The French approach to control / by Alain Pompidou

The French approach to control by Professor Alain Pompidou AIDS Counsellor for the Ministry of Health, France F rance has developed a compre-hensive five-point policy to counter the threat of AIDS , ba- sed on prevention (including infor- mation , statutory measures and screening) ; training ; monitoring and treatment ; research ; and internatio- nal cooperation. Prevention A national information campaign launched at the end of April last year included four main components. These were a series of television commercials emphasising that AIDS is an avoidable disease and that it is everyone's responsibility to stop the transmission of the virus ; a data base set up by the French Committee for Education for Health , whose daily information is made available to doc- tors through Minitel , a computerised telephone system; a booklet targeted at the health professionals and prin- ted in one million copies , and a bro- chure for the general public, printed in 13 million copies; and , finally, a billboard campaign coupled with radio commercials. In addition to this programme , financed by the Health Ministry and directed by the French Committee for Education for Health , there are many private campaigns run by the associations that deal with AIDS. The national campaign was awar- ded the label of a "great national cause," and this enabled the Founda- tion for Medical Research to receive additional funds. Two leaflets have been mailed to the country's 24 mil- lion phone users , along with their tri- mestrial bill. The first one recalls the main points of the campaign, and the second is an appeal for funds to be contributed to the Foundation. National action must involve inter- ventions among high risk groups, but this will only be undertaken after the creation of special teams among the people in contact with these groups (prisoners, drug addicts , teenagers). In hospitals , in-depth training is being given to the medical staff, to W oRLD HEALTH, March 1988 enable them to deal with AIDS virus infected persons and AIDS patients , as well as avoiding infection. An awareness campaign is being planned for children aged over 15 in high schools and colleges, so as to adapt the message to the real needs of this vulnerable population. The French government is not yet ready to adopt legal measures concerning AIDS ; but has taken cer- tain measures of a statutory nature, aimed at limiting the spread of the epidemic. The most recent of these deal with the legalisation of advertis- ing for sheaths (condoms), within the scope of the campaign against sexual- ly transmitted diseases , and the sale of syringes ; for an experimental year, people will be able to buy syrin- ges in drugstores without a prescrip- tion and without having their identity checked. The government is no less determined to fight drug abuse , but wants to stop the transmission of AIDS through contaminated need- les. Already 60 to 80 per cent of France's heroin addicts are infected with the AIDS virus. An efficient programme against drug abuse must ensure against having a population of AIDS virus carriers among people cured of their addiction , and must also try to stop heterosexual trans- mission through the drug addict population. Mandatory , systematic screening is not carried out in France, because of the high cost (16 ,000 million francs per year) and the limited results. So as to respect individual freedom , and to invoke true personal responsi- bility , we have chosen to undertake voluntary screening, with the most absolute respect of privacy and medi- cal confidence. Only coded data will be processed by the epidemiological centres . France already has around 200 centres able to conduct screening and confirm tests ; the cost of the test is reimbursed at 65 per cent by the Social Security. Free and anonymous screening will soon be carried out in 100 other centres . The screening is encouraged for high risk groups and for all couples likely to have babies , so as to avoid transmitting the di- sease during pregnancy. It is also mandatory for all blood, organ, tis- sue, cell and sperm donors. As for international travellers , the Health Ministry follows the recom- mendations of WHO and of the Coun- cil of European Health Ministers. No screening is undertaken at the bor- der, and an information brochure for French citizens leaving and for- eigners entering the country is in pre- paration. Finally, France is collabo- rating with WHO to help with the systematic screening of blood-donors in those African countries in need of this programme. Training Three types of training are current- ly available . High level clinical train- ing for hospital staff is arranged by the Claude Bernard Hospital, the WHO Collaborating Centre on AIDS and the Health Ministry. The train- ing takes place over a week, involv- ing 40 hospital doctors (clinic direc- tors and heads of staff). Its goal is to familiarise hospital staff with little clinical experience of AIDS in taking care of their patients medically, undertaking clinical and therapeutic research, and operating local educa- tional programmes outside their hospital. Training for people dealing with drug addicts is directed by the De- partment for Social Action and