Midday; Mike Osterholm on AIDS

Dr. Michael Osterholm is with us today. He is Minnesota's state epidemiologist who works out of the health department is it not. And you used to spend quite a bit of time on flu and hepatitis and things like that and now you are working almost exclusively on AIDS. Right. Right. Our department still has responsibility for all the other infectious diseases that we have confront as a society. But I think it's quite evident that from the magnitude of the AIDS epidemic and the potential impact that will have on society that AIDS does consume an increasing amount of our time. All right. Just to give us some basis for discussion here and we'll get the phone lines open for your questions a little bit. How many AIDS cases are there currently in Minnesota. As of this week we will be putting out a approximate 340 cases of AIDS from the beginning of the epidemic to this time. And how does that square with what you had been expecting say a year ago or so. Well actually it's interesting because I have had an opportunity to be a guest on this program several times over the last several years I've gone back just before coming in today's

presentation to look and see where we were at at the times that I had been here before and where we're at now and where we had projected we'd be in 1990. And we are literally within a few cases today of where we said we would be. And we're very very well on our way unfortunately to that number of roughly 4300 to 18 hundred cases by the end of 1990 and do expect it to grow just exponentially after that. Or do you see some possibility of getting it under control. Well I think that two things come into play here first of all is that again we must remember that AIDS as a disease is a process that often begins years after you've actually been exposed to the virus and have become infected so that we're now realizing that five six seven years may transpire between the time that you become infected and you develop the first signs and symptoms so the cases of AIDS well into the early 90s are individuals who are already infected and the kinds of changes in behavior that would have an impact on AIDS really won't be felt. As a society until the

mid-1990s Now that's in contrast to so many other infectious diseases that we're used to dealing with where the time from exposure to consuming that contaminated item are still breathing the infectious agent is just a matter of days before one becomes sick. So in that sense yes that's going to continue to happen I think. The second point that is important here in terms of looking at the AIDS epidemic and and what kind of impact we might have or not have is is that again it comes back to behavior and behavior is the thing we need to change. I think society we've realized that with just a few cases as we've had there's still a lot of people out there that have a real strong sense of denial that this is a problem or will be a problem. And so until I think we have four or five or six thousand cases of AIDS in the state here we're not going to see much behavior change. Now given that the numbers could continue to increase for some time so that I think that even though we talk about 2000 cases cumulatively through the first 10 years of the epidemic it will I think be quite

likely that we'll be seeing two to three thousand new cases a year maybe more at least through the mid-1990s. And so until we basically are able to get through this population of people already infected. They basically largely have an outcome of AIDS or we begin to see some real impacts with the behavior change which I'm not sure is is to the degree necessary really coming about yet in such a way as to have a major impact in AIDS. I think the numbers will rise from the mid 90s. Are you seeing any change in the profile of AIDS patients are staying pretty stable. Well in terms of Minnesota cases the risk behaviors that have been associated with transmission of the virus namely sexual transmission and particularly among gay and bisexual men continues to contribute the vast majority of cases more than 85 percent of the cases fall in that category. I.V. drug use which is where you have needle sharing occurring between individuals and therefore blood being shared basically which occurs in an additional four or five percent of gay men. Beyond the number that I mentioned and then also another

four or five percent just in those who are not Gair bisexual but use needles and the other proportion of cases as we've talked about in the past blood transfusion. Children born to infected mothers in heterosexual transmission continue to be there. So gay men and bisexual men continue to be the primary risk behavior here. Now in other areas of the country that's not true. For example now in New York City about half the cases occur in I.V. drug users and that's an increasing proportion of the number of cases and we're seeing that more and some of the inner city areas particularly on the East Coast. That again is something we projected would happen. It will continue to happen. And I think we will see the epidemic as it matures in this country not being that dissimilar to what we've seen in Europe in Europe right now. The epidemic is really one of two. Two total different presentations in southern Europe in Italy Greece countries like that. The primary risk group is as gay or as I.V. drug use in northern Europe. The primary risk behavior is multiple sex partners gay and bisexual men.

So what happens in the East Coast and in Europe will eventually make its way to Minnesota. I well we will see an increasing number of cases among I.V. drug users. Again one of the real problems in terms of giving people absolute numbers is that it's we can tell you what's happening with AIDS today. That's very clear we feel very confident that we are able to identify and basically log in the numbers of the number of people with AIDS today. But we really need to be concentrating on is where is the infection. Who is getting infected today. And I think that's a very very critical point. And that again is not going to be evident until four or five years from now. All right. We've got some folks on the line already let's go to your question. First of all you're on the air. Hi I'm Dr. Osterholm. I have a friend who has AIDS and he has heard about therapy. It's being used in a very small way in California in Puerto Rico and apparently somewhere in the Virgin Islands called

over in Turkey where ozone is used as it's used in some places the United States to purify water. It's used to purify the blood of viruses and bacteria. Can you tell me anything about that. Yes actually you really provided an excellent opportunity to discuss that particular therapy. But I think talk about the whole therapy issue in general with regard to AIDS. First of all ozone as you pointed out is a type of chemical that is very effective in destroying certain vector in viruses and we use it in disinfecting certain kinds of products. In some cases it can be used in water supply systems to to kill any infectious agents that might be in it. Now one of the problems we have though and using it in human therapy for infectious diseases is that it's not just specific to those bacteria or viruses but also can kill cells in particular at certain levels. And you take that combined with the fact that the AIDS virus as we've talked about in this very program on several occasions creates a very unusual way

