The Police Power And HIV/STDs In The Elderly

1. The Police Power And HIV/STDs In The Elderly Edward P. Richards, IIIProfessorUniversity of Missouri – Kansas CitySchool of Law5100 Rockhill RoadKansas City, MO 64110(816)235-2370/richardse@umkc.edu

2. Overview • HIV/STDs As A Special Case • HIV - Especially Dangerous To The Elderly • General Problem of Communicable Diseases • Driven By Changing Demographics • Demands A Public Health Approach • Police Powers To Protect the Community • Personal Health Services for Individuals

3. Risk Factors For HIV/STDs • Drug Use • Sharing Needles • Trading Sex For Drugs • Sexual Activity • Frequency • Number Of Partners • Practices • Core Group Dynamics

4. Why Are The Elderly At Risk? • Elderly Have Always Been At Risk • Small Numbers • Social Stigma Hides Cases • Changes in Community Demographics • Increasing The Risks • Increasing The Numbers

5. Traditional Health Status • Death Came Earlier • Less Time Retired • Less Time Widowed • Smaller Population Of Elderly • Not As Healthy • Underestimated By Life Expectancy • General Health • Sexual Dysfunction

6. Current Health Trends • Longer Life Span • Longer Retirement • Longer Widowed • Larger Elderly Population • Better Health • Masked By Static Life Expectancy • Improvements In General Health • Improvements In Sexual Function

7. Traditional Demographics • No Distinct Elderly Community • Poor • Smaller Numbers • Unorganized • Dispersed Through The Community • Integrated With Extended Family • Better Social Support Networks

8. Contemporary Demographics • Elderly Only Communities • Sun City - the Affluent • Supervised Living • Elderly Ghettos • Benefits of Homogenous Communities • Critical Mass for Special Services • Crime and Violence are for the Young • No Stigmatization • Self-Quarantine

9. Risks of Elderly Communities • Better Niche for Communicable Diseases • Concentration of Hosts • More Susceptible Population • Increases Social Interaction Spreads Disease • Ignorance of Larger World Problems • The Elderly Do Not See STDs As Their Problem • Physicians Do Not Look for STDs in the Elderly

10. Why Do Doctors Miss HIV/STDs In The Elderly? • Mistaken Social Perceptions • Elderly Do Not Have Sex • Elderly Do Not Have STDs Even If They Have Sex • Elderly Are Not Drug Abusers • Misleading Medical Cues • Elderly Already Have Weak Immune Systems • HIV Dementia Looks Like Other Dementias

11. Implications of Missing HIV • Elderly Die, On Average, 30 Days From Diagnosis • Increased Susceptibility • Evidence Of Very Delayed Diagnosis • Risks To Others • Sharing Needles (Not Just Illegal Drugs] • Sexual Activity

12. Strategies To Prevent HIV/STDs Personal Health Services Approach Public Health Police Power

13. Personal Health Services Approach • Education • Safe Sex • Avoid Sharing Needles • Importance Of Getting Tested • Role Of Health Care Providers • Must Recognize Disease • Must Counsel All Patients

14. Public Health Approach • Same Personal Health Education • Recognizes That Education Often Fails • Does Not Reach Everyone • Some Do Not Understand It • Some Do Not Think It Applies To Them • Some Do Not Care About Risks To Others • Public Health Adds Active Case Finding And Intervention

15. The Public Health Police Power • "[T]he liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly free from restraint. There are manifold restraints to which every person is necessarily subject for the common good. On any other basis organized society could not exist with safety to its members.” Jacobson v. Massachusetts, 197 U.S. 11 (1905), quoted in Hendricks at 356-367.

16. Disease Reporting • "Unquestionably, some individuals' concern for their own privacy may lead them to avoid or to postpone needed medical attention. Nevertheless, disclosures of private medical information to doctors, to hospital personnel, to insurance companies, and to public health agencies are often an essential part of modern medical practice even when the disclosure may reflect unfavorably on the character of the patient. Requiring such disclosures to representatives of the State having responsibility for the health of the community, does not automatically amount to an impermissible invasion of privacy.”Whalen V. Roe, 429 U.S. 589, 602 (1977)

17. Case Finding • Contact Tracing/Partner Notification • Voluntary • Most People Want To Help • Works Because Of Core Group Dynamics • Small Subset Accounts For Most Transmission • Contact Networks Are Redundant • Interview Enough People And You Get All The Nodes

18. InterventionsNewly Identified Contacts • Important Because HIV Is Hard To Catch • Warn That They Have Been Exposed • Counsel About The Disease And Precautions • Help Them Get Tested And Medical Care • Interview Them About Their Contacts • Add To Surveillance Database

19. Infected Contacts Who Continue Unsafe Activities • Tuberculosis Is The Best Model • Warn And Counsel • Increasing Restrictions • No Myth Of Self-Protection • What About HIV? • Mental Health Confinement If Demented? • Megan’s Law Approach? • Prosecution For Reckless Endangerment?

20. Community Ethics • The Constitution And The United States Supreme Court Support Broad Public Health Powers • How Do We Decide When We Should Use These Powers To Protect The Vulnerable? • Have Individual Rights Undermined Public Health?

21. Population Ethics • The Constitution And The United States Supreme Court Support Broad Public Health Powers • How Do We Decide When We Should Use These Powers To Protect The Vulnerable? • Have Individual Rights Undermined Public Health?