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A Decade of a Maturing Epidemic: An Assessment and Directions for Future Public Policy

Published online by Cambridge University Press:  24 February 2021

Larry Gostin
Larry Gostin*
Affiliation:
American Society of Law & Medicine; Harvard School of Public Health; Harvard University/World Health Organization Collaborating Center on Health Legislation.
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Extract

It has been nearly a decade since the first cases of AIDS were reported by the United States Centers for Disease Control (CDC). During that time there have been over 200 statutes enacted in every jurisdiction in the country. Unfortunately, the content of the legislation is highly diverse, even inconsistent, from state to state, and there is very little guiding federal legislation or regulation. The profound social, moral and public policy dilemmas that are magnified by the Human Immunodeficiency Virus (HIV) epidemic are still no closer to resolution. Should testing for HIV infection be voluntary, routine or compulsory when there is a higher risk of transmission of HIV? Should America return to traditional moral values of abstinence outside of marriage and zero tolerance of drug use, or should we teach safe sex and use of sterile injection equipment? Should health care professionals maintain strict confidentiality or do they have a duty to protect third parties in imminent danger?

Type
Articles
Information
American Journal of Law & Medicine , Volume 16 , Issue 1-2: The Harvard Model Aids Legislation Project , 1990 , pp. 1 - 32
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 1990

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Footnotes

*

Portions of this preface are adapted and updated from a number of my earlier papers: AIDS and the Health Care System (1990); The Nucleus of a Public Health Strategy to Combat AIDS, 14 LAW MED. & HEALTH CARE 226 (1986); Screening for AIDS: Efficacy, Cost and Consequences, 2 AIDS & PUB. POL'Y J. 14 (1987); Legal and Ethical Issues in AIDS (with R. Bayer), in 2 CURRENT TOPICS IN AIDS 263 (M. Gottlieb, D. Jeffries, D. Mildvan, A. Pinching, T. Quinn & R. Weiss eds. 1989); Public Health Strategies for Confronting AIDS, 261 J. A.M.A. 1621 (1989). For a more complete examination of health care issues, see AIDS AND THE HEALTH CARE SYSTEM (1990). For a more complete examination of litigation, see AIDS Litigation Project: A National Review of Court and Human Rights Commission Decisions, 259 J. A.M.A. (two-part series forthcoming Apr. 1990); THE AIDS LITIGATION PROJECT (1990) (with L. Porter & H. Sandomire).

References

1 Gostin, , Public Health Strategies for Confronting AIDS: Legislative and Regulatory Policy in the United States, 261 J. A.M.A. 1621 (1989).Google Scholar

2 Id.

3 The following papers for the Project were developed under the overall direction of Professor William J. Curran and myself:

Testing: Martha Field, Harvard Law School;

Education: Mary Clark, Harvard School of Public Health;

Confidentiality & Discrimination: Harold Edgar and Hazel Sandomire, Columbia Law School;

Financing: Daniel Fox, The Milbank Memorial Foundation;

The Drug Epidemic & The Needle-borne Spread of HIV: Larry Gostin, Harvard School of Public Health. (My own paper on drug use is not included here due to space limitations, but will be published at a later date).

4 An invitational meeting was held near Albany, New York on May 10-11, 1989, where each author for the Harvard Model AIDS Legislation Project was assigned a number of nationally prominent advisors in the field of public health, law and financing. Key advisors included:

5 REPORT OF THE PRESIDENTIAL COMM'N ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC (June 24, 1988) [hereinafter PRESIDENTIAL COMM'N].

6 INSTITUTE OF MEDICINE, NAT'L ACADEMY OF SCIENCES, CONFRONTING AIDS: DIRECTIONS FOR PUBLIC HEALTH, HEALTH CARE, AND RESEARCH: UPDATE 16b (1988) [hereinafter INSTITUTE OF MEDICINE].