of getting into the body and hiding in the body in such a way that the body doesn't even detect it's there. You can actually transmit this virus from one individual to another with only the genetic material inside of for example of white blood cell. So let's say two people are having sex and a male ejaculates whether it be into a female vagina or rectum whatever they're not need be any full virus. They're only that white blood cell from that donor who is contributing that that has the genetic material for the virus inside of it that white blood cell in of itself would not be recognized as being something that shouldn't be there per se. Now that individual who receives that that white blood cell has cells in their own body that normally would gobble that cell up and get rid of it. But in the process then becomes infected itself. That cell of the recipient. Now that cell has the virus in it only in the genetic since it has a virus in it. But at any time later on that that could take off ozone would not distinguish those cells. It would not get rid of the virus out of there.

So that again from the longterm standpoint no it's not going to impact it's not going to basically eradicate the virus out there. And quite frankly it can be a therapy that actually can be a very significant health problem because of the potential impacts that it has. Which leads me to my second point is as one of the things I think that has been most disturbing to too many of us working in the AIDS epidemic. And now I tend to look back on this is something that I've been involved with AIDS since 1981 with his first recognition and that's more now spans more than half of my entire public health career. So for those who are just getting into AIDS today for some of us we have had an opportunity to see it. What we consider to be almost light years worth of time. And one of the things that has been most disturbing has been how many times I have watched individuals pray on what I consider to be very vulnerable people and those are people who are infected with the AIDS virus. I realize that with any serious life threatening disease there are people who will try almost anything as a method of therapy or a means of trying to

intervene with this condition when in fact standard medical practice can offer only a very limited kind of response to this. But with that we have seen people who have literally been taken not only financially but in some cases they have been I think they put their lives in serious jeopardy in terms of the kinds of treatments they have gotten. And there have been several exposé is on TV and other media forms trying to flush these kind of people out. And you know make it clear that these are unorthodox therapies that there's just no basis in medicine or science for why they should work and in many cases are damaging. So hopefully that as these new therapies come up before they are used at all people would make some attempt to do to justify that they have some medical basis that there's some data discussed they work and most of all they look at the safety issue. I think that's a very very important point. And it's going to continue to get worse when we're talking about the potential for 270000 cases of AIDS in this country by the end of 1990

91. And today we only have 58 thousand you can see that 58000 has caused a great disruption in this country in seven years. Think what an additional 220000 are going to do in the next three years so that the potential for these kinds of therapy issues are going to become more important a lot less oh so many implications of that. I mean let's let's just talk about one very briefly that is cost. I mean who is going to pay for the treatment of these people. Well cost is going to be an issue and it's going to be an issue that we as a society have to deal with. But I think that AIDS has to be put in appropriate perspective. I kind of shudder sometimes when I hear people making these very very grim prognostic kinds of statements about the impact that aids will have on our health care delivery system. They say basically it's going to break the system. In fact with some rather well conducted studies that have looked at the cost of AIDS to date extrapolating into the future even with the 270000 cases and looking at possible

ramifications of some drug therapies that are coming down the line that may keep patients alive longer in yet still they would require a fair amount of medical care. AIDS in 1990 in this country is projected to cost us about 15 to $20 million but put that in comparison to our what it's expected to be our national health care cost expenditure for 1990 and $650 million. I think that we as a society for fail to realize that we spend a great deal of money keeping people alive between the ages of 65 and 90. And I think that's a whole topic in itself that deserves comment. It's one that I know when I get to be 65 I'm going to want to stay alive as long as I can. But it's one that I think that AIDS is going to be costly in terms of the number of young lives it's going to take. It will be the number one cost in terms of we call years of potential life lost in the words early death in this country and all men in a very short period of time it will be that the state within two years. So it's going to cost us early in terms of lives. But in terms of total cost

the healthcare delivery cost issue is a whole nother one that is is a real quagmire and AIDS is only going to contribute to it but it's not going to be the straw that breaks the camel's back. It's almost a quarter past the hour already talking with Dr. Michael Osterholm about the AIDS epidemic and more folks with questions you're next. Thanks for waiting. Hello. Yes. My question concerns the so-called public health measure that the Minneapolis City Council passed recently after a very long campaign of hysteria and hate supported by the Health Department. Dr. Frank Grame repeatedly asked the question What is the evidence that causing the bats will stop the spread of AIDS. Where is the scientific evidence. No one ever including the health department presented one shred of evidence that this would have any effect. I have seen the Health Department recommendation that they cite the report preceding it in the MMW. Dr. Osterholm statement there is not one shred of evidence in any of those places including the National Institutes of Health that report confronting AIDS.

