Understanding AIDS : Disease Control and the Health Care System

1. Understanding AIDS : Disease Control and the Health Care System Edward P. Richards, JD, MPH Director, Program in Law, Science, and Public Health Harvey A. Peltier Professor of Law Louisiana State University Law School Baton Rouge, LA 70803-1000 http://biotech.law.lsu.edu

2. Venereal Diseases in History • Venereal - Venus, goddess of love - diseases are as old as mankind • "Wages of Sin are Death" • VD is not politically correct any more - STI • Major diseases • Syphilis • Gonorrhea • Genital Herpes • Chlamydia • Second most common infectious diseases

3. Syphilis • Treatment • 1800s - Antimony and mercury • 1946 - Penicillin • Untreated • Primary • Secondary • Tertiary

4. Congenital Syphilis • Why being a virgin mattered, but not just for women • Early syphilis • Late pregnancy • Death • Severe malformations • Brain injury • Blood tests for marriage

5. Tuskegee Syphilis Experiment • Public Health Service • Tuskegee Alabama • 1930s • Complications of untreated syphilis • No consent as we now know it • Local docs and medical society were part of it • Continued until 1970 • Undermined faith in PHS and research

6. Core Group Transmission • General population has multiple subpopulations with limited mixing • Most spread is by a small number of highly active individuals - core group • Core group members also cross subpopulation lines • Identifying and treating core group members is key to controlling STI

7. Traditional STI Control • Syphilis • Reporting • Contract tracing • Partner notification • Gonorrhea and the rest • Notification by patient • Too common (expensive) to trace and follow-up

8. Other Blood Borne Diseases • Hepatitis B • Virus • Severe liver disease • Spread sexually • IV drug users sharing needles • Malaria, syphilis, West Nile, and many others are also spread by sharing needles • All are spread by blood transfusions • Now hepatitis C and other new viral diseases

9. Why do we need blood? • Injuries • Disease - ectopic pregnancy • Surgery

10. Where do we get blood? • Now • Volunteer donors for whole blood • Paid donors for blood products • Paid donors for rare blood • Pre-1976 • Paid donors • Who makes their living selling blood?

11. Hepatitis B and Blood • In the early 1970s, 1 in 3 people who got blood got hepatitis B • You only gave blood if it was really necessary • Blood banks finally gave in to public pressure and stopped paying donors in the 1970s • Did not start screening for Hepatitis B or for behavior that put people at risk for Hepatitis B • Still a lot of hepatitis B • Why?

12. Blood Banks • Non-Profit • American Red Cross is the largest • All work together on standard setting and use the same standards • What does this mean for standard of care in a negligence lawsuit? • Where does TJ Hooper come in?

13. Blood as a Product • Tremendous pressure to treat blood as a product • Would have created huge liability • What really happens when a non-profit blood bank, of which there is only one in a community, has to pay a big verdict? • Blood shield laws • We will read more about these and this debate next class

14. Stone Wall Riots • Stone Wall Bar in NYC • Gay patrons fought back when the police tried to roust them • Beginning of the gay rights movement • Beginning of visible gay political organizations with real power in big cities with large gay populations

15. Gay Bathhouses • Old Russian steam baths • The old guys died off • Became gay clubs • Bette Midler got started there • Became sex clubs • 10-20 anonymous sexual contacts a night • Tolerated because of politics, unlike Plato's Retreat

16. Everything is a STI if you try hard enough • Huge spread of infections in bathhouses • Syphilis • Gonorrhea • Giardia lamblia (traveler's diarrhea) • Mid-1970s it was shown that nearly everyone became infected with hepatitis B • But for HIV, we would be worried about the terrible consequences of the hepatitis B epidemic

17. Where was local Public Health? • Political officials did not want to have the gay political groups against them • Conservatives did not care about diseases that affected only gays • And the Band Played On, by Randy Shilts (1987) • Don't offend the gays and don't inflame the homophobes. These were the twin horns of the dilemma on which the handling of this epidemic would be torn from the first day of the epidemic. Inspired by the best intentions, arguments paved the road toward the destination good intentions inevitably lead.

18. Where was the CDC? • They depend on local public health for information • They were distracted by the Swine Flu vaccine campaign and its politically disastrous aftermath

19. Why does this Matter? • HIV is hard to catch • HIV v. Gonorrhea • HIV spread in bathhouses in the late 1970s • When it was discovered in 1980, there were already 500,000+ mostly gay men infected • Without the bathhouses, there would have been relatively few cases when it was discovered

20. Impact on the Blood Supply • HIV was in blood donated in the late 1970s and in 1980 • By 1981 we knew HIV affected the same people who had hepatitis B • How did we know this? • What does it tell us? • What would this have been different if blood banks had cared about hepatitis B in the 1970s?

21. How did the Blood Banks Respond? • Stonewalled, to be poetic • Resisted questioning donors • Depended on voluntary deferral • Would not screen for hepatitis B • Economic reasons • Legal and political reasons

22. What was the Impact of HIV in the Blood System? • Many persons who had elective and non-elective surgery got HIV • Arthur Ashe • Hemophiliacs • Depend on pooled blood products • Most got HIV

23. How Have Times Changed? • The French put some blood products people in jail • They were sued and got terrible publicity in the US and Canada • Now they are run scared of everything that might be in the blood • We are now seeing a huge number of hepatitis C cases and the resulting litigation