the General Department of Health of the Health Ministry. It aims at improving the level of knowledge about AIDS in drug addiction specialists, and at helping to organize medical networks offering complete coverage for infec- ted drug addicts in special centres and hospital departments. Health education in prisons is directed by the Ministry of Justice, and seeks to train people in each prison (doctors, nurses, counsellors) as health educators. At present , patients are especially cared for by hospitals, mostly in the 19 The French approach to control Paris area . Eleven centres for AIDS information , cli nical and biological monitoring, and treatment were cre- ated last year, and more will be cre- ated this year. In these centres , AIDS patients will have access to different hospital services according to their symptoms (infectious disease service , pneu- mology, neurology, and dermatolo- gy). Those patients who can be cared for on an outpatient basis will come to a day hospital of eight to ten beds, with the necessary personnel. There will also be immunology and virology laboratories specially equipped for the purpose. The major preoccupation today is keeping track of the infection's pro- gression and understanding its natu- ral evolution so as to develop a prog- nosis, guide therapeutic research and determine its repercussions on health structures and budgets. This will be done by creating prospective models, studying groups of volunteers and setting up specific studies . More than 50 teams of scientists have already been constituted , who will benefit from the 100 million "A IDS will not be passed on by me." France's health education campaign fea - tures youngsters who show their aware- ness of risk and who break off the rising red line of disease transmission. francs granted for AIDS research by the government . The National Pro- gramme for AIDS Research presided over by the Ministry of Research deals mainly with five fields of re- search : molecular and cellular biolo- gy and viral multiplication, immuno- logy, di agnosis, therapeutics ( chemi- cal and biological, and vaccination), epidemiological and clinical research. More than 80 group projects have been submitted, and each will be based on collaboration and coordi- nation between different research groups, especially between private and public companies. The Pasteur Institute in Paris is playing a leading role in this research and its resources will be increased considerably. With- in two years, it will have a large tailor-made building fo r retrovirus studies. Early on , France realised what an important coordinating role WHO was to play. Besides collaborating with the Global Programme on AIDS, France is ready to exchange info rma- tion inside the European Commun- ity, and is willing to take part in group research programmes. Together with WHO , it is participating in the Anti- AIDS programme developed for the African French-speaking countries that wanted help . And it has estab- lished historical bonds with its United States partners through an agreement between the Pasteur Institute and the National Institutes of Health . • A IDS could turn out to be the greatest medical chal-lenge this century. This worldwide pandemic is presenting more unique problems than we are able to cope with. AIDS has now spread to several African countries, notably those of Central and East Africa. In those countries, the infrastructure is gen- erally inadequate to meet the in- creasing demand for relatively specialised services to respond ef- fectively to the epidemic. Uganda is one of those affected. Situated in the heart of Africa along the equator, Uganda is a fo- . cal point of human interaction and trade. It is fairly densely populated, especially the townships along the trans-African highway leading to the Indian Ocean ports. On this route, studies have implicated long- distance truck drivers, 33 per cent of whom are infected, in the spread of infection. Civil disturbances leading to the displacement of large populations are also considered a transmission factor. The first cases of AIDS in Ugan- da were suspected during the last quarter of 1982. Several business- men died at Kasensero , an isolated fishing village on Lake Victoria, known for its smuggling and illicit trading. When these deaths oc- curred, fellow traders laughed them off as "witchcraft." Others thought they were natural justice for infidelity. The victims were all young and sexually active, and stayed away from home for several days chasing wealth and making merriment. Soon there were corresponding deaths among their wives. The social victimisation and prejudice which followed spread to bigger towns inland, to the capital, Kampala, and to places which hitherto had not experienced the disease. It became clear that we were dealing with a completely new dis- ease. Cases increased from 17 in 1983 to over 1,000 by 1987, but were still among young sexually active people. About 80 per cent of the cases were aged between 20 and 40, and there were virtually no cases between the ages of 5 and 14 or among the elderly. But the latest notifications show an increasing number of in- fants and children below five years, which suggest an increase in mother to child transmission. WORLD HEALTH, March 1988