AIDS What Risk to Save a Life?

HEALTH

Firefighters are backing off. The decision of whether to render lifesaving first aid—mouth-to-mouth resuscitation—has become a mind-wrenching one for responders in some neighborhoods where the perceived threat of AIDS looms large.

It is in impoverished locales where drug addiction is common that body bags are filled most often, mouth-to-mouth given most frequently, extrication accomplished routinely, trauma aid performed regularly, and firefighter injuries suffered at record-breaking paces.

“I don’t mind risking my life if there is the slimmest chance of success, but I won’t risk it along with my family’s against a sure thing,” one firefighter in an active district on Manhattan’s Upper West Side, home to a large gay population, told me. “Ditto,” echoed an emergency responder assigned to San Francisco’s hard-living Tenderloin District. In fact, the sentiment is growing to a thunderous cry of frustration among many of our urban firefighters, both paid and unpaid.

With sympathy and feeling in my heart for them all, I began to look for answers. Sure—AIDS information is everywhere. I read everything I could get my hands on. Not enough!

Bodily fluid transfer seems to be at the root of the problem. But bodily fluid is the name of our game. Burn victims, extrication victims, mouth-to-mouth operations all put the firefighter in direct contact with every type of bodily fluid imaginable. Besides—I never knew a firefighter who didn’t receive some kind of wound in rescue and extrication attempts.

Our effort to gain reliable information for the real world of firefighting has resulted in the article that follows. We believe it makes a significant breakthrough in the informational void that has surrounded the fire service in our concern about AIDS. If it doesn’t answer every one of the questions you have, we ask you to consider it the start of a dialogue that we pledge to continue as needed.

—Tom Brennan, Editor

Acquired immune deficiency syndrome is transmittable, incurable, and—so far—inevitably fatal. But the facts indicate that prudence, not panic, is the appropriate response for firefighters and their families.

The New York City Health Department has had one of the best opportunities to examine the facts, because more than one quarter of the nearly 35,000 AIDS cases reported in the United States have been in New York. In short form, the facts are these:

• Not a single occupation—not firefighting, nursing, dentistry, or any other line of work that involves physical contact—has been identified as increasing the likelihood of contracting AIDS.
• We know of absolutely no case in which AIDS has been transferred through saliva, through vomit, or by blood touching the skin.
• Nevertheless, firefighters should take precautions against contracting other transmittable diseases in the performance of their duties.
• And all people in any occupation must take the proper precautions against AIDS if they’re sexually active.

The infectious agent that can lead to AIDS is the human immunodeficiency virus (HIV). The latency period for HIV—the time between becoming infected and actually displaying symptoms— can be quite long. In some cases, people have developed AIDS five or more years after being infected with HIV.

Thus far, fortunately, only a minority of the individuals infected have actually developed symptoms. These people fall into the first of three categories of outcomes resulting from infection with HIV: They have an asymptomatic infection, something that can happen with any virus. It’s estimated that more than 1 million people in the United States have been infected with HIV, the majority without showing any signs of disease. Even without symptoms, though, these people can infect others with HIV.

At the other end of the scale is the most severe form of HIV infection, AIDS, in which the patient’s immune system is so severely suppressed that the person becomes susceptible to certain malignancies and opportunistic infections—infections that wouldn’t pose a threat to persons with normal immune function but seize the opportunity to infect patients who have immune dysfunctions. Examples are an unusual cancer called Kaposi’s sarcoma and a parasitecaused pneumonia known as Pneumocystis carinii.

The symptoms of AIDS are often nonspecific and may appear the same as those of other illnesses, such as a cold or the flu. However, the symptoms usually last a long time and occur again and again. They include:

• Prolonged fatigue that’s not explained by physical activity or by other disorders;
• Unexplained swollen glands that have lasted longer than three months;
• Persistent fevers or night sweats;
• Unexplained weight loss of more than 10 pounds during a period of less than two months;
• The recent appearance of purplish or discolored lesions of the skin or mucous membranes that don’t go away and gradually increase in size;
• A persistent, unexplained cough;
• Thrush, a fungal infection that produces a thick, whitish, hairy coating on the tongue or in the throat; and
• Easy bruising or unexplained bleeding.

There are many conditions that don’t constitute AIDS but are caused by the HIV infection. Doctors often call these conditions AIDS-related complex. ARC can involve a number of the same symptoms as AIDS, such as extreme fatigue, diarrhea, thrush, weight loss, and swollen glands. These aren’t contagious in themselves and aren’t likely to be detected by others as AIDS-related.

