AIDS is spread by acts, not by casual exposure. As AIDS spreads further, some are urging that those acts, including sexual acts, be treated as crimes. Indeed, two AIDS carriers have already been charged with crimes for risking sexual transmission of AIDS to others. In one case, the United States Army has court-martialed an infected soldier, Pfc. Adrian Morris, Jr., charging that when he had sex with two other soldiers, he committed the crime of “aggravated assault.” Aggravated assault requires use of a “dangerous weapon or other means of force likely to produce death or grievous bodily harm.” What was the “weapon” in his case? The sexually transmittable AIDS virus itself. In the other case, the Los Angeles district attorney has charged an AIDS carrier, Joseph Markowski, with attempted murder for selling his blood and for having sex with another man while infected.

The role of the Centers for Disease Control (CDC) in the development of recommendations and guidelines on acquired immunodeficiency syndrome (AIDS) evolves from a tradition that originates in the earliest editions of the Morbidity and Mortality Weekly Report (MMWR). In 1961 responsibility for the Public Health Service's MMWR was transferred to CDC from the National Office of Vital Statistics. During the first decade that CDC published it, the MMWR continued the tradition of providing detailed statistics on reportable communicable diseases and unusual occurrences of disease or outbreaks of illness. Only rarely did editorial comments on the data appear. However, as early as 1962 the MMWR became the vehicle the Public Health Service used to publish the recommendations of the surgeon general's Oral Poliomyelitis Vaccine Advisory Committee, the predecessor of the current Immunization Practices Advisory Committee. This practice of publishing immunization and other public health recommendations in the MMWR has continued.

Public health is fundamentally about the values of community, the shared interests in life, health, and security. How the community perceives disease is not solely an issue of medical knowledge, but a function of the interrelated economic, social, and moral beliefs of the society. Our response to particular diseases will be colored to some extent by our image of the individuals or groups most directly affected by that disease.

Acquired immunodeficiency syndrome (AIDS) clearly poses a considerable threat to public health. The disease is thus far medically uncontrollable, and always fatal. The grim prognosis for persons with AIDS has intensified the urgency of developing a program to control and prevent the spread of the syndrome.

Expectations of a vaccine to prevent acquired immunodeficiency syndrome (AIDS) are rising. Not only are the prospects for an effective immunogen improving, but immunization appears to hold the greatest promise for halting the spread of infection and disease. Identification of the causal agent—the retrovirus called HTLV-IIII, LAV, or generically, HIV (human immunodeficiency virus)—has provided the direction and limited the options for containing the disease.

Prevention is, of course, critical where the disease must be presumed to be fatal in all cases. Although there is no clear evidence that any single exposure-to HIV will result in infection or disease, prudence dictates that all exposures be considered potentially infectious and, ultimately, disease-producing until more is known. Public education or, more specifically, behavior modification, intended to reduce or eliminate unsafe sexual contact and the sharing of syringes and needles by users of illicit intravenous (IV) drugs, is perhaps the only effective means of prevention that currently exists.

This article surveys proposals for public health statutes and regulations to control the spread of the human immunodeficiency virus (HIV). The data were collected by the Harvard School of Public Health in pursuance of a contract for the U.S. assistant secretary for health and by the Intergovernmental Health Policy Project at George Washington University. The intention is to provide a representative overview of legal and policy alternatives, not to offer a comprehensive account of statutes and proposals in all jurisdictions.

The AIDS epidemic has refocused attention on public health law, raising anew questions about the application, effectiveness, and constitutionality of various disease control measures. State and local legislatures have considered a broad range of measures designed to control the spread of AIDS. Virtually every state legislature has debated AIDS-related bills; between January 1 and April 15, 1987, more than 360 AIDS-related bills were introduced in the United States. Thus far, approximately twenty-eight states have enacted AIDS-related legislation.

Given the pain, incapacity, and death that afflict persons with AIDS, it is not surprising that those exposed to HIV or those who have developed AIDS may sometimes feel themselves wronged and entitled to legal damages. There are two main areas of potential AIDS-related litigation: liability related to medical malpractice and liability related to transmission, whether via contaminated blood or blood products, needle-sharing, childbirth, or sexual intercourse.

This article will examine the precedents, arguments, and possible defenses in these areas and in relationship to a variety of potential defendants.

A cause of action for medical malpractice in AIDS-related diagnosis may arise in several ways: failure to diagnose, failure to inform a patient of a diagnosis, failure to provide proper counseling and treatment when patients test positive for HIV antibodies, and failure to report AIDS diagnoses to health authorities or at-risk sexual partners.

Research on AIDS involving human subjects poses in stark form a familiar dilemma: Can the demands of a rigorous scientific research design be met without violating the rights or harming the interests of research subjects? The dilemma is especially troubling in the early phases of drug research, when promising medications showing some signs of success in combatting this fatal disease must be tested for safety and efficacy. The research design using randomized controlled trials, in which an experimental drug is tested against a placebo, highlights the dilemma. Although the use of this research design does not pose the only ethical problem for AIDS research, it is perhaps the most dramatic. Related ethical issues include the question of when an experimental drug that holds out the only present hope may be released for general use; who should be selected to receive experimental drugs that are in short supply; how much information should be released about safety and efficacy while a clinical trial is still in progress; and what factors determine the appropriateness of early termination of a study.