7 THE WHITE HOUSE, IMPLEMENTING RECOMMENDATIONS OF THE PRESIDENTIAL COMM'N ON THE HUMAN IMMUNODEFICIENCY VIRUS EPIDEMIC: THE 10-POINT PLAN (Aug. 2, 1988).

8 “We don't have time to sit around and have this Commission live out its life and issue another report and have another report, another commission…. We have to act and we have to act quickly.” This testimony was quoted and endorsed by the National Commission on Acquired Immunodeficiency Syndrome Report Number One 2 (Dec. 5, 1989).

9 Id. at 6.

10 National Comm'n on Acquired Immunodeficiency Syndrome, National Comm'n on AIDS Takes Position on Bleach and HIV Control Research, Press Release (Nov. 7, 1989).

11 THE WHITE HOUSE, NATIONAL DRUG CONTROL STRATEGY (Sept. 1989) (available for sale from the U.S. Gov't Printing Office). The White House report provided a comprehensive strategy for combatting the drug epidemic. Despite the fact that needle-sharing among drug users is one of the most prevalent forms of transmission of HIV, the AIDS epidemic was barely considered.

12 Blendon, & Donelan, , Discrimination Against People with AIDS, 319 NEW ENC. J. MED. 1022, 1023-24 (1988)Google Scholar; Singer, , Rogers, & Corcoran, , The Polls — A Report: AIDS, 51 PUB. OPINION Q. 580, 582, 590-93 (1987)Google Scholar.

13 Blendon & Donelan, supra note 12, at 1023-24.

14 See, e.g., Continuing Resolution for FY 88 Appropriations, H.R.J. Res. 395, 100th Cong., 2d Sess. (1988) (Helms Amendment), as modified by Health Omnibus Programs Extension Act of 1988, Pub. L. No. 100-607, § 2500, 102 Stat. 3093 (1988) (forbids funding AIDS prevention programs that “promote or encourage, directly, homosexual or heterosexual activity or intravenous drug use“).

15 See generally Gostin, , The Politics of AIDS: Compulsory Stale Powers, Public Health and Civil Liberties, 49 OHIO ST. L.J. 1017 (1989)Google Scholar; Sullivan, & Field, , AIDS and the Coercive Power of the State, 23 HARV. C.R.-C.L. L. REV. 139 (1988)Google Scholar.

16 See Gostin, supra note 15, at 1039 n. 115.

17 Indiana v. Haines, 545 N.E.2d 834, 835 (Ind. App. Ct. 1989).

18 Sullivan & Field, supra note 15, at 158-59 & nn.64-65.

19 See Gostin, supra note 15, at 1020-26; Friedland, & Klein, , Transmission of the Human Immunodeficiency Virus, 317 NEW ENG. J. MED. 1125 (1987)Google Scholar.

20 There is a range of 0.03% to 0.9% probability that a person will contract HIV following a documented case of percutaneous exposure to HIV-infected blood. Friedland & Klein, supra note 19, at 1128. This rate of seroconversion compares favorably with the risk of 12% to 17% after percutaneous injection with HIV-contaminated blood. Id. at 1127. Centers for Disease Control, Update: Human Immunodeficiency Virus in Health Care Workers Exposed to Blood of Infected Patients, 36 MORBIDITY & MORTALITY WEEKLY REP. 285 (1987)Google Scholar.

21 The Centers for Disease Control (CDC) estimates that 500 to 600 health care professionals whose jobs entail exposure to blood are hospitalized annually with HIV infections, and over 200 of those hospitalized die from the virus. 52 Fed. Reg. 41,818 (1987).

22 Centers for Disease Control, Additional Recommendations to Reduce Sexual and Drug Abuse-Related Transmission of Human T-Lymphotropic Virus Type III/Lymphadenopathy-Associated Virus, 35 MORBIDITY & MORTALITY WEEKLY REP. 152 (1986)Google Scholar.