People can catch AIDS from building look such evidence. Let's get our. Let's get our guests reaction to that. It certainly is a current topic. Well first of all we really do strongly support the Minneapolis approach to this and I think that the listeners need to be aware of exactly what this measure talked about. Basically what it does is it does not prohibit such things as bathhouses or bookstores or so forth from existing and impart. That is a legal issue. And it's been tried in the courts already and it's been found that these various institutions do have a legal right to exist. But it's been found that with local ordinances as is possible to reduce the likelihood of high risk behavior from occurring in these institutions. In the case of bathhouses it means taking doors off the stalls or opening doors lighting up so that the so-called orgy rooms cannot exist. The same thing is true in the bookstores. In terms of the bathhouse issue the caller was asking for the definitive data. One of the real problems you have in public health is how do you

measure something you prevent. You know we have that problem all the time where if it doesn't occur then you don't know. Would it have occurred if you hadn't done something or not. Whereas if you don't do something that occurs everyone knows and it becomes very evident we had clear evidence that high risk activity has occurred and continues to occur in some of these areas. One can argue that if you basically make it untenable for that activity to occur there it just occur somewhere else. I don't buy that and I have not bought that. We have seen far too many individuals who particularly in the state of intoxication and so forth who have come into these establishments who might very well in a better frame of mind not choose to do that. And if that place didn't exist conveniently wouldn't do it. And I think that what the department has wrestled with over the past several years is the best legal way to do it. I think that if anyone's going to put all their eggs in one basket and dealing with the AIDS epidemic they will obviously miss the target by a long shot and closing bathhouses or reducing the likelihood of high risk behavior in a bathhouse or a bookstore is not going to stop the

AIDS epidemic. But it is one step of what has to be a very large and comprehensive program to deal with this. So we have supported the Minneapolis ordinance the Commissioner of Health has written record of having supported it personally as a state biologist and I can speak for my other colleagues and the other 50 states we have strongly endorsed such measures and we hope to see that other communities in the state of Minnesota continue to follow the lead of the Minneapolis ordinance and where appropriate enact similar ordinances. And and as one small part of a very very large problem begin to deal with it head on. Let's move along quickly to some more folks with questions for my foster home. Hello you're next all. Thank Bonnie. I'm now wondering if you had to go to California for this guy was raped by four minor children boys and girls. And they finally got him and he was completely support me you know

I'm not ready yet. But right now he's got too much homework for. How long it will take 40 percent. Now I'd like to hear his opinions on that. If he heard about it and you know OK well I think that the situation you describe is one that has occurred. There is evidence that with sexual abuse you can transmit the AIDS virus. I'm aware nationally of the same issue. In fact I served on the Surgeon General's group that studied the issue of pediatric AIDS a year ago and came out with a document one of the areas that we emphasized needed much further effort and work was the whole area of child sexual abuse and potential transmission for HIV virus with the AIDS virus in that setting. And I might add that that doesn't occur just for children. We have to look at that also in adult sexual abuse rape and so forth with the same issue. I think that it's a very volatile issue. It's one that HIV and of itself should not be associated just with a rapist. We know that

there are a lot of people out there who may in fact be victims of sexual assault who who were not sexually assaulted by an HIV positive person. And I think one of the things I would just caution about is as difficult as that issue is to deal with and as angry as it makes people like ourselves to deal with when we know that someone may be HIV positive and forcibly having sex with someone and that there are a whole lot of HIV positive people out there who are not and unfortunate have been in several situations where people have broadly painted HIV positive people as people who do that kind of thing. And I think that just so that we don't forget that that there are a lot of people out there that have contracted the virus through sexual contact with three new usage. But when you look at there are level of personal responsibility. They have never knowingly or even suggestively exposed anyone else to the virus. So yes we have to deal with these kinds of individuals. But I would label them almost in the category of social past psychopaths that in fact we deal with every day.

Not just related to the AIDS virus issue and moving on now to another question. Go ahead please you're on the air with Dr. Osterholm. Hello. Yes. I have a question about the latency of the AIDS virus as long as January 1 1996. There was a piece called the slow insidious nature of the HBO series that argued that the AIDS virus is latent in human T-cells for a long time until triggered by systemic infections. The question is if if the virus can be that latent and we see that in trance transfusion. In fact these times of up to five years. And if the virus varies considerably in its infectivity depending upon the stage of infection of the donor of the virus. Is it appropriate to say that there is no risk of casual infection and is it appropriate to say that everybody will convert within 60

days after exposure. OK actually you have about five questions in that single question. Let me try to kind of go through it and maybe address each one of them. First of all again the information you talked about with the quote unquote latency is in fact something we've talked about for some time as early as 1985. Again on this very program here we've talked about the problem. In fact we really kind of hit on it earlier today of front once you're infected How long does it take before one actually might develop full blown AIDS if in fact they're going to. Even when we had only had people infected for a short period of time remember the vast majority of people in this country have become infected since 1980. So at the most we have at best seven years experience with this virus as a population. But even when we had just several years in that number of individuals who we knew to have gone on from the initial infection to full blown AIDS is about 10 to 20 percent there were those of us that said wait a minute. Because of what we know about these types of viruses in other

situations one probably has a lifetime risk in that we really won't have a good handle on what's going to happen until we followed populations for 10 years or more. And that obviously was not the kind of news and a lot of infected people wanted to hear. But as from a public health perspective and from a medical care standpoint it was very important. Well now as late as two weeks ago the group in San Francisco which has been following individuals who are infected as early as in early 1980s and that was determined even though we didn't know about AIDS then or we didn't have a test for it. We had blood samples stored away in these individuals who were involved in another kind of study. And we can tell exactly when they got infected so that we do have this group from 1980 and 81 that became infected and followed them forward. And now given where they see it with AIDS in some of the other serious consequences the AIDS virus infection not actually officially called AIDS. They're projecting at seven years that 75 percent will have developed AIDS or or serious illness associated with the virus. That's far different than 10 or 20 percent. So

