Current Trends Prevention of Acquired Immune Deficiency Syndrome (AIDS): Report of Inter-Agency Recommendations

Since June 1981, over 1,200 cases of acquired immune deficiency syndrome (AIDS) have been reported to CDC from 34 states, the District of Columbia, and 15 countries. Reported cases of AIDS include persons with Kaposi's sarcoma who are under age 60 years and/or persons with life-threatening opportunistic infections with no known underlying cause for immune deficiency. Over 450 persons have died from AIDS, and the case-fatality rate exceeds 60% for cases first diagnosed over 1 year previously (1,2). Reports have gradually increased in number. An average of one case per day was reported during 1981, compared with three to four daily in late 1982 and early 1983. Current epidemiologic evidence identifies several groups in the United States at increased risk for developing AIDS (3-7). Most cases have been reported among homosexual men with multiple sexual partners, abusers of intravenous (IV) drugs, and Haitians, especially those who have entered the country within the past few years. However, each group contains many persons who probably have little risk of acquiring AIDS. Recently, 11 cases of unexplained, life-threatening opportunistic infections and cellular immune deficiency have been diagnosed in patients with hemophilia. Available data suggest that the severe disorder of immune regulation underlying AIDS is caused by a transmissible agent.

A national case-control study and an investigation of a cluster of cases among homosexual men in California indicate that AIDS may be sexually transmitted among homosexual or bisexual men (8,9). AIDS cases were recently reported among women who were steady sexual partners of men with AIDS or of men in high-risk groups, suggesting the possibility of heterosexual transmission (10). Recent reports of unexplained cellular immunodeficiencies and opportunistic infections in infants born to mothers from groups at high risk for AIDS have raised concerns about in utero or perinatal transmission of AIDS (11). Very little is known about risk factors for Haitians with AIDS.

The distribution of AIDS cases parallels that of hepatitis B virus infection, which is transmitted sexually and parenterally. Blood products or blood appear responsible for AIDS among hemophilia patients who require clotting factor replacement. The likelihood of blood transmission is supported by the occurrence of AIDS among IV drug abusers. Many drug abusers share contaminated needles, exposing themselves to blood-borne agents, such as hepatitis B virus. Recently, an infant developed severe immune deficiency and an opportunistic infection several months after receiving a transfusion of platelets derived from the blood of a man subsequently found to have AIDS (12). The possibility of acquiring AIDS through blood components or blood is further suggested by several cases in persons with no known risk factors who have received blood products or blood within 3 years of AIDS diagnosis (2). These cases are currently under investigation.

No AIDS cases have been documented among health care or laboratory personnel caring for AIDS patients or processing laboratory specimens. To date, no person-to-person transmission has been identified other than through intimate contact or blood transfusion.

Several factors indicate that individuals at risk for transmitting AIDS may be difficult to identify. A New York City study showed that a significant proportion of homosexual men who were asymptomatic or who had nonspecific symptoms or signs (such as generalized lymphadenopathy) had altered immune functions demonstrated by in vitro tests (2,13,14). Similar findings have been reported among patients with hemophilia (2,15,16). Although the significance of these immunologic alterations is not yet clear, their occurrence in at least two groups at high risk for AIDS suggests that the pool of persons potentially capable of transmitting an AIDS agent may be considerably larger than the presently known number of AIDS cases. Furthermore, the California cluster investigation and other epidemiologic findings suggest a "latent period" of several months to 2 years between exposure and recognizable clinical illness and imply that transmissibility may precede recognizable illness. Thus, careful histories and physical examinations alone will not identify all persons capable of transmitting AIDS but should be useful in identifying persons with definite AIDS diagnoses or related symptoms, such as generalized lymphadenopathy, unexplained weight loss, and thrush. Since only a small percentage of members of high-risk groups actually has AIDS, a laboratory test is clearly needed to identify those with AIDS or those at highest risk of acquiring AIDS. For the above reasons, persons who may be considered at increased risk of AIDS include those with symptoms and signs suggestive of AIDS; sexual partners of AIDS patients; sexually active homosexual or bisexual men with multiple partners; Haitian entrants to the United States; present or past abusers of IV drugs; patients with hemophilia; and sexual partners of individuals at increased risk for AIDS.

Statements on prevention and control of AIDS have been issued by the National Gay Task Force, the National Hemophilia Foundation, the American Red Cross, the American Association of Blood Banks, the Council of Community Blood Centers, the American Association of Physicians for Human Rights, and others. These groups agree that steps should be implemented to reduce the potential risk of transmitting AIDS through blood products, but differ in the methods proposed to accomplish this goal. Public health agencies, community organizations, and medical organizations and groups share the responsibility to rapidly disseminate information on AIDS and recommended precautions.

