more about AIDS than many diseases that we have studied for even longer periods. While there is no vaccine or cure, the results from the health and behavioral research community can only add to our knowledge and increase our understanding of the disease and ways to prevent and treat it.

In spite of all that is known about transmission of the AIDS virus, scientists will learn more. One possibility is the potential discovery of factors that may better explain the mechanism of AIDS infection.

WHY ARE THE ANTIBODIES PRODUCED BY THE BODY TO FIGHT THE AIDS VIRUS NOT ABLE TO DESTROY THAT VIRUS?

The antibodies detected in the blood of carriers of the AIDS virus are ineffective, at least when classic AIDS is actually triggered. They cannot check the damage caused by the virus, which is by then present in large numbers in the body. Researchers cannot explain his important observation. We still do not know why the AIDS virus is not destroyed by man's immune system.

SUMMARY

AIDS no longer is the concern of any one segment of society; it is the concern of us all. No American's life is in danger if he/she of their sexual partners do not engage in high risk sexual behavior or use shared needles or syringes to inject illicit drugs into the body.

People who engage in high risk sexual behavior or who shoot drugs are risking infection with the AIDS virus and are risking their lives and the lives of others, including their unborn children.

We cannot yet know the full impact of AIDS on our society. From a clinical point of view, there may be new manifestations of AIDS --for example, mental disturbances due to the infection of the brain by the AIDS virus in carriers of the virus. From a social point of view, it may bring to an end the free- wheeling sexual lifestyle which has been called the sexual revolution. Economically, the care of AIDS patients will put a tremendous strain on our already overburdened and costly health care delivery system.

The most certain way to avoid getting the AIDS virus and to control the AIDS epidemic in the United States is for individuals to avoid promiscuous sexual practices, to maintain mutually faithful monogamous sexual relationship and to avoid injecting illicit drugs.

LOOK TO THE FUTURE

THE CHALLENGE OF THE FUTURE

An enormous challenge to public health lies ahead of us and we would do well to take a look at the future. We must be prepared to manage those things we can predict, as well as those we cannot.

At the present time there is no vaccine to prevent AIDS. There is no cure. AIDS, which can be transmitted sexually and by sharing needles and syringes among illicit intravenous drug users, is bound to produce profound changes in our society, changes that will affect us all.

INFORMATION AND EDUCATION ONLY WEAPONS AGAINST AIDS

It is estimated that in 1991 54,000 people will die from AIDS. At this moment, many of them are not infected with the AIDS virus. With proper information and education, as many as 12,000 to 14,000 people could be saved in 1991 from death by AIDS.

AIDS WILL IMPACT ALL

The changes in our society will be economic and political and will affect our social institutions, our educational practices, and our health care. Although AIDS may never touch you personally, the social impact certainly will.

BE EDUCATED -- BE PREPARED

Be prepared. Learn as much about AIDS as you can. Learn to separate scientific information from rumor and myth. The Public Health Service, your local public health officials and family physician will be able to help you.

CONCERN ABOUT SPREAD OF AIDS

While the concentration of AIDS cases is in the larger urban areas today, it has been found in every state and with the mobility of our society, it is likely that cases of AIDS will appear far and wide.

SPECIAL EDUCATIONAL CONCERNS

There are a number of people, primarily adolescents, that do not yet know they will be homosexual or become drug abusers and will not heed this message; there are other who are illiterate and cannot heed this message. They must be reached and taught the risk behaviors that expose them to infection with the AIDS virus.

HIGH RISK GET BLOOD TEST

The greatest public health problem lies in the large number of individuals with a history of high risk behavior who have been infected with and may be spreading the AIDS virus. Those with high risk behavior must be encouraged to protect others by adopting safe sexual practices and by the use of clean equipment for intravenous drug use. If a blood test for antibodies to the AIDS virus is necessary to get these individuals to use safe sexual practices, they should get a blood test. Call your local health department for information on where to get the test.

ANGER AND GUILT

Some people afflicted with AIDS will feel a sense of anger and others a sense of guilt. In spite of these understandable reactions, everyone must join the effort to control the epidemic, to provide for the care of those with AIDS, and to do all we can to inform and educate other about AIDS, and how to prevent. it.

CONFIDENTIALITY

Because of the stigma that has been associated with AIDS, may afflicted with the disease or who are infected with the AIDS virus are reluctant to be identified with AIDS. Because there is no vaccine to prevent AIDS and no cure, many feel there is nothing to be gained by revealing sexual contacts that might also be infected with the AIDS virus. When a community or a state requires reporting of those infected with the AIDS virus to public health authorities in order to trace sexual and intravenous drug contacts -- as is the practice with other sexually transmitted diseases -- those infected with the AIDS virus have gone underground out of the mainstream of health care and education. For this reason current public health practice is to protect the privacy of the individual infected with the AIDS virus and to maintain the strictest confidentiality concerning his/her health records.