23 Centers for Disease Control, Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS, 36 MORBIDITY & MORTALITY WEEKLY REP. 509 (1987)Google Scholar.

24 Professor Martha Field's article in this symposium properly calls attention to the possibility of false positive test results. However, the likelihood that a person who has engaged in high risk behavior will have a false positive result should be very low if double ELISA and Western Blot tests are performed properly. Burke, Brundage, Redfield, Damato, Schoble, Putman, Visintire & Kim, , Measurement of the False Positive Rate in a Screening Program for Human Immunodeficiency Virus Infections, 319 NEW ENC. J. MED. 961 (1988)Google Scholar; Schwartz, , Dans, & Kinosian, , Human Immunodeficiency Virus Test Evolution, Performance, and Use: Proposals to Make a Good Test Better, 259 J. A.M.A. 2574 (1988)Google Scholar; see generally Gostin, , Curran, & Clark, , The Case Against Compulsory Casefinding in Controlling AIDS: Testing, Screening and Reporting, 12 AM. J.L. & MED. 7 (1987)Google Scholar; AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS, RECOMMENDATIONS FOR THE PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) TRANSMISSION IN THE PRACTICE OF ORTHOPAEDIC SURGERY 9-10 (1989).

25 Marzuk, Tierney, Tardiff, Gross, Morgan, Hsu, & Mann, , Increased Risk of Suicide in Persons with AIDS, 259 J. A.M.A. 1333 (1988)Google Scholar [hereinafter Marzuk]; Glass, AIDS and Suicide, 259 J. A.M.A. 1369 (1988)Google Scholar.

26 An alternative test site is a place where individuals can be tested usually on an anonymous basis. Originally, these sites were established by states and municipalities to discourage persons at high risk for HIV from being tested at blood collection centers.

27 See Rhame, & Maki, , The Case for Wider Use of Testing for HIV Infection, 320 NEW ENG. J. MED. 1248 (1989)Google Scholar.

28 Bauer, , AIDS Testing, 2 AIDS & PUB. POL'YJ. 1 (1987)Google Scholar. For the politically charged history of testing, see R. BAYER, PRIVATE ACTS, SOCIAL CONSEQUENCES: AIDS AND THE POLITICS OF PUBLIC HEALTH 101-36 (1989). “Routine” screening is seldom carefully denned, but appears to involve widescale testing without requiring a specific informed consent in each case.

29 See generally Gostin, Curran & Clark, supra note 24, at 7; Gostin, , Screening for AIDS: Efficacy, Cost, and Consequences, 2 AIDS & PUB. POL'YJ. 14 (1987)Google Scholar.

30 See generally Becker, & Joseph, , AIDS and Behavioral Change to Reduce Risk: A Review, 78 AM. J. PUB. HEALTH 394 (1988)Google Scholar.

31 See Rhame & Maki, supra note 27, at 1248. The authors make it clear, however, that they do not support involuntary testing.

32 See BRANDT, A., NO MAGIC BULLET: A SOCIAL HISTORY OF VENEREAL DISEASE IN THE UNITED STATES SINCE 1880 (1985)Google Scholar.

33 NATIONAL INSTITUTE FOR ALLERGIES & INFECTIOUS DISEASE, PROTOCAL 019: AZT TREATMENT OF ASYMPTOMATIC HIV INFECTED INDIVIDUALS (Clinical Trials Information Service, May 9, 1989).

34 Yarchoan, , Mistsuya, & Thomas, , In VIVO Activity Against HIV and Favorable Toxicity Profile of 2,3 - Dideoxyinosine, 245 SCIENCE 412 (1989)Google Scholar.

35 Centers for Disease Control, Guidelines Prophylaxis Against Pheumocystic Carinii Pneumonia for Persons Infected with Human Immunodeficiency Virus, 38 MORBIDITY & MORTALITY WEEKLY REP. S-5, 1 (1989).

