They are also seeking to get the estimated number of people infected every year — a term known as incidence — below the number of annual deaths, a metric that officials have said would signal an end of the epidemic. At the same time that New York and cities like San Francisco have made major inroads in fighting AIDS, national health officials have been troubled by a leveling-off in H.
A February report from the Centers for Disease Control and Prevention showed that rates of infection between and had remained stable among gay and bisexual men, who make up more than two-thirds of new infections, with a marked increase among Latino men. Although none of these women tested positive for the virus that causes AIDS, the large amount of women getting testing was a good thing.
Even though at the time the only people considered high risk for contracting AIDS were sexually active homosexuals and intravenous drug users, the health warnings about AIDS were having a positive impact since low risk women were getting tested. An advertisement that educated people that women can get AIDS too. This would include a 98 million dollar increase from million dollars to million dollars in city funds to go towards treatment, testing, counseling, and education for AIDS.
Critics like Richard D. Out of the whole nation, New York City was hit the hardest. It is important to note that less than 10 percent of these children were infected with the AIDS virus.
In order to help children who were orphaned by AIDS, groups like Pioneers, a group of 11 mothers living with AIDS, helped parents by providing free legal services so parents can draft a will, select a guardian for their children, and assign a medical proxy to make their medical decisions when they are not able to. Groups like these stressed the importance of planning ahead. There are different types of HIV tests. Some involve drawing your blood, while others involve pricking your finger or swabbing your mouth to get fluid.
Some tests are "rapid tests" and the results are ready in 20 minutes. A person is told that he or she has HIV infection only if the test result is confirmed by a second, or sometimes a third test. HIV test results are confidential.
Talk to your doctor about having an HIV test. Your health care provider will arrange for HIV treatment for you. Clinical guidelines suggest that all people with HIV begin treatment as soon as possible. Early treatment will prevent the virus from damaging your health and will help keep you healthy. They also reduce the chance that HIV will be passed to others. It also stops the virus from reproducing.
Keeping the virus at a very low level prevents damage to your immune system, or allows damage to be reversed. There is evidence of trial delays and limitations on court access because of HIV status, problems with the behavior of court officers e. The unit replaced the very inadequate facilities that had existed since In prisoners with AIDS were moved to an expanded bed annex to the infirmary.
The new facility at Rikers Island is considered to be a model of efficient and humane care, but it is a segregated unit, and all of the men in the unit know they have a fatal disease. The extended report on the situation in Rikers Island by Dobie indicates that the fear of dying in prison is widespread among the men in the unit and that there are difficulties in arranging compassionate release even for seriously ill men.
The policy of segregating inmates with "recognizable" AIDS most inmates with "unrecognized" HIV disease are in the general prison population was justified on a number of bases, including the risks to those infected if their status were known to other inmates. However, the segregation appears to be based on management considerations relating to institutional efficiency and movement in the institution and to and from court, as well as for health care and public health considerations.
Actual medical care in the institution is now provided under contract by Montefiore Hospital located in the Bronx , and acute care takes place in a number of municipal hospitals with secure units when beds are available; in there were a total of 66 such beds in two hospitals, Bellevue and Kings County. When beds are not available or specialized care is needed, prisoners, including those with HIV disease, are placed in wards meant for the general population.
The prisoners are usually shackled 24 hours a day, although there are some circumstances in which manacles are not used. For a detailed discussion of the use of manacles, see Association of the Bar of the City of New York, In part this has been the result of a policy decision at the highest administrative levels. In , Thomas A. Coughlin III, the commissioner of the department, stressed that their primary mission is not one of health care quoted in Association of the Bar of the City of New York, :.
As Commissioner I would resist any attempts to redefine our mission to include primary responsibility for health care. Our system is predicated on the use of community health resources … AIDS is a devastating personal and societal problem; prison should not be the place to treat that problem. Any attempt to replicate in prison services that should be provided in the community to treat this problem is, in my opinion, bad public policy.
The sentences of state offenders are longer than those of inmates in the city correctional system. As a consequence, state inmates are more likely to find themselves in the end stages of their disease while imprisoned.