that's there that's not new. And I think ultimately the question will be how many people over 10 15 or 20 years will develop full blown AIDS or know an outcome namely death related to AIDS itself. And that question has to be answered yet that will be impacted hopefully by some of the new drugs we're dealing with today. None of us believe for a second that the drugs that we are talking about will cure AIDS. That in fact you don't you'll get rid of the virus but that can we keep it in check. In other words can we kind of live in a coexistence with this virus with these drugs keeping it suppressed. That's the question is there. But let me emphasize again part of the question that you talked about that I think kind of crept in there is suggesting that individuals who might be infected over time may have some change in the virus such that it could be transmitted casually and in fact. No that's not the case at all. And let me go back and use an example of another viral disease that has the ability to change part of its outside coating and that's all the AIDS virus does is it doesn't as a virus change it merely

changes its outside coating a bit. And the influenza virus the true influenza which is a respiratory type disease that you hear about every winter and an early spring causing serious pneumonia that type of illness individuals. And the reason we have outbreaks of this is because every several years the influenza viruses change or outside coding a little at the outside it isn't quite the same as it was several years ago in the body therefore having previously been infected with this virus and made an antibody or a chemical that if exposed again would fight it off immediately doesn't recognize having been infected before. That's why in 1976 we were so concerned about swine flu because we hadn't seen it since 1918 and when we last saw it in 1918 it killed millions of people. But in all of the course of history as many times as we've had influenza epidemics and this happens over and over again you know how it's transmitted through the respiratory route. It's never changed the epidemiology the disease is identical. What is different is whether or not the body recognizes having seen that particular influenza virus before and to what degree it can cause serious illness. The AIDS virus is going to be the

same way the epidemiology of AIDS which is already well-defined is carved in stone for the future. It's not suddenly going to change overnight and have mosquitoes or any of these other avenues that keep coming up. It's basically sex it's blood sharing relative to the drug issue in particular in its transmission from an infected mother to her unborn child relative to developing antibodies. The question you asked the final one in the you know basically suggesting maybe the blood supply was as safe because some people have suggested is that the vast majority of people do develop antibodies within 60 days but not all. But when we actually make the calculations about how effective this test is in screening out potential blood donors we have in Minnesota come up with an estimate that is very conservative meaning that we've actually erred on the side of saying a higher risk than a lower risk. And we still come up with a risk of less than one in four thousand. Now your risk of having a serious life threatening consequence of getting blood for other reasons such as hepatitis

and so forth is much much higher than that AIDS virus is way down the line. We expect once every two to three years someone may pick up the AIDS virus infection from Minnesota blood donation situation. And I think that that has to be put into context of how many people's lives are saved every day in the state because they get blood. The risk is not comparable at all so. So there shouldn't be any doubt left hopefully in the listener's minds out there about this issue with the blood supply. That is the one technological breakthrough the one victory we've had in AIDS is that the blood supply is safer today than it's ever been. Public health issues surrounding AIDS is our topic of discussion today with Dr. Michael Osterholm state epidemiologist and we'll move along to our next question. Hi you're on the air with him. Hello. Hello. I have to question one I'd like you to comment on the recent article that masters have. Had a. Time. As. We talk about. Their theory the purpose of the crossover of the AIDS virus to the heterosexual. And also another question. As a healthcare professional I'm

wondering. If they feel that gay rights are violated or that gay rights are violated. A nurse would know that happy I just want to be here. I know that sometimes they are kind of protective of their right. And I was afraid because. I was beginning to wonder if somebody is going to ask the Masters and Johnson question and I'm aware that you don't like what your answer to that. Well the Masters and Johnson issue I think in time was juxtaposed to a very interesting article that also appeared in Cosmopolitan just two months before and I think that they serve to reflect on each other. In the February issue of Cosmopolitan a prominent position in this country I wrote an article that basically said that heterosexual transmission of the AIDS virus did not occur. It was not an important problem and frankly everyone was scaring the hell out of people for no reason and that we were overreacting. Now some 40 some days later Masters and Johnson come out with this

book that basically say it's running rampant in heterosexuals and you know I would basically like to take the phone messages I got when I had to deal with the cosmopolitan article and have those people call back the people to call them. I had to deal with the Masters and Johnson article and and maybe they would like to talk. But in all seriousness I think that one of the things that we have happening today in this country is we have a lot of people who have become self-appointed experts on AIDS. I liken the situation of Masters and Johnson who quite frankly do know something about human sexuality. They've studied it but they don't know a whole lot about viruses and they don't know a whole lot about epidemiology. And I liken that to the situation that if I had someone who was the world's greatest jet engine mechanic I think that would be just great if they worked on the engine to the jet plane that I was about to take off on. But I'm not sure I'd want him flying the plane. I would much rather have a skilled pilot do that. I'm not sure. As a mechanic they necessarily know how to land and take off and all those kinds of things. Yet we somehow have would in a comparable situation ordain

that jet engine mechanic as an expert totally on all aspects of flying an airplane. And that's just not the case. Masters and Johnson unfortunately because of their expertise nearly human sexuality was just assumed that they would be experts on AIDS and this is just isn't it. If you've read the book and I have had a chance to read their book you realize that it basically is fraught with air after air after air. The study that they did I liken it to the recent criticism that came out from the Shehri Heights study look into human sexuality in which there was great criticism about the study design. Masters and Johnson study was no better at all they went to basically bars in places like that and asked people who might want to anticipate an AIDS study. Would they like to do so. The self-selection method that they used was one that hardly could be extrapolated to the rest of the country. And in that study they basically found people who were very sexually active. They looked at it and they sure they found that 12 to 14 percent were in fact to the AIDS virus. So that's what we've been saying all along.