STATE AND LOCAL AIDS TASK FORCES

Many state and local jurisdictions where AIDS has been seen in the greatest numbers have AIDS task forces with heavy representation from the field of public health joined by others who can speak broadly to issues of access to care, provision of care and the availability of community and psychiatric support services. Such a task force is needed in every community with the power to develop plans and policies, to speak, and to act for the good of the public health at every level.

State and local task forces should plan ahead and work collaboratively with other jurisdictions to reduce transmissions of AIDS by far-reaching informational and educational programs. As AIDS impacts more strongly on society, they should be charged with making recommendations to provide for the needs of those afflicted with AIDS. They also will be in the best position to answer the concerns and direct the activities of those who are not infected with the AIDS virus.

The responsibility of State and local task forces should be far reaching and might include the following areas:

-- Insure enforcement of public health regulation of such practices as ear piercing and tattooing to prevent transmission of the AIDS virus.

-- Conduct AIDS education programs for police, firemen, correctional institution workers and emergency medical personnel for dealing with AIDS victims and the public.

-- Insure that institutions catering to children or adults who soil themselves or their surrounding with urine, stool, and vomitus have adequate equipment for cleanup and disposal, and have policies to insure the practice of good hygiene.

SCHOOL

Schools will have special problems in the future. In addition to the guidelines already mentioned in this pamphlet, there are other things that should be considered such as sex education and education of the handicapped.

SEX EDUCATION

Education concerning AIDS must start at the lowest grade possible as part of any health and hygiene program. The appearance of AIDS could bring together diverse groups of parents and educators with opposing views on inclusion of sex education in the curricula. There is now no doubt that we need sex education in schools and that it must include information on heterosexual and homosexual relationships. The threat of AIDS should be sufficient to permit a sex education curriculum with a heavy emphasis on prevention of AIDS and other sexually transmitted diseases.

HANDICAPPED AND SPECIAL EDUCATION

Children with AIDS or ARC will be attending school along with other who carry the AIDS virus. Some children will develop brain disease which will produce changes in mental behavior. Because of the right to special education of the handicapped and the mentally retarded, school boards and higher authorities will have to provide guidelines for the management of such children on a case- by-case basis.

LABOR AND MANAGEMENT

Labor and management can do much to prepare for AIDS so that misinformation is kept to a minimum. Unions should issue preventive health messages because many employees will listen more carefully to a union message than they will to one from public health authorities.

AIDS EDUCATION AT THE WORK SITE

Offices, factories, and other work sites should have a plan in operation for education of the work force and accommodation of AIDS or ARC patients >before< the first such case appears at the work site. Employees with AIDS or ARC should be dealt with as are any workers with a chronic illness. In-house video programs provide an excellent source of education and can be individualized to the needs of a specific work group.

STRAIN ON THE HEALTH CARE DELIVERY SYSTEM

The health care system in many places will be overburdened as it is now in urban areas with large numbers [of] AIDS patients. It is predicted that during 1991 there will be 145,000 patients requiring hospitalization at least once and 54,000 patients who will die of AIDS. Mental disease (dementia) will occur in some patients who have the AIDS virus before they have any other manifestation such as ARC or classic AIDS.

State and local task forces will have to plan for these patients by utilizing conventional and time honored systems but will also have to investigate alternate methods of treatment and alternate sites for care including homecare.

The strain on the health system can be lessened by family, social, and psychological support mechanisms in the community. Programs are needed to train chaplains, clergy, social workers, and volunteers to deal with AIDS. Such support is critical to the minority communities.

MENTAL HEALTH

Our society will also face an additional burden as we better understand the mental health implications of infection by the AIDS virus. Upon being informed of infection with the AIDS virus, a young, active, vigorous person faces anxiety and depression brought on by fears associated with social isolation, illness, and dying. Dealing with these individual and family concerns will require the best efforts of mental health professionals.

CONTROVERSIAL ISSUES

An number of controversial AIDS issues have arisen and will continue to be debated largely because of lack of knowledge about AIDS, how it is spread, and how it can be prevented. Among these are the issues of compulsory blood testing, quarantine, and identification of AIDS carriers by some visible sign.

COMPULSORY BLOOD TESTING

Compulsory blood testing of individuals is not necessary. The procedure could be unmanageable and cost prohibitive. It can be expected that many who >test< negatively might actually be positive due to >recent< exposure to the AIDS virus and give a false sense of security to the individual and her/her sexual partner concerning necessary protective behavior. The prevention behavior described in this report, if adopted, will protect the American public and contain the AIDS epidemic. Voluntary testing will be available to those who have been involved in high risk behavior.