AIDS What Risk to Save a Life?

Photo by Al Trojanowtcz

Some people with ARC later develop a life-threatening opportunistic infection; it’s not until this point that the person is classified as having AIDS.

Epidemiologic surveillance studies of the groups of people who become ill with AIDS reveal that HIV transmission occurs in three ways: through sexual contact with infected partners (penis-vagina, penis-rectum, mouth-rectum, mouth-vagina, mouth-penis); through injection of the virus directly into the body by sharing needles or getting a transfusion of HIV-infected blood; and during pregnancy, from an infected mother to her unborn child. A person may fall into more than one risk group, thus increasing the risk.

As important as it is to know how AIDS is transmitted, it’s equally important to know how AIDS is not spread.

AIDS infection is not spread through air, food, water, urine, or feces, or by close nonsexual contact such as shaking hands, coughing, hugging, sneezing, or sharing eating utensils. There are no known cases of AIDS transmission by insects, such as mosquitoes. Dogs, cats, and domestic animals are not a source of HIV infection.

Nor has AIDS been contracted from swimming in pools or bathing in hot tubs or eating in restaurants (even if a restaurant worker has AIDS or carries the AIDS virus). AIDS is not contracted from sharing bed linens, towels, cups, straws, dishes, or any other eating utensils. You can’t get AIDS from toilets, doorknobs, telephones, office machinery, or household furniture. You can’t get AIDS from body massages or masturbation.

In a few cases, HIV has been isolated in very low percentages in samples of human saliva and tears. There’s no evidence, however, that transmission can occur through exposure to these fluids. Furthermore, most persons with HIV in their blood don’t show evidence of the virus in saliva.

On the evidence

We’re confident of our conclusion that no occupation, as an occupation, faces any special AIDS risk, because of how information on specific cases has been gathered. In New York City, a person can have the blood test for HIV antibodies done through a New York City Health Department clinic or a private physician. Either way, all test results and questionnaires that come into the health department are anonymous.

The health department is always on the alert for information indicating unrecognized risks involving AIDS. So when someone who’s been exposed to AIDS claims not to have been involved in the known high-risk activities— sexual contact with AIDS carriers or the sharing of intravenous needles—we contact that person’s physician (if the test was done outside the health department) and ask for help in getting the patient’s permission for an interview.

The patient’s usually scared and looking for help. We quickly make it clear we won’t be tracing the patient’s personal contacts, and at that point, the person almost always gives us honest answers.

Studies of health care workers also provide strong evidence against casual contact. Health care workers have greater exposure to people with AIDS than any other occupational group. There are more than 200,000 health care workers in New York City; not one has been infected with HIV without being otherwise at risk.

One ongoing study, followed in the Morbidity and Mortality Weekly Report of the federal government’s Centers for Disease Control in Atlanta, tracks 1,758 health care workers, including many who’ve been exposed to the blood of people with AIDS by accidentally sticking themselves with hypodermic needles. In only two cases have workers become infected after inadvertent, deep injections of blood from people with AIDS; three more recent cases allegedly linked to other blood contact are under investigation.

In other studies followed by the CDC, of more than 300 household contacts in the United States, not one person, other than a sexual contact or a child born to an infected mother, has developed AIDS or shows evidence of HIV infection.

Some of the best evidence against casual transmission comes from studies of the brothers and sisters who live with a sibling who has AIDS. In these family studies, most of the young people have shared food and drinks, used the same eating utensils and toothbrushes, slept together in the same beds, fought and wrestled, cuddled and kissed. In many of these cases, it wasn’t originally known that one of the children was infected, and thus no special precautions had been taken. Nonetheless, none of the siblings has developed AIDS or evidenced infection with HIV as a result of contacts with infected siblings.

Some have asked whether HIV can be transmitted through a bite by an infected person, or by exposure of open skin lesions to the blood of an infected person. There may be a theoretical possibility that HIV can be transmitted in these ways. As a practical matter, though, the risk of such transmission is nonexistent. In addition to the results of the health care worker and family studies already mentioned, an extensive study of biting as a route of transmission was conducted at Montreal General Hospital. Of 30 people who could have been exposed to HIV through bites there, not one became infected. Keep in mind that the body’s natural protective mechanisms are well-developed; blood from a cut flows outward, not inward, and scabs form quickly.

The likelihood of developing an HIV infection once exposed depends on a person’s own underlying health and on the exposure. The virus’s effect is cumulative, so the more times a person comes in contact with it, the greater the risk is going to be. The amount of virus in each exposure is also critical.

