HIV/AIDS:The development of the evidence base

andpublic health policy

1981-1991

Hudson Birden

15 March 2007

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Hierarchy of evidence

• Systematic Reviews/ Meta-analyses

• Randomized Controlled Trials (RCTs)

• Cohort studies

• Case control studies

• Cross sectional studies (surveys)

• Case reports

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Multicenter AIDS Cohort Study- Baltimore

• Cohort recruited 1983-1985

• baseline for 1983-84 subjects assessed retrospectively

• cohort study group= 5,622 men– 2,195 HIV+ at baseline– 3,427 HIV- at baseline

• 551 seroconverted through 1997

Opposition to PN for HIV

• No treatment available• Long incubation period• Prevention messages should be sufficient

– Safe sex avoids risk, need for PN

• May provide a disincentive for testing– Fear of driving the epidemic underground

• Lack of trust of PH process– Confidentiality of records– Mechanism of PN

Barriers to PN for HIV

• insufficient funding or personnel • inability to retain staff • non-cooperation

– private providers – community-based organizations

• political opposition– men who have sex with men – organizations opposed to condom distribution

• absence of mandatory HIV infection reporting

» Source: Golden et al STD 2003:30(6);490-496

An “innocent victim of AIDS”• Fort Pierce, Fla.--A year after Kimberly

Bergalis died of AIDS, her parents claim they are frustrated and angry that their daughter's death has not led to mandatory HIV testing of health-care workers– UPI 12/08/92

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Gross: N Engl J Med, Volume 340(24).June 17, 1999.1881-1887