But to extrapolate that population and say that that represents every heterosexual in the country and therefore this is where the virus is out there is just absolutely not true. Let me give you an example in Minnesota where we have now tested over 350000 blood donors which should represent low risk individuals namely those who do not have a previously stated risk factor. We try to screen those people out up front of those individuals out of those more than 300000 people. We now have found only 16 positive or 16 infected people. And of those 16 all of them had identified risk factors. Once we actually did the follow up and the evaluation if this thing was running rampant in heterosexuals out there that had no reason to suspect they are at risk. We surely should have picked up some positives in that blood donor population. We didn't at all. So I think that the Masters and Johnson article was a real disservice in terms of this epidemic and that's why I saw people like the surgeon general who who tends to I think hold his tongue sometimes when others of us wish he wouldn't did not in this case he blasted him very strongly. I think it's also why Masters and Johnson

only completed two days of their 28 day national tour to sell their book and then elected not to go onto the tour anymore because they were being eaten alive by reporters who actually knew more about the AIDS epidemic and he asked very good questions and Masters and Johnson knew. And so I think that that's just an unfortunate chapter and I would again juxtapose it to the cosmopolitan article and say if you want you know go read the two in comparison and then you'll realize that there will be a lot of people who are making statements who don't know what they're talking about in terms of the second part of the health care professional issue. I think that quote unquote gay rights have really no place as such in the issue of health care delivery. Human rights do. And I think that that means that any of us who who might come in into some kind of contact with health care delivery have certain expectations of certain types of care and it shouldn't be distinguished whether you're male or female you're white black whether you're gay heterosexual whatever. At the same time I think health care

employees have a certain right to certain kinds of of protections or certain aspects to what they do in their job. What we have recommended from the very beginning of the epidemic and in fact I might even say much much earlier than that because of problems that we've actually had in this state way back into the mid-1970s of health care workers picking up a type of hepatitis virus as a result of handling blood and bodily fluids. Is that you have to assume in the health care area that everyone you deal with is infected. And if you only worry about AIDS patients you will come in contact with people who you had no idea might be infected with the virus who are brought in as a result of a trauma you know an automobile accident or in there for elective surgery and you have no idea that they are infected and we have argued that for some time in the night 1970's and we had a lot of cases of hepatitis occurring and healthcare workers in the state and some of them dying. What we found happening was that when they were caring for yellow patients jaundice patients who had hepatitis themselves they exercised a great deal of care handling their blood and bodily fluids. But when

they dealt with other patients they didn't. And these were the patients who unsuspectingly were carrying the hepatitis virus and transmitted it. So we emphasizes universal blood and body fluid precautions treating everybody the same way. So from that standpoint I don't have any reason to suggest that we should deal with AIDS patients differently today than we should any other patient that walks in the door. Now the question is Should health care workers have a right to know that someone's infected with the AIDS virus. And I believe strongly that there is what we call a health care team and I think it's naive to suggest as only physicians nurses play a very important role in that. And I think anyone who is developing a plan for dealing with that patient or on a day to day basis deals with the patient in that health care delivery system like that should be aware of that patient status. Now that doesn't mean that Jenner has to be that doesn't mean that maybe some even the lab technicians have to be that might never see the patient. But if I'm for example a nurse and I'm trying to put together the daily plan for that patient even that patient's in there with a broken leg

I think that's very important to the patient that the nurse understand that that patient has other underlying health problems or potential health problems that exist. So we've strongly advocated that the whole area of professionalism of confidentiality and so forth. Now more than ever be reviewed in the hospital setting and that the important health care team members do know who is infected but then they treat that information with the responsibility and the kinds of confidentiality statuses that they themselves would want if they were the patient sitting in the bed. All right it's about 25 minutes before the hour as we continue with Dr. Michael Osterholm. On the topic of AIDS in your next trouble there thanks for waiting. Hello. Yes. Yes. I've been dating a nurse who works in a major hospitals with cancer patients and some of the procedures are tidy just Administration and the catheter into the heart and some of her patients to carry the AIDS virus and that is the server she

knows about that is she has significant risk and then I in turn if I have sexual relations with her. First of all I'd like to congratulate her and carrying out those kinds of procedures and patients like this because it can be done and it can be done with a great deal of safety and care. And again once one knows that kind of information I think that that is very helpful. The risk that one has with the exposure to the AIDS virus and that kind of setting is one where if you have a needle stick that actually only pierces a glove or you get the blood on a open sore cut. Then there is a potential risk of transmitting the virus so we don't want to minimize it but that risk even when a situation occurs where it's a positive sample. So I for example am working with a patient I actually like stick myself the needle that I just use in that patient that patient is in fact with the AIDS virus. Studies that have looked at individuals such as this find that between one and two hundred to one in 1000 health healthcare workers will go on to develop the

infection themselves. Now that's not necessarily comforting if you're one of those 200 or 1000 that become infected. But it even points out that in the setting where you haven't documented exposure you know not just be working with the patient but now you know you stuck yourself you know you have the exposure the risk is still very very small. So I think the point is to use very careful technique and that you you have to do that. I continue to to feel strongly that. And as someone who supervises staff people who draw bloods all the time from people who handle blood samples you know I have to worry about my own staff that way. It's not as if I can be cavalierly worried about somebody in somebody else's shop and not mine. But I think that if people have a fear of that and they don't feel comfortable dealing in those settings with that potential situation and can't use the kinds of precautions that would reduce it to prevent it then I think they shouldn't be in the health care area just as I don't want a fireman who's afraid of fire out there and the fire truck I don't want a policeman who absolutely