State prison facilities are far flung, often in rural counties, far from the concentrated health care resources of the urban regions. Prior to the epidemic the state prison system depended on limited-care infirmaries within the institutions, a few dedicated acute care beds in outside hospitals, and a case-by-case arrangement with community hospitals. Since the epidemic, problems have increased, but the response of the department has been modest—special needs units have been established in three institutions and a dormitory in a fourth.
The differential in survival time may have a number of causes, including delays in identifying those who are infected and show signs of illness, inadequate care as a result of limited staff training, and understaffing Potler, One might add to these causes the relative lack of treatment drugs available to prisoners especially to those who are asymptomatic and the stressful conditions of life for prisoners.
The failure of attempts to remediate the current health care crisis in state institutions is signaled by the fact that this most recent report of the Correctional Association now focuses on early release and clemency for the terminally ill while treating a major improvement in the health care facilities of the prison system as desirable goal. Medical parole for terminally ill inmates has been urged by a number of legislators, inmate groups, citizen groups, and correctional officials.
A clemency program might increase contacts between terminally ill inmates and their families and would prevent prisoners from dying alone. In addition, it would save the prison system money by transferring the costs of treating terminally ill prisoners to the budgets of nonprison institutions. They are nearly almost all poor and from African American or Hispanic communities.
Women are often viewed only in terms of their ''reproductive function," and an invidious distinction is drawn between "guilty" women infected by drug use or sex and "innocent" children Chavkin, The distinction between innocent and guilty sufferers has serious consequences for resource allocation. Funds are more readily devoted to babies and children with AIDS than to women who need drug treatment, housing, or other social resources.
Ethnographic studies document numerous negative experiences on the part of poor African American and Hispanic women in their interactions with the health care system. These have the effect of disempowering women, reducing their sense of control over their own lives, and preventing them from seeking health care or complying with instructions given to them Kenny et al. Finally, the division of the world into guilty mothers and innocent children focuses the health care debate for women around the issues of childbearing, the prevention of reproduction, and decisions that women "ought to make" about whether to have children.
Such debates generally do not result in the practical programs that are required to give women the resources with which to manage their own choices about sexuality and reproduction. Research activity is also skewed toward women in their relation to their children or to children rather than to women themselves.
The scientific reasons offered for the exclusion of women from clinical trials for drugs for HIV disease are complex. A number of feminists have pointed out, however, that women were previously excluded from other trials e. Such clinics, as planned, would focus on the social, economic, political, and psychological situation of women, factors that are often at the center of dealing with the nonmedical cofactors that affect the transmission and management of HIV disease.
As rates of HIV infection among women have increased, a number of medical investigators have begun to question earlier findings about the effects of HIV infection on the outcome of pregnancies. Asymptomatic HIV-infected female intravenous drug users in a New York City methadone program were not found to have decreased pregnancy rates or increased risk of adverse pregnancy outcomes.
Moreover, acceleration in HIV disease during pregnancy was not found to be common Selwyn et al. Data suggest that HIV-positive women are giving birth at rates normal for their age. Knowledge of their own HIV infection does not necessarily deter women from bearing children. Medical investigators associated with Montefiore Medical Center in the Bronx found that knowledge of HIV antibody status was not the overriding factor in decisions to terminate pregnancies; matters related to pregnancy—such as experience with a prior elective abortion, a negative emotional reaction to pregnancy, and whether the pregnancy had been unplanned—were more important Selwyn et al.
Research conducted by anthropologist Anitra Pivnick among the same community of women explored the notion of reproductive choice in a broader context of family and social relations, economic circumstances, and cultural influences see Pivnick et al. The women in the study population—62 percent Hispanic predominantly Puerto Rican , 30 percent African American, and 8 percent white—had a mean age of Three factors distinguished HIV-positive women who chose to bear children from those who chose to terminate their pregnancy: prior abortion experience, the duration of knowledge of serostatus, and history of the mother's residence with existing children.