QUARANTINE

Quarantine has no role in the management of AIDS because AIDS is not spread by casual contact. The only time that some form of quarantine might be indicated is in a situation where an individual carrying the AIDS virus knowingly and willingly continues to expose other through sexual contact or sharing drug equipment. Such circumstances should be managed on a case-by-case basis by local authorities.

IDENTIFICATION OF AIDS CARRIER BY SOME VISIBLE SIGN

Those who suggest the marking of carriers of the AIDS virus by some visible sign have not thought the matter through thoroughly. It would require testing of the entire population which is unnecessary, unmanageable and costly. It would miss those recently infected individuals who would test negatively, but be infected. The entire procedure would give a false sense of security. AIDS must and will be treated as a disease that can infect anyone. AIDS should not be used as an excuse to discriminate against any group or individual.

UPDATING INFORMATION

As the Surgeon General, I will continually monitor the most current and accurate health, medical, and scientific information and make it available to you, the American people. Armed with this information you can join in the discussion and resolution of AIDS-related issues that are critical to your health, your children's health, and the health of the nation.

COPING WITH THE GROWING AIDS PROBLEM

An interview with Surgeon General, Dr. C. Everett Koop by Patricia Cohen, New York Newsday

Q: Experts say that there are more than 1.5 million Americans who are infected with the AIDS virus. Should we trust this estimate any more than government budget projections?

A: I have the same problem with budget figures, but I have great faith in statistics on this. Estimates like 1.5 million people carrying the virus are made the way you do a Gallup Poll. We plotted what the incidence of new cases would be for 1986, and that's what they turned out to be. Barring a cure, a vaccine or a remarkable concerted effort to change lifestyles, all of which seem unlikely, you're not going to see much change in [our] projections.

Q: So you don't feel you're being alarmist?

A: No. The wrong people are alarmed. There are a lot of people out there who couldn't catch AIDS if they tried, yet they're scared to death of the things they shouldn't worry about, such as using telephones, eating in restaurants, shaking hands with people, playing with pets and sharing towels. That is not the way you catch AIDS. But the people who are leading promiscuous sexual lifestyles or shooting drugs ought to be scared to death. Yet they sort of think they're immortal. A lot of them are young people, and that's one of the problems, and one of the great joys, of being young.

W: Are you completely satisfied with the results of the White House Domestic Policy Council meetings?

A: The [AIDS] report was accepted unanimously. [As for sex education], everyone who spoke about that there was in favor of what I had said about it. The only dissenting voice about that was Gary Bauer, the under secretary for education [and recently appointed presidential domestic policy adviser]. We each drew up our own position on sex education, and they were very, very close together. Education Secretary William Bennett and I have agreed on five points. Parents are responsible for the education of their children, but sex education will have to be undertaken in schools. Parents should be involved in what is taught and how it's taught and when it's taught. And it should include AIDS education.

Q: But parents in New York City are allowed to pull their kids out of sex education classes.

A: When people begin to see the tremendous problem that AIDS presents, they are going to realize that sex education is going to [be taught] whether parents in a given area want it or not. San Francisco has compulsory sex education, and as I understand it, only two parents would not let their children attend those classes. I am not in favor of those curricula that teach sex techniques without [teaching] responsibility or morality. There are lots of good sex education curricula that are value-laden. Of course, there are a lot of barriers [that keep] parents [from educating their own kids].

Q: What barriers?

A: Parents are so embarrassed that they shut up and retreat. A lot of parents today never were told a thing about sex themselves. They don't know the name of this or the function of that, so they feel inadequate and they clam up. Secondly, it's a tremendous invasion of their privacy.

Q: In what sense?

A: All the time they were raising their kids, there were two rooms in the house that were inviolate -- the bedroom and the bathroom. Suddenly they've got to tell their child what goes on behind those locked doors. Third, parents do not like to discuss the nature and the quality of their own relationships. With the tremendous number of divorces that take place very year, a lot of marriages aren't great. But what parent can explain that to his child when the child has a fantasy of what marriage should be. It's tough. We've got to help [parents]. We have enough doctors who, with the proper organization, can teach parents to teach children and can teach teachers to teach children.

Q: What's your view of the more drastic proposals to contain the disease?

A: Mandatory testing is an unbelievably large and difficult task. The very people who suspect that they are seropositive or know that they are would somehow avoid getting picked up in that net. That's not hard to do in a country this big. Second, such testing would be inaccurate. Anybody who tests negatively today but in the past two weeks to three month has either had sexual intercourse or shot drugs could be positive but not [have shown up] positive. That would not only give you inaccuracies but also give the people who have negative tests a tremendous false sense of security. I have absolutely no objection to [premarital testing]. You'll find more and more people doing that. We had it for years for other sexually transmitted diseases, and the reason we stopped is that those diseases are treatable. Now this disease isn't treatable, it's fatal. And everything I said about testing applies to [contact tracing]. Several states have found that the very people they want to [trace] go underground.