refuses to ever be involved in a possible altercation be a policeman. It's not that these people are bad people they're still very good people but there are a lot of us who might not feel real comfortable working around fire or whatever. And so I think that's where the health care area is going to come down to now. So you're the woman you're dating her risk is extremely small. To date we know of in this country 11 healthcare workers who have become infected or suspected have become infected as a result of their work. Now that's in spite of the fact that there are thousands and thousands and thousands of healthcare workers who have been exposed day in and day out to the AIDS virus and have not. So I don't want to say it doesn't occur but I think we have to put it into the big picture. Last year in this state there were several health care workers and I'm aware of who died just on their way to and from the hospital in their automobiles and results of an accident that would hardly tell us is that they should stop going to work every day because of the risk. So we've got to put that into perspective. The risk for you now is totally dependent on whether she should become infected and then it becomes a matter of what kind of sexual activities you have with her and it becomes a matter of how infectious she is. We do

know that people who carry the AIDS virus get more infectious with time so that even though we've had some situations where we had one partner who was infected and we tested the second partner who had been having ongoing sexual relationships with the first partner and two years. Nothing no transmission but suddenly the third or fourth year it occurs. And so that I think you also have to be aware of that. And in this case again but the paramount point is that you have to worry about whether she's infected or not and I can tell you that her risk is extremely extremely extremely low. Moving on to more people who are waiting to talk with Michael Osterholm today and you're next. Thanks for waiting. Hi. Hi. I'm going to commend him here on they're very sensitive and thorough coverage. I feel very well informed by your coverage. I would like Dr. Osterholm to comment from the epidemiology of small children for example my husband and I have had chosen not to have a son circumcised some members or family have believes very firmly that we have increased responsibility

by not having an impact. Also I work outside my home and my head is going to take care of you spend six weeks old. And again from people in our family believes that I've increased his. Likelihood of getting AIDS because he is in day care. He might be bitten by a child or he might want a toy that is. In fact a child has played with. I'd appreciate your comment. OK. First of all I'd like to thank you for your thoughtful questions and most of all I guess I would like to take the opportunity to to to say that I think NPR has done a very responsible job of covering the AIDS issue and as someone who deals with the media quite frankly on this issue I think that one of the areas that we've really appreciated has been the ongoing interest of NPR in this issue both on national and local level and their their willingness to cover it at times when some of the issues have been pretty hard to cover. And I think that I would really just echo what you said in terms of the two issues that you you brought up the circumcision issue is one that may be

confusing for people in this country because there has been some attention raised to the potential increase risk of HIV among uncircumcised males but that risk has been associated with an increased risk of also contracting certain sexually transmitted diseases in Africa where HIV because of the way that it's transmitted in Africa you know where heterosexual transmission plays a much more important role where the frequency of prostitute use and the frequency of multiple heterosexual partners in the larger urban areas is very different than we might see here in that area there particularly in the study that first addressed this issue on its own circumcision was done in Nairobi Kenya by Frank Plummer and the group from the University of Manitoba in Winnipeg who has a research station over there along with Peter Piot and colleagues from Antwerp Belgium and they found that men who were uncircumcised had a higher risk of HIV infection given the same likelihood of sexual contact to someone

who was. But what they found was these men also had a much higher risk of a certain kind of sexually transmitted diseases called Schank roid caused by the homologous Dougray organism. And Shane Croyde is very similar to the. Also you might see with herpes a big big ulcer and that facilitates transmission if you've got a lot of white blood cells at the site of an ulcer like that which is why ulcers occur in part and you basically now have an open sore that for example if you're having sex with a female partner if the virus is in her vaginal secretions and now you don't you have to just get it through a small abrasion APENAS but you've got this big open sore there that in fact it's likely the transmission will be facilitated. Now so that the reason for skin in the circumcision issue comes in is because it's it's more likely probably to trap the Hamamelis do create this organism under the skin and therefore enhance the likelihood that you might actually win having sex with someone who was infected with that particular agent. You yourself actually not only be exposed but then develop the infection yourself.

So it's kind of a circular situation here one thing requires another requires another. In this country relative to circumcision on circumcision in this state where those kinds of illnesses are very rare and so forth I see absolutely no problem. The reason to or not to circumcise a child in this country particularly in state of Minnesota should not having a do with HIV transmission as we know it now. I think hopefully that will put to rest that you don't need to worry about that. The second point in terms of child daycare is an issue that gets back to that whole idea of how is this virus transmitted in re-iterating over and over again you know it's through sex's through the needle sharing and through the infected mother to child. I again I can report and I think this is where time continues to only help the public health community further its its message that way is is that we can continue to follow situations where in particular children have become infected as a result of a transfusion prior to 1985 or in some cases from an infected mother and the child's delivered

infected but no one knows that situation to be there. No one knows that child's infected suddenly at age three or four. The child shows the first signs and symptoms of an AIDS like illness. People work the child up for AIDS they find out infected and at that point they begin to look back now who had this child potentially exposed. Well let's talk about what's a potential exposure Biotene all these kinds of things. I mean as a as a parent of two children I can tell you that you know more than once you know we've had the dripping down the leg in and through the diaper and the runny nose and the booboos and the bites and all those kinds of things that occur when you have children and then and for those of us at work and other diseases if you really want a good way to facilitate transmission you bring about five toilet trained children together. We're also there biting and scratching and drooling all over. They put everything in their mouth that's a very good way to facilitate transmission of some organisms in this case. And we do the follow up of the families in many cases even the daycare where these children were in. We have yet to document a single transmission not talking about AIDS. Now we go in and do blood tests to find