Women who elected to continue with their pregnancies had a significantly lower lifetime abortion rate than women who chose abortions. They had also known of their serostatus for a significantly longer period of time, which presumably enabled them to consider decisions about childbearing without the pressures of pregnancy.
Finally, women who had not lived with any child for percent of the child's life were more likely to choose to bear a child than women who had that experience. Many women in the study had themselves been "given away" by their own mothers and had confessed to life-long feelings of sadness and reproach.
Women who had managed to keep at least one of their own children felt a profound sense of accomplishment. The study suggests that drug treatment options and family services, the first steps in keeping families together, could relieve many women of the need to replace lost offspring by giving birth to infants who face an unpromising future Pivnick et al.
HIV positive women have difficulty obtaining abortions. In one study, test calls were placed to 25 abortion clinics. After the appointment was made, the caller revealed that she was HIV positive: 16 clinics 64 percent canceled the appointment and refused to perform the procedure; others charged higher rates Franke, Data from a national, population-based survey to measure the prevalence of HIV infection in women giving birth to infants indicate that an estimated 1.
Assuming a perinatal transmission rate of 30 percent, the authors estimate that approximately 1, newborns acquired HIV infection during one month period Gwinn et al. In another study, blood specimens collected from parturients in a recent New York City study indicate that as many as 2 percent of live births occur among women with HIV infection Barbacci et al.
On the basis of the testing of blood specimens obtained from all infants born in the state between November 30, , and March 31, , the study found an overall seropositivity rate of 0. The magnitude of the health problem was most striking in New York City, where in some zip code areas as many as 1 of every 22 childbearing women were found to be HIV-infected Novick et al.
The rates were highest in the Bronx, followed by Manhattan and then Brooklyn. This underscores the need for small-area information in assessing large geographic areas: apparently low seropositivity may mask communities with rates that are a serious public health concern Novick et al. The New York State study also showed the mothers of black and Hispanic newborns with the highest 0.
The rate of 0. Moreover, newborn seropositivity increased with maternal age: an especially sharp rise in the infection rate was seen for women in New York City—from 1 in at age 14 to 1 in 71 at age Identifying the patterns offers insight into the environmental factors that determine prevalence and that allow for the targeting of preventive measures.
Furthermore, as the rate of HIV infection among heterosexuals increases, current policies of offering HIV testing only to women with currently acknowledged risk factors will become even more inadequate Barbacci et al. Women in single-parent households must deal not only with the impact of their illness, but with their concerns about the children they will be leaving behind when they die Indyk et al.
Children of a mother who has died of AIDS are likely to confront stigma in school and in the community. Ignorance and prejudice about AIDS still undermine the intervention efforts of community-based health organizations attempting to deal with the special educational needs of those children.
Thus, a child with HIV disease is often the index case that leads to the identification of infected parents and siblings previously considered healthy. Extended kin often assist in the care of these children, providing support or acting as foster parents, and uninfected siblings are left to witness the deterioration and destruction of their family.
Few diseases of childhood affect an entire family with such clarity Abrams and Nicholas, The situation at Harlem Hospital was described for the panel by pediatrician Elaine Abrams. Only one-half of the children are accompanied by their natural parents; many are in alternative or foster care settings. Extended kin—aunts, uncles, and especially grandmothers—often provide care for the children. The grandmothers, who may be suffering from the loss of their natural children, also face the burdens of failing health, limited financial resources, and multiple responsibilities, which further complicate the medical management of a sick child Abrams and Nicholas, The care program at Harlem Hospital is supported to a significant degree with research funds.
Although supporting clinical care through research grants is a strategy born of necessity, participation in a research protocol can enhance overall care. A research protocol enforces thoroughness and follow-up in cases for which medical and social data on patients may be hard to locate.
The program's focus on integrated medical and social services for mothers and children allows research to be carried out in an otherwise chaotic milieu. The provision of primary care that focuses on the needs of families permits mothers, caretakers, and children to comply with the requirements of a research protocol. The reverse is also true: in the absence of integrated care, research would not be possible.