36 Centers for Disease Control, Prevention and Control of Influenza, 37 MORBIDITY & MORTALITY WEEKLY REP. 369 (1988)Google Scholar.

37 Centers for Disease Control, Pneumococcal Polysaccharide Vaccine, 38 MORBIDITY & MORTALITY WEEKLY REP. 64 (1989)Google Scholar.

38 See Willenbring, Henry & Crossley, , Human Immunodeficiency Virus Antibody Testing: A Description of Practices and Policies at U.S. Infectious Disease — Teaching Hospitals and Minnesota Hospitals, 259 J. A.M.A. 1819, 1821 (1988)Google Scholar. Thirty-four percent of the United States infectious disease hospitals and 57% of the Minnesota hospitals estimated that the consent of the patient was rarely obtained when an HIV test was ordered. Id.

39 Glass, supra note 25, at 1369; Marzuk, supra note 25, at 1333.

40 Gostin, The AIDS Litigation Project: A National Review of Court and Human Rights Commission Decisions, Part II: Discrimination in Education, Employment, Housing, Insurance and Health Care, J. A.M.A. (forthcoming 1990).

41 Mueller, , The Epidemiology of the Human Immunodeficiency Virus Infection, 14 LAW MED. & HEALTH CARE 250, 250, 252-53 (1986)Google Scholar.

42 As of July 1989, 28 states required reporting of HIV positive rest results to the state public health department. All states required reporting of CDC-defined AIDS. Centers for Disease Control, HIV Infection Reporting — United States, 38 MORBIDITY & MORTALITY WEEKLY REP. 496 (1989).Google Scholar

43 Cleary, , Barry, , Mayer, , Brandt, , Gostin, & Fineberg, , Compulsory Pre-Marilal Screening for the Human Immunodeficiency Virus: Technical and Public Health Considerations, 258 J. A.M.A. 1757, 1758 (1987)Google Scholar [hereinafter Cleary]; Meyer, & Pauker, , Screening for HIV Can We Afford the False Positive Rate?, 317 NEW ENG. J. MED. 238-39 (1987)CrossRefGoogle Scholar.

44 Cleary, supra note 43, at 1757.

45 See Gostin, , Vaccination for AIDS: Legal and Ethical Challenges from the Test Tube, to the Human Subject, Through to the Marketplace, 2 AIDS & PUB. POL'YJ. 9 (1987)Google Scholar; Mariner, , Why Clinical Trials of AIDS Vaccines Are Premature, 79 AM. J. PUB. HEALTH 86 (1989)Google Scholar.

46 See Des Jarlais & Friedman, HIV Infection Among Intravenous Drug Users: Epidemiology and Risk Reduction, in CURRENT CONCEPTS IN PSYCHO-ONCOLOGY AND AIDS 279 (1987) (available from the Sloan-Kettering Cancer Center).

47 See Becker & Joseph, supra note 30, at 394; see also OFFICE OF TECHNOLOGY ASSESSMENT, U.S. CONGRESS, STAFF PAPER NO. 3, How EFFECTIVE IS AIDS EDUCATION? (1988).

48 Winkelstein, , Wiley, , Padian, , Samuel, , Shiboski, , Ascher, & Levy, , The San Francisco Men's Health Study: Continued Decline in HIV Seroconversion Rates Among Homosexual/Bisexual Men, 78 AM. J. PUB! HEALTH 1472 (1988)Google Scholar.

49 See, e.g., INSTITUTE OF MEDICINE, supra note 6, at 64-68; Fineberg, , Education to Prevent AIDS: Prospects and Obstacles, 239 SCIENCE 592 (1988)Google Scholar; Cleary, , Education and Prevention of AIDS, 16 LAW MED. & HEALTH CARE 267 (1988)Google Scholar.

