Our subject today is HIV and the law. We will begin with laws that are designed to protect public health. We'll move on to the major US law that provides care for HIV positive people and we'll briefly set the stage for another session on criminal laws bearing on HIV. In the United States and many other countries, the government can take action to protect people from contagious diseases. These laws have generally not been used in the case of HIV and AIDS, but I begin with them for two reasons. People often wonder about whether isolation or quarantine was appropriate in this epidemic. And in the early stages of the epidemic when there was a lot of fear, even panic, there was suggestions that public health measures should be taken. The US law allows the government to order isolation, the separation of sick people with a contagious disease from people who aren't sick. It also allows for quarantine which both separates and restricts the movement of people exposed to a disease to determine whether they will become sick. The Federal government maintains a list of diseases for which isolation and quarantine are authorized. Here's the list which currently includes nine diseases. As you can see, viral hemorrhagic fevers, like Ebola, are on the list and HIV is not. Clearly, there is a tension between public health considerations and civil liberties. Public health officials acting under these laws can restrict the freedom and movement of citizens. The health dangers must be serious and the underlying medical knowledge must be very strong in order to justify such isolation and quarantine. What about HIV? As I have said, the panic that many people felt early in the epidemic led some to demand restrictions on the movement and behavior of infected people. As information accumulated about how the disease spread, it became clear that casual, incidental contact with an infected person was not dangerous. There was not a generalized public health danger from HIV. It is certainly a good thing that officials resisted pleas for restriction on HIV-positive people. One country, Cuba, isolated HIV-positive people by law until 1993. You may remember that Professor Larry La Fountain-Stokes mentioned that, when I asked him to review the HIV situation in several Caribbean countries. Although no longer required to do so by law, some of these HIV-positive people still live in the quarantine sanatoria. And the harshness of the Cuban response has generally been moderated. The story of HIV in Cuba is complex and positive. There is universal healthcare in Cuba and an extremely aggressive HIV education program that also saturates the country with condoms. Cuba has a very low HIV prevalence and I'm not in a position to judge the extent to which the early quarantine policy contributed to it. Let's move on from the provisions of public health laws, which generally had little influence on the HIV AIDS epidemic, to the legislation in the United States that bears directly upon the treatment and prevention if HIV. A large, fast growing, deadly epidemic requires governmental action. In the United States, only the Federal government had the resources and the reach to respond to the spread of HIV. We have discussed the criticisms of President Reagan for not showing public leadership and for not rapidly increasing budgets when HIV hit. The federal government did, however, respond very positively in 1990 when Congress passed the Ryan White Care Act. We saw this photo at the very beginning of the course. Ryan White was a teenager who contracted HIV from blood products used to treat his hemophilia. He was the target of discrimination because of his HIV and became a spokesperson and symbol in the struggle for fair treatment of HIV positive people. Ryan died just before his 18th birthday in 1990. And a major piece of comprehensive legislation on HIV and AIDS was named in his honor that same year. For almost 25 years now, the Ryan White Care Act, reauthorized and revised in some ways, has been the key law that has defined and funded care and prevention in the United States. The primary goal of the act is to provide help to HIV people who do not have sufficient money or healthcare insurance to pay for their care and treatment. This makes the government the payer of last resort when no other sources of funds are available. In 2014, 536,000 people are receiving assistance under this act, and the bill is authorized at $2.32 billion. This compares with the original funding level in 1991 of 220 million. About one-third of the money goes to ADAP, the AIDS drug assistance program that helps people pay for their anti retro viral medicines. The law has special provisions to provide assistance to minority communities and areas that have been especially hard hit by the epidemic. It provides incentives to localities for testing and identifying HIV infected people who do not know their status. The Care Act also funds a variety of programs to attempt to improve treatments and services for HIV positive people. Of course, there are exceptions. Some people don't know about available medical services. Some people live in remote areas where they can't reach medical care. But it is generally true that because of the Ryan White Care Act, virtually every HIV-positive person in the United States can get access to medical care, support services and the medicines that they need. It took about a decade for the US Federal government to move from a President who barely mentioned aids to legislation that aimed to care for everyone who was infected. I'll conclude with an odd provision of the Ryan White Care Act. When it was passed in 1990, it required every state to certify that its criminal laws could prosecute any HIV positive person who knowingly exposed another person to HIV. That brings us to another aspect of HIV and the law. It is often called the criminalization of HIV, and we'll discuss that in another session.