The benefits of this approach are clear, but difficulties are also present. The continuity of research funds cannot be guaranteed. Balancing the needs of mothers and children may cause conflicts. Some hospital staff, patients, and child welfare professionals tend to mistrust or fear scientific research.
Many HIV-positive children are in foster custody, and social workers and others who care for those children understandably wish to protect their rights. The staff at Harlem Hospital, however, work closely with the foster care system, acknowledging the disadvantages as well as the advantages of experimental protocols. The Child Welfare Administration of New York City has developed a medical advisory board to evaluate protocols and now advises that the "best potential treatment option" may be experimental therapy.
In such cases, a child's natural parents are approached for their consent. If the parents are deceased or cannot be found after diligent effort, the commissioner may grant consent for the child's entry into an experimental protocol.
In and few alternatives existed for the care of HIV-positive children outside of the households of their natural parents. Many children who were medically ready for discharge but whose natural parents could not care for them thus spent much of their lives as "boarder babies," hospitalized for want of a less institutional setting for care Hegarty et al. Since several options have been developed.
Resources have been made available to recruit foster care families willing to care for children at risk for HIV infection. New York City established the Incarnation Children's Center ICC , a transitional unit that offers medical care and nurturing in a home-like environment. Children remain at ICC until an appropriate foster home is identified.
About one-third have frequent weekly visits from parents or immediate extended kin, and about one-third have occasional visits every 2 to 4 weeks from both male and female family members. Fathers visit children at the Center which is located at the edge of Harlem more often than they do at Harlem Hospital.
The homelike atmosphere at ICC perhaps encourages more frequent visits, especially by older fathers who work and who have relationships with drug-addicted mothers. A total of children have so far been cared for at ICC, of whom children are now in homes: 85 percent are in foster homes with nonrelatives, and 15 percent have been returned to their natural families, although they were originally slated for transfer to foster homes.
As the number of infected children continues to rise, the need for additional alternate care facilities will also increase. The experience at ICC shows that the length of the children's stays in hospital can be reduced and that children and their families can be offered nurturing care that is difficult to provide in hospital settings. Some were infected through blood products; others became infected through perinatal transmission.
The availability of medical treatments has increased the expected lifespan of infected children, and HIV-infected children as old as 10, 11, and 12 years of age are in school. In addition to HIV-related health problems, some children manifest behavior disorders related to factors other than HIV. Fetal alcohol syndrome may be evident, as well as the long-term effects of low birthweight, lack of prenatal care, and maternal drug use during pregnancy.
And some children may live with mothers who continue to take drugs or who live with men who do. At school, HIV-infected children often face a staff that lacks the knowledge or means to confront the many problems associated with their condition.
At home, for complex reasons that include fear of community reaction or the desire to protect the child from full knowledge about the illness, parents or caretakers may also avoid discussing the full dimensions of the disease.
However, with earlier diagnosis and treatment that can now prolong life, there are stronger incentives to deal with the fear and prejudice that HIV infection arouses. Some experts argue that the concept of long-term, complex medical therapy should be presented to educators, caretakers, and medical staff including physicians and reinforced over time Abrams and Nicholas, This debate has been particularly sharp when the targets of the educational and condom distribution programs have been young people of high school age, although there has been strong resistance in the national government to condom education for persons of all ages Specter, The proponents of safer sex education and condom provision to youths point out that they do not necessarily approve of early sexual experimentation on the part of young people, but that large numbers of young persons are sexually active under conditions of relative ignorance about the consequences of their conduct.
The decision not to provide safer sex education or condoms to young people places them in danger of the transmission of HIV and other STDs that increase the likelihood of HIV transmission. The arguments of the proponents are short term, pragmatic, and health oriented: young people are sexually active; it is unlikely that they will abstain regardless of how often they are exhorted, and they are in danger of contracting a fatal disease.
The logical consequence of this position is the provision of age-appropriate sex education that includes information about same-gender sex, modes of HIV transmission and methods of prevention, as well as the provision of condoms without either mandatory counseling or parental consent.
The opponents of safer sex education and the provision of condoms stress the long term, the role of the parent and church versus the school and the state, and issues of morality.