50 See Gostin, supra note 1, at 1624.

51 See generally U.S. ACCOUNTING OFFICE, AIDS EDUCATION: RESEARCHING POPULATIONS AT HIGHER RISK (Sept. 1988).

52 Clark, , AIDS Prevention: Legislative Options, 16 AM.J.L. MED. 107, 115-18 (1990)Google Scholar.

53 FLA. STAT. § 455.226, amended by 1989 Fla. Laws 350.

54 See generally Centers for Disease Control, Guidelines for Effective School Health Education to Prevent the Spread of AIDS, 37 MORBIDITY & MORTALITY WEEKLY REP. S-2 (1988).

55 Mozert v. Hawkins City Bd. of Educ, 827 F.2d 1058 (6th Cir. 1987).

56 150 A.D.2d 14, 545 N.Y.S.2d 316, appeal denied, 74 N.Y.2d 829, 545 N.E.2d 629, 546 N.Y.S.2d 339, reh'g granted, 75 N.Y.2d 114 (1989).

57 75 N.Y.2dat 131.

58 See generally Centers for Disease Control, supra note 54, at S-2.

59 INSTITUTE OF MEDICINE, supra note 6, at 65.

60 Id. at 69.

61 See W.J. CURRAN & L. GOSTIN, INTERNATIONAL SURVEY OF LEGISLATION RELATING TO THE AIDS EPIDEMIC (1988).

62 Dep't of Health & Human Services Appropriations Act of 1988, Pub. L. No. 100-202, § 514, 101 Stat. 1329-289 (1988).

63 Id.

64 Pub. L. No. 100-607, § 2500, 102 Stat. 3093 (1988).

65 Id. (emphasis added).

66 Gostin, supra note 15, at 1045.

67 INSTITUTE OF MEDICINE, supra note 6, at 66; see Booth, , Another Muzzle for AIDS Education?, 238 SCIENCE 1036 (1987)Google Scholar.

68 See CITIZENS COMM'N ON AIDS FOR NEW YORK CITY AND NORTHERN NEW JERSEY, AIDS PREVENTION AND EDUCATION: REFORMING THE MESSAGE (1989).

69 See generally Note, The Constitutional Status of Sexual Orientation: Homosexuality as a Suspect Classification, 98 HARV. L. REV. 1285 (1985); Ginzburg, , Intravenous Drug Abusers and HIV Infections: A Consequence of Their Actions, 14 LAW MED. & HEALTH CARE 268, 268-72. (1986)CrossRefGoogle Scholar.

70 In California, a referendum that would have declared AIDS a communicable disease and permitted employment restrictions for persons carrying HIV was defeated. California's Proposition 64 Overwhelmingly Rejected by Voters, 1 AIDS POL'Y & L. 1 (1986).

71 Centers for Disease Control, supra note 23, at 509.

72 See generally Bayer & Gostin, Legal and Ethical Issues in AIDS, in 2 CURRENT TOPICS IN AIDS (M. Gottlieb, D. Jeffries, D. Mildvan, A. Pinching, T. Quinn & R. Weiss eds. 1989).

73 It is suggested forcefully that this would discourage people from being tested. See Fordyce, , Sambala, & Stoneburner, , Mandatory Reporting of Human Immunodeficiency Virus Testing Would Deter Blacks and Hispanics, 262 J. A.M.A. 349 (1989)Google Scholar.

74 ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS, GUIDE TO PUBLIC HEALTH PRACTICE, INTERIM REPORT, AIDS CONFIDENTIALITY AND ANTI-DISCRIMINATION PRINCIPLES (1987).

75 American Med. Ass'n, Prevention and Control of Acquired Immunodeficiency Syndrome: An Interim Report, 258 J. A.MA. 2097 (1987)Google Scholar.

76 INSTITUTE OF MEDICINE, NAT'L ACADEMY OF SCIENCES, CONFRONTING AIDS: DIRECTIONS FOR PUBLIC HEALTH, HEALTH CARE, AND RESEARCH 125, 129-30 (1986); INSTITUTE OF MEDICINE, supra note 6, at 71-74.