out if these children or other family members would have been infected. Only further substantiating that if you can't if you don't transmit it in that kind of setting that more than anything should talk about quote unquote just casual contact and that in fact I have as a father I've had two children in day care. I I'm very happy that they were in daycare in the sense that I think it added a great deal to our whole family structure. And I would have no concern at all about a child in day care today with HIV infection. The AIDS virus infection to me that's not an issue very quickly is there a substantial difference in the way the disease progresses in children than among adults. There does appear to be some difference in terms of the time that children become infected to the time that they actually develop the full blown symptoms of AIDS. And in some cases even some of the clinical presentations what types illnesses they get first children tend to get sicker sooner and have a poor prognosis in terms of the initial episodes or the first couple of episodes so it can be particularly

devastating in children. But we now have children who are eight nine years old who are developing needs now who clearly picked up the infection from their infected mother who was an I.V. drug user in 1979 or 80 so it's not to suggest that all children will die within within a short period of time. More recent data has come out actually looking at the issue of blood recipients particularly children of hemophilia who have become infected and actually it looks of it. If the virus is not transmitted right of birth but they pick it up at age seven years of age. And again these are then the past tense because this is when they picked him up in the past that if they pick it up before the early adult years that actually they do better. We're seeing that for example in following groups of children who are infected in their teen years versus adults who are infected in their older years that the teens have a lower rate per year going under developing full blown AIDS. Now after 10 years they may be the same with more of it occurring later on but at least initially they're not showing as many signs and symptoms there so in the youngest kids it's more of a problem than it can actually dips a

bit. But then as you get older it gets to be worse again. But in the end like I said in within 10 years it may all be a moot point if in fact most people want to develop full blown symptoms. All right we got about oh 10 11 minutes left with Michaels to whom were you on the air with him. You're next. Hello there. Hi I'm I'm here. Yes. OK. It's about this bathhouse controversy now I guess wanting to cite some evidence against this policy. Well I think that we've discussed that you didn't discuss the evidence but Dr. Gary rich were all right. Very quickly stated sir then please. OK. He is a professor of Public Health at UCLA School and he is an epidemiologist and he testified in a deposition in a successful fight fight to stop the bathouse closing in San Francisco and the interviews he gave you tabulated 60 percent of his data at the time.

What is the bottom line conclusion. I don't want a lot of with three point three percent of people felt that the bathouse had played a major role in their understanding of AIDS prevention. Thirty nine point six percent felt that they would be more likely to have safe sex in the bath house and eighty point nine percent said that if the bathouse were they would have the same kind of sex they were currently having elsewhere. This is a sample of a hundred twenty. All right. That's that's an interesting observation there and I don't know if you want to say anything further but I think again it's an issue that there is a legitimate point to saying that in some cases people may actually have the bathhouse as their only avenue of information or so closet or bisexual male if they come there that they only place to leave and see the information is there. But I counter that with saying that basically suggesting the bathhouse is the place to change behaviors like conduct in AA meetings in a bar and I think that I don't believe that that is ultimately going to be the major way if in fact a bathhouse is made safer because environmentally it's not conducive to high risk sex. And

that still continues to be the source of information that's fine. But I think the data would otherwise suggest different. OK. We've discussed that rather thoroughly is going to more people who got other concerns or your next title there. I I'm calling from Michigan and like the other caller said I appreciate the coverage of course given my question was about the blood issue at the hospitals and just a question was I thought that anybody could take a long time to show up and I'd heard that a flood couldn't be tested for that. You know if you're an incubation period to see the AIDS virus could be carried but not detected because antibodies haven't been produced. Yes thanks. Actually that is true. As I stated earlier that there are some individuals who not develop antibodies right away but as we get more into this we find that that is a very very rare phenomenon that it doesn't occur within a relatively short period of time. And again that may mean you'd have to find that blood donor right at the time and have them come in just before they did develop antibodies. I might add though that given what we're finding today let's assume that I mentioned earlier we have 16 positive blood donors out of

over 300000 Minnesota blood donors even if we miss 10 percent that's 1.6 per 300000. And I think all the studies we have today would suggest is far far less than 10 percent closer at most to 1 percent at the very very highest end. I think that also is another piece of information that points out something very important though is that people who are at high risk for this infection are staying away from the blood donation centers. Also not only have the blood centers asked people in a very extensive history before they donate blood so that in fact that they don't go in and donate. But they've also put in a system that allows an individual who feels compelled to go. We've had situations where we've had individuals who have gone in to donate blood because they were the chairman of the company's blood drive for the last 15 years. There are closeted bisexual man if they don't donate blood this year is going to be obvious to everyone that something's different because so-and-so is not donating blood. And so to even account for that there's now a check off on your final signature sheet before you donate the blood that says I

do not want his blood use for transfusion purposes so that you can go through all the motions even of donating the blood so no one would raise any questions if you felt that that might you know give you away. And yet that blood then would not be used so the whole point is that even with the number of pozières we found. I think that's a remarkable statement to the degree that high risk people were staying out of the blood sites long before even testing went into place. Moving on then to another questioner thank you for calling from the state of Michigan. You're next to the older guy there is an imported case of HIV. I have him tested in foster homes the overall quality condoms in the Twin Cities. Listeners might like to know how to stop living with a guy they can get information about to happen. 7 can happen straight in terms of HIV too.