The AIDS (acquired immunodeficiency syndrome) crisis has aroused scientists to major research efforts and the public at times to near-hysteria. The media and their audience eagerly await the latest scientific reports, yet the public seems to respond selectively, embracing the most frightening interpretation of the data and discounting attempts to place those data in perspective. One might be tempted to conclude that questions of public health policy are best dealt with by expert judgment unsullied by lay opinion. Yet such an attitude supposes scientists to be governed by pure reason and to be beyond influence by narrow self-interest or by political or moralistic considerations, a self-serving assumption belied by an examination of the record. The erosion of public confidence in science has indeed bedeviled health authorities in their efforts to generate consensus on the policies they wish to implement, but the public response—including the response of scientists to AIDS—is a far more complex phenomenon.

Despite philosopher George Santayana's famous injunction that those who do not remember the past are condemned to repeat it, history holds no simple truths. Nevertheless, there are a number of significant historical questions relating to the AIDS epidemic. What does the history of medicine and public health have to tell us about contemporary approaches to the very difficult dilemmas raised by AIDS? Is AIDS something totally new, or are there instances in the past that are usefully comparable? Are there some lessons in the way science and society has responded to epidemic disease in the past that could inform our understanding of and response to the current health crisis?

There are obviously no simple answers to such questions. History is not a fable with the moral spelled out at the end. Even if we could agree on a particular construction of past events, it would not necessarily lead to consensus on what is to be done. And yet, history provides us with one means of approaching the present. In this regard, the history of responses to particular diseases can inform and deepen our understanding of the AIDS crisis and the medical, social, and public health interventions available.

Researchers trying to resolve the questions surrounding the AIDS epidemic may feel like Hercules trying to slay the Hydra: for every head that is cut off, two new ones grow in its place. Doctors have never treated their patients in a social vacuum, but the expectations and anxieties engendered by AIDS are bringing fundamental changes in clinical p-actice. Drugs are being raced from the laboratory bench to the bedside, health care providers are being forced to recognize new types of family constellations, and the general public is being shocked into awareness of the importance of prudent infection control policies. Clinical practitioners have had to deal with the ethical consequences of routine and arcane decisions as never before, knowing that yesterday's experiment or hospital rounds can become tomorrow's lead feature in the news media.

The acquired immunodeficiency syndrome (AIDS) and the entire spectrum of disease associated with infection by the human immunodeficiency virus (HIV) are the subject of intense international interest and concern. From the viewpoint of the World Health Organization (WHO), HIV is not simply one of a series of newly recognized diseases emerging during the past decade but is a problem with several biological and epidemiological features that justify a unique sense of urgency among public health officials, political leaders, and the general public.

This article describes the evolution of a global perspective and response to HIV, reviews the current international epidemiological situation, explores the principal elements, both conceptual and operational, of WHO's global strategy for HIV control, and discusses the major approaches to HIV prevention in the current global context.

It is nearly six years since the first evidence of the AIDS epidemic was seen, with the report of five cases of Pneumocystis carinii pneumonia diagnosed in young, otherwise healthy homosexual men in Los Angeles. The report was surprising, for although P. carinii is a common human commensal, the pneumonia essentially occurs only in the presence of severe immune suppression. Similar reports quickly followed from New York City and San Francisco, with the additional observation that Kaposi's sarcoma—a malignancy usually seen only in elderly men in this country—was also occurring epidemically among young homosexual men.

Since then, the epidemic has evolved at a relentless pace to a reported 32,000 cases in the United States by March 1987. The epidemic has sparked a massive multidisciplinary scientific effort, resulting in the successful identification of the causal agent—the human immunodeficiency virus (HIV)—within two years from the first report and producing a commercially available antibody test within four years.

This paper presents the available epidemiological data on human immunodeficiency virus (HIV) infection and AIDS among intravenous (IV) drug abusers, reviews HIV disease among intravenous drug abusers, and focuses on initial research findings that indicate intravenous drug abusers not only are educable but may indeed be altering their lifestyles as a direct consequence of their fear of HIV infection.

Although the initial clinical cases of AIDS were described in 1981, among gay men living in Los Angels, only a short time elapsed before IV drug abusers who shared their drug paraphernalia were identified as another risk group. A reasonable hypothesis, based on reports from the New York metropolitan area, is that there has been a relative increase in the percent of AIDS cases among IV drug abusers as compared to homosexuals. This may be explained by the transition group of sexually active homosexual men who also used intravenous drugs and thereby spread HIV from the gay community to IV drug abusers. In support of this hypothesis, the Centers for Disease Control (CDC) estimates that 8 percent of all reported AIDS cases from New York City have both risk factors.