77 PRESIDENTIAL COMM'N supra note 5, at 126-27.

78 R. SABATIER, BLAMING OTHERS: PREJUDICE, RACE AND WORLDWIDE AIDS 1-6 (1988).

79 See supra note 12 and accompanying text.

80 AIDS Litigation Project, A National Review of Court and Human Rights Commission Decisions, Parts I and II, J. A.M.A. (forthcoming Apr. 1990).

81 School Bd. of Nassau County, Fla. v. Arline, 480 U.S. 273, 284 (1987).

82 See Friedland & Klein, supra note 19, at 1125.

83 WORLD HEALTH ORGANIZATION, GLOBAL PROGRAMME ON AIDS, PROGRESS REPORT No.3 (1988).

84 INSTITUTE OF MEDICINE, supra note 6.

85 American Med. Ass'n, supra note 75.

86 PRESIDENTIAL COMM'N, supra note 5.

87 Pub. L. No. 93-112, 87 Stat. 355 (1973).

88 See, e.g., AMERICAN BAR ASS'N, AIDS COORDINATING COMMITTEE, AIDS: THE LEGAL ISSUES 152-78 (1988); Memorandum from D.W. Kmiec of the U.S. Dep't of Justice to the Counsel to President Bush on the Application of Section 504 of the Rehabilitation Act to HIV-infected Individuals (Sept. 27, 1988); Parmet, Antidiscrimination Law: Necessary But Not Sufficient, in AIDS AND THE HEALTH CARE SYSTEM (L. Gostin ed. 1990); Gostin, supra note 40.

89 Civil Rights Restoration Act of 1987, Pub. L. No. 100-259, 102 Stat. 28, 31-32 (1988).

90 See, e.g., Chalk v. Orange County Dep't of Ed., 832 F.2d 1158 (9th Cir. 1987); Doe v. Centinela Hosp., 57 U.S.L.W. 2034 (CD. Cal. 1988); Ray v. School Dist. of DeSoto County, 666 F. Supp. 1524 (M.D. Fla. 1987).

91 Pub. L. No. 100-430, 102 Stat. 1619 (1988).

92 S. 933, 101st Cong., 1st Sess. 1989. The bill was passed by the Senate on Sept. 7, 1989.

93 See, e.g., Shuttleworth v. Broward County, 639 F. Supp. 654 (S.D. Fla. 1986); Cronan v. New Eng. Tel. Co., Civ. No. 80332 (Mass. Aug. 15, 1986).

94 NATIONAL GAY RIGHTS ADVOCATES, AIDS AND HANDICAP DISCRIMINATION: A SURVEY OF THE 50 STATES AND THE DISTRICT OF COLUMBIA (1986) (updated as of Jan. 1988 by the ADA at the Annual meeting of the APHA, Nov. 14, 1988).

95 For a review of antidiscrimination law relating to HIV, see Gostin, supra note 40; Bridgham & Rowe, Individual State Summaries: AIDS and Discrimination — A Review of State Laws that Affect HIV Infection 1983-1988 (1989). For a review of enforcement mechanisms, see R. STEELE, S. KARSTEN, B. LORENZ & J. RITTER, IDENTIFICATION AND ASSESSMENT OF STATE AND LOCAL STRATEGIES TO PREVENT DISCRIMINATIONS (1989).

96 In addition to his essay in this symposium, see Fox, & Thomas, , The Cost of AIDS: Exaggeration, Entitlement and Economics, in AIDS AND THE HEALTH CARE SYSTEM 197 (L. Gostin ed. 1990)Google Scholar; Fox, & Thomas, , AIDS Cost Analysis and Social Policy, 15 LAW MED. & HEALTH CARE 186 (1988)Google Scholar.