Again this is an issue that we've raised before in this very show here is that there's going to be a whole family of AIDS viruses that will emerge with this epidemic early on HIV one which for those in the listening audience that has some familiarity familiarity with AIDS will recall that this was also previously called HTL v3 or in some cases LLV HIV wonner human immunodeficiency virus. One is the virus responsible for the disease in this country. In 1986 in early 87 it became clear that in some areas of west central Africa as opposed to east central Africa that there was some individuals developing an illness that was very very similar to the AIDS picture of Central Africa. And in testing him there was some reactivity there and the tests that would suggest some kind of virus infection similar to HIV one but not HIV one was only a short time later that looked mantion colleagues at the institute passed or in fact did discover HIV too which is very very smart HIV one. Now there is evidence probably what it will be called

HIV three and four now the questions raised is this Does this mean something's happening with the AIDS epidemic. No not at all. I liken it to the situation with polio. Very few people in this country realize that there are three different polio viruses one two and three. They cause the same disease. The epidemiology is the same and we vaccinate we vaccinate against all three. You don't even realize the difference between 1 2 and 3. HIV will be the same way it will be one two three four whatever the test methods that we have today in this country do not routinely pick up HIV 2 but we're constantly monitoring for that in a research setting we're testing blood samples all the time. And should we ever see any evidence of HIV to in this country of transmission here. I think it'll take a matter of just a very short time before you end up testing for one and two simultaneously. And ultimately it wouldn't surprise me in five or 10 years if in fact we do test for one to three Assata. The second question I believe was really related to condoms in the quality of condoms I think this may have come as a result of some news media attention over the weekend to thousands and thousands of condoms that were being

held in a warehouse in which the failure rate was found to exceed that of the FDA standards FDA requires that less and I believe it's three per thousand condoms fail on a pressure test where they basically exert a certain pressure inside the condom and if it leaks water it suggests there's holes or defects in the condoms. And I think this gets back to the whole issue of the what do you say about condoms. Can they be used to really to to deal with the AIDS epidemic. I have and I continue to liken condoms to wearing your seatbelt while going 45 miles an hour in a 25 mile an hour zone eventually are going to get hit. It's a matter of whether or not when you get hit the seatbelt will save you or not. In many cases it will. The real way to avoid HIV infection is to not put yourself into a setting where you might be exposed. But I can tell you that for many people in this country where they are sexually active already that falls on deaf ears and we ignore those people or do we in fact then say OK but if you can avoid that activity or you don't choose to avoid at least this is a

way to reduce the risk. Condoms will reduce it but how much. I don't think any of us know yet. We are getting near the end of the hour with Dr. Michael Osterholm state epidemiologist for Minnesota as we talk about public health concerns surrounding the AIDS situation. And I think we've got time for one maybe two more questions. Let's take you next to Bill. Thanks for waiting. My question regards the comments on that Jason Johnson study. I'm wondering if people who donate blood are any less of a self-selected population than the people in the bars that they interviewed particularly when you just said that the high risk people are staying away from Tony. Actually that's a good point. I'm actually glad you raised that because I did not make that clear and I do want to make that clear. You're right they are very self-selected. Hopefully they're self-selected as blood donors because in fact we we want them to come in thinking that they're not infected at all and there's no reason to be infected. My whole point there was that this was running rampant in unsuspected contacts meaning that individuals had no idea they had been exposed or that they should be

exposed. We do not keep people from donating blood if they've had more than one heterosexual contact when we don't tell them does not donate blood. And all I'm pointing out that should be the truest litmus test in a group that doesn't think they're infected and so therefore we're kind of using the opposite extreme. So they would be just as self-selecting on the far side as are the groups that feel that they might be exposed they're very sexually active. On the other side if you don't find it that far side then that's a good indication if we found it there then we would have evidence that you know yes in fact it was in this unsuspecting group we had no idea how they picked it up that type of situation. All right. Time for one more. Very briefly please. You're on the air with Michael Osterholm hello. Yes going on OK let's try the next line then quickly refuted. Yes I am very much interested in the epidemiology of fires and how it compares with other viruses. Right. So it's so different in Europe. Right. And in particular in our search for a solution or

solutions to this problem it occurs to me that we're getting an awful lot of knowledge as a result of putting a lot of resources to bear on it. It may have applications in other areas like out here. It sounds to me like about a half hour discussion or a two hour lecture or maybe a week long seminar you want to just give us the broadest possible I think. Let me just say I think in fact the caller is absolutely right. I mean what we're learning about AIDS is having implications elsewhere. We've learned a great deal about the immune system that we didn't know before because of the AIDS virus issue. And I think that information will be used in other disciplines of medicine in terms of cancer treatments in terms of a lot of immunologic diseases. So yeah that's there and I think Bob's hit right in the head that that that's a two hour discussion in of itself. But I think the caller is right on target. Well we'd have indeed come down to the only our. Thank you very much for. Well thank you again for your ongoing coverage of this issue. Michael Osterholm with us today talking about some public health concerns related to AIDS. He

is the epidemiologist for the state of Minnesota works in the Minnesota Health Department