In their view, the control of the sexuality of young people properly resides with parents and the religious institutions to which parents and children belong, which emphasize chastity before marriage and fidelity afterward. The provision of safer sex education and condoms threaten these goals and appear to condone sexual experimentation.
For some religious groups, such as the Roman Catholic church, condoms are a completely forbidden form of birth control. The antagonists in New York City have been locked in a debate largely directed not at each other, but at the relatively uncommitted wider community. The immediate targets of the arguments are such decision makers, such as school board members and school administrators or those who appoint them. When condom provision in the public senior high schools was proposed in , an active coalition of religious groups, spearheaded by the Archdioceses of New York and Brooklyn, persuaded the school board to reject the proposal.
In the fall of the new school chancellor asked that the members of the newly appointed school board support a plan for condom distribution Berger, b. He noted the many AIDS cases among young people and reported that 80 percent of New York City's , public high school students were having intercourse. Four of the five new members of the seven-member board reported that they favored such distribution. The plan was opposed by one board member, who said, "It sends a message to young people that we expect them to have sex" Berger, b:B4.
The officials of the Roman Catholic church made their position clear by pointing out that condom provision "says that the universal value that places sexual activity as acceptable only within the context of marriage can neither be taught by our schools nor accepted by our students" Berger, b:B4.
In December the Board of Education received the chancellor's plan to distribute condoms to all students who requested them. All public high schools were to be included, and counseling or parental consent was not required Berger, d. Opponents remained adamant, and some potential supporters wanted counseling to be provided, including information on condom use and how to persuade a partner to use one.
In addition, they wanted all students to be told that sexual abstinence before marriage is the best method of prevention Berger, a. Proponents of the program wished to dissociate it from pregnancy prevention—the issues were simply those of HIV disease and health. They hoped to avoid further conflict with the Roman Catholic church over birth control. The role of the Roman Catholic church in AIDS education and prevention had already produced conflict regarding church obligations in AIDS prevention education when receiving state funds for health care services.
AIDS activists opposed receipt of public funds by Catholic-operated institutions unless they agreed to provide prevention information e.
The church stated that such information violates its "institutional conscience" and can be received elsewhere. In another dispute, the Archdiocese refused to lease to the Board of Education unused Catholic parochial school space for special education classes on AIDS prevention. The leases were barred unless the board waived its sex education curriculum, which includes information on forms of contraception not approved by the church.
The decision was based on the evaluation of the sex education curriculum that, according to the evaluation "makes no mention of modesty, chastity, premarital sexual abstinence or even marital fidelity" Goldman, The Board of Education itself was divided on the condom plan.
The four African American and Hispanic members favored it in varying degrees , and the three white members opposed it, again in varying degrees. One of the opponents objected to the board's citation in its curriculum of literature from a gay and lesbian organization that had published a booklet that one board member considered particularly offensive, although that booklet was not used in school education Berger, c.
An open meeting conducted by the board in February attracted speakers and ran from 10 a. The division between the proponents and opponents was clear: on one side were religious groups and those whose allegiance was to traditional values; on the other side were health professionals, AIDS workers, persons with AIDS, and activist groups.
The disagreements among African Americans mirrored the larger debate, with distortions born of racial discrimination: Did the provision of condoms to African American youths signal a racist lack of faith in their ability to be sexually abstinent? This same subtext framed the needle-exchange debate: the conflict between health promotion and the danger that needle provision would simply support or expand the use of drugs in already afflicted communities. Actual research about the utility of condoms, either in preventing HIV transmission or in influencing the sexual activity of young people, was rarely cited in the debate over condom use.
The actual experiences of school districts across the country that had implemented condom programs were rarely discussed Lewin, The complexity of the studies and the mixed results they presented seemed to limit their usefulness in public debate Dreyfoos, A few weeks after the public meeting Mayor David Dinkins backed the condom plan without counseling or parental consent Berger, a.
The board approved the plan for condom provision without parental consent by a vote of four to three, divided along racial and ethnic lines, with some discussion of a future provision for a parental option to exclude their children from the program Berger, b.
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