97 Fox & Thomas, AIDS Cost Analysis and Social Policy, supra note 96, at 186.

98 Pub. L. No. 99-272, 100 Stat. 82 (1986) (codified in scattered sections of 42 U.S.C.).

99 My section of the Harvard Model AIDS Legislation Project concerning IV drug users will be published at a later date.

100 CENTERS FOR DISEASE CONTROL, HIV/AIDS SURVEILLANCE (Dec. 1989). For reports of seroprevalence in several major cities, see Mascola, , Lieb, , Iwakoshi, , McAllister, , Siminowski, , Giles, , Run, , Fannin, & Strantz, , HIV Seroprevalence in Intravenous Drug Users: Los Angeles, California 1986, 79 AM. J. PUB. HEALTH 81 (1989)Google Scholar; Chaisson, , Bacchetti, , Osmond, , Brodie, , Sande, & Moss, , Cocaine Use and HIV Infection in Intravenous Drug Users in San Francisco, 261 J. A.M.A. 561 (1989)Google Scholar.

101 K. HOPKINS & W.B. JOHNSTON, INCIDENCE OF HIV INFECTION IN THE UNITED STATES (1988).

102 Friedman, , Sotheran, , Abdul-Quader, , Primm, , Jarlais, Des, Kleinman, , Mange, , Goldsmith, , El-Sadr, & Maslansky, , The AIDS Epidemic Among Blacks and Hispanics, 65 MILBANK Q. 455 (1987)Google Scholar.

103 See CENTERS FOR DISEASE CONTROL, supra note 100.

104 See generally PRESIDENTIAL COMM'N, supra note 5, at 94-104; Schuster, , A Federal Agency Perspective on AIDS, 43 AM. PSYCHOLOGIST 846 (1988)Google Scholar.

105 See generally Jarlais, Des & Friedman, , The Psychology of Preventing AIDS Among Intravenous Drug Users: A Social Learning Conceptualization, 43 AM. PSYCHOLOGIST 865 (1988)Google Scholar.

106 See Becker & Joseph, supra note 30; Des Jarlais, , Friedman, & Hopkins, , Risk Reduction of Acquired Immunodeficiency Syndrome Among Intravenous Drug Users, 103 ANNALS INTERNAL MED. 755 (1985)Google Scholar.

107 Ginzburg, supra note 69, at 269.

108 See generally Stryker, , IV Drug Use and AIDS: Public Policy and Dirty Needles, 14 J. HEALTH POL. POL'Y & L. 719, 730-32 (1989)Google Scholar.

109 Id.

110 See Anon, , Drug Misuse and AIDS Prevention: Policy on the Right Track, 83 BRIT. J. ADDICTION 1237 (1988)Google Scholar; Stimson, , Dolan, , Donoghue, & Lart, , Syringe Exchange Schemes: A Report and Some Commentaries, 84 BRIT. J. ADDICTION 1283 (1989)Google Scholar.

111 See Tsai, , Goh, , Webeck, & Mullin, , Prevention of Human Immunodeficiency Virus Infection Among Intravenous Drug Users in New South Wales, Australia: The Needles and Syringes Distribution Programme Through Retail Pharmacies, 2 ASIA-PAC. J. PUB. HEALTH 245 (1988)Google Scholar; Wodak, & Penny, , A Report on the National Advisory Committee on Acquired Immunodeficiency Syndrome Workshop on the Human Immunodeficiency Virus Infection and Intravenous Drug Abuse, 149 MED. J. AUSTL. 373 (1988)Google Scholar.

112 Bunning, van Brussel & Santen, Amsterdam's Drug Policy and its Implication for Controlling Needle Sharing, in NEEDLE SHARING AMONG INTRAVENOUS DRUG ABUSERS: NATIONAL AND INTERNATIONAL PERSPECTIVES 59 (R.J. Battjes & R.W. Pickens eds. 1988) [hereinafter NEEDLE SHARING].