Since AIDS attacks the immune system, a healthy body will be better able to resist than one that’s been worn down by repeatedly fending off other types of infections. Many people now suffering from AIDS have a long history of sexually transmitted diseases which have weakened their physical defenses. But no one should rely on general health to resist AIDS. The key is to avoid contact with the virus (but not with the person who has the virus).

There are three safety precautions firefighters and other emergency response personnel should follow in the course of doing their jobs. Fire departments should make them part of their standard operating procedures—ideally, in consultation w’ith the director of the state or local health department.

• Keep a pair of gloves with you (in the pocket of your turnout coat, for example) for handling injured victims whose body fluids could otherwise come in contact with injuries you may have. Your regular turnout gear should prevent contact with other parts of your body.
• Carry a small, disposable mask with a spring-operated bypass on you for use in administering mouth-to-mouth resuscitation. This is to protect yourself not against AIDS, but against diseases that are transmittable through saliva, such as herpes and hepatitis-B. [See “Hepatitis-B: Preventive Medicine for Emergency Responders,” Fire Engineering, May 1987. ] The mask is more effective than a C-shaped tube in preventing a patient’s bodily fluids from reaching the mouth of the person conducting resuscitation.
• If you’ve come in contact with an emergency victim’s bodily fluids, take the normal precaution of washing up when you first get the opportunity. Wash down your turnout gear as usual; it doesn’t require any special decontamination procedures, because the virus is fragile outside the body and dies quickly once it comes in contact with air.

Some personal measures are also in order to protect yourself and others from infection by the AIDS virus:

• If you have been involved in any of the high-risk activities or have reason to believe a victim you’ve aided has an HIV infection, you should have a blood test to see if you have been infected. (A regular blood workup doesn’t check for HIV antibodies, so a routine checkup won’t tell you anything about whether you’ve been exposed to AIDS.) Some gay activist groups counsel against having the test performed for fear the records could someday leak out and become the basis for discrimination. In contrast, the New York City Health Department encourages testing. The department keeps the form describing the results separate from any insurance forms so an individual’s insurance company doesn’t know about the test. However, the procedures may differ in other states and locales.
• If your test is positive or if you engage in high-risk activities and choose not to have a test, you should tell your sexual partner. If you jointly decide to have sex, you must protect your partner by always using a condom from start to finish during sexual intercourse (vaginal or anal).
• If your partner has a positive blood test showing that that person has been infected with the AIDS virus, or if you suspect your partner has been exposed by previous heterosexual or homosexual behavior or the use of intravenous drugs with shared needles or syringes, a condom should always be used, start to finish, during sexual intercourse.
• If you or your partner is at high risk, avoid mouth contact with the penis, vagina, or rectum.
• Avoid all sexual activities which could cause cuts or tears in the linings of the rectum, vagina, or penis.

These precautions are for the physical safety of you and your sexual partners. When AIDS occurs, precautions should also be taken to protect the victim’s rights and dignity, both in the workplace and at home.

The U.S. Justice Department took a stand last year that fear of AIDS is a legally permissible reason for an employer to fire a victim of the disease. But that opinion seems to have been superseded by a Supreme Court ruling based on the Rehabilitation Act of 1973, which bans discrimination based on a handicap. The ruling extends that ban to cover transmittable diseases. Experts in personnel administration generally agree that AIDS will not be a legally allowed basis for job discrimination.

To reiterate the information from the Centers for Disease Control’s ongoing study, AIDS is not spread by the casual contact of living together in a nonsexual relationship. Consider the fact that people don’t fear they’ll catch the disease from sitting in a disco having a drink; they have no more reason to fear it when sitting down to eat lunch with an AIDS victim in a firehouse kitchen.

In my counseling experience, the people around an AIDS victim react more to the implication of how the person got the disease than they do to the fact of the AIDS itself. If you find out that someone you know has AIDS, it’s important to remember that this is the same person you knew the day before. This person, who has been your friend or family member for years, needs your support now more than ever before.

Spouses, especially, should be aware that the AIDS virus can lie dormant in a person’s body for as long as five years. The development of AIDS doesn’t necessarily say anything about the victim’s recent activities; the news of AIDS is bound to be a huge, emotional burden, but as best as possible, it should be an occasion for dignity and understanding rather than doubts and recriminations.

AIDS is going to continue to spread—to those who’ve been infected in the past and to those who ignore proper protections in the future. As it does spread, more and more of us will know a friend or a relative who has the disease. It will become more personalized, giving us more cause to learn the facts. As AIDS and information about it spread, the hysteria will subside.