Q: Would you quarantine people with AIDS?

A: Suppose you could magically round up everybody today. Where are you going to put 2 million people? What about the people who are going to turn positive in the next three month? It isn't logical [or] doable, and it leads to all kinds of problems that would not prevent the disease but would make life miserable for a lot of innocent people.

Q: What do you say to those who believe that one day research will show that AIDS can be transmitted through casual contact?

A: On the basis of everything one knows scientifically, it's very unlikely something's going to turn up at this late date. We have studied well over a thousand health workers who have the highest exposure to AIDS. patients. They start IVs on AIDS patients, they take blood from them, they handle their urine, their stool, their vomit. They change their dressing. If there was a chance you could pick it up from even this extended casual contact, you'd expect them to do it. Every single one of those who tested seropositive stuck him or herself with a needle that they just pulled out of an AIDS patient. The other group [studies] was hemophiliacs who are men. The conclusions was you can't get AIDS even in close family contact from such things as using the same eating utensils, cooking utensils, toilets, towels, toys, playing with the same pets or sharing the same toothbrushes.

Q: What is the best historical analogy for AIDS?

A: In reference to the stigma, one analogy is to lepers. Nobody got near them. As far as devastating numbers, it would be more like the bubonic plague. None of them are exactly the same because this is 100 percent fatal and with those other diseases, there was something you could do.

Q: Some people believe that if this disease had hit the heterosexual population rather than the homosexual population and IV drug users, the government would have reacted differently?

A: We had a pretty strong response. We really put out a tremendous amount of information to [male homosexuals], that high-risk group, and the fascinating thing is that that group responded. Promiscuous homosexuals have changed their lifestyles. Unfortunately, it's sort of closing the [stable] door after the horse has left. Now you've got to tell the people who had that very antagonistic attitude toward homosexuals and IV drug abusers that there are now a tremendous number of "innocent" people out there. Women who become infected from their husbands or lovers who are bisexual, and had no idea; those infected by someone who has occasionally shot drugs in secret; and a lot of people who engage in sexual relationships and don't know their partners. Then there are the babies.

Q: How safe are the safe sex guidelines?

A: To IV drug abusers, we say, don't use drugs, and if you do use drugs, don't be such a fool as to use dirty needles. The problem with that is when he needs a fix, he doesn't care if the needle is clean or dirty. For sexual problems, what we are pushing as our official position is this: The absolutely foolproof way of not getting AIDS is to be absolutely abstinent. A mutually faithful monogamous relationship is second best. But knowing how long it takes for a patient who has been infected with the virus to show symptoms of the disease, we have to say this in very crude terms: If A has sexual intercourse with B, he is having sexual intercourse with every person that B has had sexual intercourse with for the last 10 years. And all of those people and all of those people. It's an unbelievable Christmas tree. Finally we say, if you are foolish enough not to heed the warning of the Public Health Service about sexual behavior, then for heaven's sake, protect yourself and your partner by using condoms.

Q: Is some of the discrimination that the Defense, Labor and State Departments practice against people with AIDS fair or warranted -- particularly the Justice Department's decision that irrational fear is a legitimate basis to dismiss someone with AIDS?

A: Certain department have very special scientific, humanitarian and legal problems. In a time of emergency, the army is its own walking blood lank, and you can't have a contaminated blood supply. People in the armed forces are immunized against all sorts of diseases, and if you [inoculate] someone who has the AIDS virus with a live vaccine, you could kill him. It's the same thing for the Foreign Service and Peace Corps. The Justice Department's decision is the only opinion it could come to. Society has made a decision that people with AIDS are disable, while people who carry the virus. aren't. The law protects only the disabled. So if you've got AIDS and I've got the virus, we come under two separate laws, though we work for the same guy. He can't discharge you because you're disabled, but he can discharge me -- it's his privilege. [Someday], they're going to change the definition. Either that or there'll be so many people around eventually with AIDS that the stigma will become less important.

Q: It seems the next major AIDS issue will be the skyrocketing costs of health care.

A: It's here. Direct health care will cost $8 to $16 billion annually by 1991. The Palo Alto Medical Foundation said that it you figured all indirect costs such as time lost, it's closer to $70 billion a year.

Q: In 1981, when President Reagan first nominated you, a lot of editorial pages around the country urged him to dump Koop. Now they're praising you for your enlightened approach toward AIDS, smoking, child abuse. Do you feel vindicated?

A: How sweet it is. I realized a lot of it was theater, a lot of it was against the president, most of it was because of my antiabortion stand. But I've established credibility with the public and with the press. I have not done any of the things people said I would do. The conservative who supported me are now denouncing me and the liberals who didn't like me now say I'm right.

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