113 See generally THE WHITE HOUSE, supra note 11.

114 See Des Jarlais & Friedman, supra note 105, at 869-70.

115 See Ginzburg, supra note 69, at 268; Stryker, supra note 108, at 722.

116 See HAMMETT, T.M., AIDS IN CORRECTIONAL FACILITIES 12-13, 41, 53 (1988)Google Scholar.

117 See DAWSON & HARDY, AIDS KNOWLEDGE AND ATTITUDES OF HISPANIC AMERICANS: PROVISIONAL DATA FROM THE 1988 NATIONAL HEALTH INTERVIEW SURVEY (National Center for Health Statistics Advance Data No. 166, Apr. 11, 1989); see also Dalton, , AIDS in Blackface, 118 DAEDALUS 205, 207 (1989)Google Scholar.

118 Des Jarlais, & Hopkins, , Free Needles for Intravenous Drug Users at Risk for AIDS: Current Developments in New York City, 103 NEW ENG. J. MED. 313 (1985)Google Scholar.

119 See Pascal, Intravenous Drug Abuse and AIDS Transmission: Federal and State Laws Regulating Needle Availability, in NEEDLE SHARING, supra note 112, at 119, 123-24.

120 Id.

121 MASS. GEN. LAWS ANN. ch. 94C, § 27(a) (West 1984).

122 Commonwealth v.Jefferson, 377 Mass. 716, 719, 387 N.E.2d 579, 581 (1979).

123 THE WHITE HOUSE, supra note 11, at 16, 25.

124 Des Jarlais, & Friedman, , HIV Infection Among Intravenous Drug Users: Epidemiology and Risk Reduction, 1 AIDS 67 (1989)Google Scholar.

125 See Hartgers, , Buning, , van Santen, , Verster, & Coutinho, , The Impact of the Needle and Syringe Programme in Amsterdam on Injecting Risk Behaviour, 3 AIDS 571 (1989)Google Scholar; COMMITTEE ON LAW REFORM, NEW YORK COUNTY LAWYERS ASS'N, DRUG-RELATED AIDS AND THE LEGAL BAN ON OVER-THE-COUNTER HYPODERMIC NEEDLE SALES (Jan. 12, 1988).

126 See Williams, Crack is Genocide 1990s Style, N.Y. Times, Feb. 15, 1990, at A31, col. 1.

127 Recent studies, however, show that the AIDS virus probably remains on discarded needles even if they appear visibly clean. Chitwood, , McCoy, & Inciard, , HIV Seroposilivity of Needles from Shooting Galleries in South Florida, 80 AM. J. PUB. HEALTH 150 (1990)Google Scholar; Risk Behaviour, 3 AIDS 571 (1989); COMMITTEE ON LAW REFORM, supra note 125.

128 See supra notes 110-12.

129 See O'Brien, , Needle Exchange Programs: Ethical and Policy Issues, 4 AIDS & PUB. POL'Y J. 75, 76 (1989)Google Scholar.

130 Needle exchange programs were blocked successfully by political opposition in Los Angeles, Boston and Chicago. Purdum, Dinkins to End Needle Plan for Drug Users, N.Y. Times, Feb. 14, 1990, at Bl, col. 2.

131 Id.

132 See generally R. HUBBARD, M. MARSDEN, J. RACHAL, H. HARWOOD, E. CAVANAUGH & H. GINZBURG, DRUG ABUSE TREATMENT: A NATIONAL STUDY OF EFFECTIVENESS (1989).

133 See Schuster, supra note 104, at 847.

134 See Batki, , Treatment of Intravenous Drug Users with AIDS: The Role of Methadone Maintenance, 20 J. PSYCHOACTIVE DRUGS 213 (1988)Google Scholar.

135 Fox, , Day, & Klein, , The Power of Professionalism: Policies for AIDS, in Britain, Sweden and the United Slates, 118 DAEDALUS 93 (1989)Google Scholar.

130 See Hevesi, , FDA Extends Methadone Experiment in Harlem, N.Y. TimesGoogle Scholar, Dec. 5, 1988, at B3, col. 3.