Although the cause of AIDS remains unknown, the Public Health Service recommends the following actions:

1. Sexual contact should be avoided with persons known or suspected to have AIDS. Members of high risk groups should be aware that multiple sexual partners increase the probability of developing AIDS.

2. As a temporary measure, members of groups at increased risk for AIDS should refrain from donating plasma and/or blood. This recommendation includes all individuals belonging to such groups, even though many individuals are at little risk of AIDS. Centers collecting plasma and/or blood should inform potential donors of this recommendation. The Food and Drug Administration (FDA) is preparing new recommendations for manufacturers of plasma derivatives and for establishments collecting plasma or blood. This is an interim measure to protect recipients of blood products and blood until specific laboratory tests are available.

3. Studies should be conducted to evaluate screening procedures for their effectiveness in identifying and excluding plasma and blood with a high probability of transmitting AIDS. These procedures should include specific laboratory tests as well as careful histories and physical examinations.

4. Physicians should adhere strictly to medical indications for transfusions, and autologous blood transfusions are encouraged.

5. Work should continue toward development of safer blood products for use by hemophilia patients. The National Hemophilia Foundation has made specific

recommendations for management of patients with hemophilia (17).

The interim recommendation requesting that high-risk persons refrain from donating plasma and/or blood is especially important for donors whose plasma is recovered from plasmapheresis centers or other sources and pooled to make products that are not inactivated and may transmit infections, such as hepatitis B. The clear intent of this recommendation is to eliminate plasma and blood potentially containing the putative AIDS agent from the supply. Since no specific test is known to detect AIDS at an early stage in a potential donor, the recommendation to discourage donation must encompass all members of groups at increased risk for AIDS, even though it includes many individuals who may be at little risk of transmitting AIDS.

As long as the cause remains unknown, the ability to understand the natural history of AIDS and to undertake preventive measures is somewhat compromised. However, the above recommendations are prudent measures that should reduce the risk of acquiring and transmitting AIDS. Reported by the Centers for Disease Control, the Food and Drug Administration, and the National Institutes of Health.

References

1. CDC. Update on acquired immune deficiency syndrome (AIDS)--United States. MMWR 1982;31:507-8, 513-4.

2. CDC. Unpublished data.

3. CDC. Update on Kaposi's sarcoma and opportunistic infections in previously health persons--United States. MMWR 1982;31:294, 300-1.

4. CDC. Opportunistic infections and Kaposi's sarcoma among Haitians in the United States. MMWR 1982;31:353-4, 360-1.

5. CDC. Pneumocystis carinii pneumonia among persons with hemophilia

1. MMWR 1982;31:365-7.

6. CDC. Update on acquired immune deficiency syndrome (AIDS) among patients with hemophilia A. MMWR 1982;31:644-6, 652.

7. Vieira J, Frank E, Spira TJ, Landesman SH. Acquired immune deficiency in Haitians: opportunistic infections in previously healthy Haitian immigrants. N Engl J Med 1983;308:125-9.

8. CDC. Unpublished data.

9. CDC. A cluster of Kaposi's sarcoma and Pneumocystis carinii pneumonia among homosexual male residents of Los Angeles and Orange Counties, California. MMWR 1982;31:305-7.

10. CDC. Immunodeficiency among female sexual partners of males with acquired immune deficiency syndrome (AIDS)--New York. MMWR 1983;31:697-8.

11. CDC. Unexplained immunodeficiency and opportunistic infections in infants--New York, New Jersey, California. MMWR 1982;31:665-7.

12. CDC. Possible transfusion-associated acquired immune deficiency syndrome (AIDS)--California. MMWR 1982;31:652-4.

13. CDC. Persistent, generalized lymphadenopathy among homosexual males. MMWR 1982;31:249-51.

14. Kornfeld H, Vande Stouwe RA, Lange M, Reddy MM, Grieco MH. T-lymphocyte subpopulations in homosexual men. N Engl J Med 1982;307:729-31.

15. Lederman MM, Ratnoff OD, Scillian JJ, Jones PK, Schacter B. Impaired cell-mediated immunity in patients with classic hemophilia. N Engl J Med 1983;308:79-83.

16. Menitove JE, Aster RH, Casper JT, et al. T-lymphocyte subpopulations in patients with classic hemophilia treated with cryoprecipitate and lyophilized concentrates. N Engl J Med l983;308:83-6.

17. Medical and Scientific Advisory Council. Recommendations to prevent AIDS in patients with hemophilia. New York: National Hemophilia Foundation, January 14, 1983.

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