Lessons from Chautauqua County.

• Author: Gottfried, Richard N.
• Position: New York - Symposium on Health Care Policy: What Lessons Have We Learned from the AIDS Pandemic?

1. INTRODUCTION

   As we consider what we have learned in the years of the HIV epidemic, the case of Nushawn Williams in Chautauqua County, New York, presents a series of important lessons. Unfortunately, most news media and political responses to the case have drawn mistaken lessons, which, if followed, would seriously endanger public health.

   Nushawn Williams is the HIV-infected man who reportedly had unprotected sex with dozens of women and girls, and apparently infected several of them.(1) Williams's alleged activity occurred, at a minimum, in rural Chautauqua County and New York City.(2) Much of this sexual activity occurred after Williams learned he was HIV positive, and he did not tell his sex partners he was infected.(3) Assuming he did what he is alleged to have done, the case is a moral outrage.

   The story has a great deal to teach us. How we respond to it will either strengthen or seriously weaken our ability to deal with the HIV epidemic and other public health concerns.

   This Article addresses some key lessons which should be drawn from the Williams case. Part II examines our failed efforts to reach out to young people about drugs, sex, and HIV, and notes that the epidemic is far from over.(4) Part III discusses the provisions relating to HIV testing in New York's current Public Health Law and argues that the law did not "get in the way" in the Williams case, but actually prevented this horrifying case from being much worse.(5) Part IV examines the need for a strong public health network in the fight against HIV, including education on sexually transmitted diseases (STDs), family planning, prenatal care, school health clinics, and community health care centers.(6)

2. SOCIETAL ISSUES

   1. Reaching Out to Young People

      The fact that dozens of girls and women in a small rural community would have unprotected sex with Williams should be an alarm bell. We do not know what, if any, education any of them received about drugs, sex, and HIV prior to their contact with Williams. It appears, however, that society's messages on the dangers of unprotected sex are not getting through. We need to multiply our work, and use a more effective message than "Just Say No."

      Ironically, communities in Chautauqua County are reported to have some excellent programs.(7) Teen pregnancy rates in the county have declined dramatically in recent years.(8) But the area has also suffered a heavy loss of its former industrial base in the last decade and a half, and has a substantial poverty problem.(9)

   2. The Epidemic Continues in All Communities

      Recent statistics about slowing death rates from HIV can feed the misleading and dangerous public impression that we can heave a sigh of relief.(10) Death rates are down primarily because many people with HIV who have access to complex, expensive treatments are living longer.(11) The number of people with AIDS continues to grow, however, especially among women(12) and heterosexual men.(13)

      Unfortunately, HIV is a long way from being "a long-term manageable condition like diabetes."(14) The available treatments are quite complex, require meticulous compliance and monitoring, and are extremely expensive.(15) Moreover, for many patients, they do not work.(16) Even the hope offered by new drug "cocktails" is tempered with caution.(17) There are no studies on the long-term effects of these treatments, and there is now a suspicion that they will ... "`burn out.'"(18) The hope of AIDS' eradication is still just that. It is, and for the near future is likely to remain, a horrible disease.

      As the Chautauqua County story demonstrates, the effects of the AIDS epidemic is not relegated to "someplace else" or "somebody else"--it is not about "them." It is estimated that 30.6 million people world-wide are living with the HIV virus.(19) The death toll for 1997 was expected to reach 2.3 million.(20) If it can reach school-age girls in Jamestown, Chautauqua County, New York, it can reach anyone.

3. NEW YORK'S PUBLIC HEALTH LAW

   Our Public Health Laws Work and Must Not Be Dismantled

   As horrifying as the Williams case is, sensible public health laws kept it from being much worse. They certainly did not "get in the way." In 1988, New York State enacted Public Health Law Article 27-F.(21) Setting forth the guidelines for HIV testing and confidentiality, Article 27-F has a clear but often misunderstood purpose: to encourage people to be tested, so they can be counseled, have their sex and needle-sharing partners notified, and be offered treatment.(22) As legislators, we knew that to help bring about these results, people needed to be assured that their privacy would be protected.(23) We were applying long-established public health principles.(24)

   When Nushawn Williams was tested for HIV in September, 1996 (at the urging of staff at a Chautauqua County STD clinic), public health officials were given the opportunity to counsel him about the need to notify his sex partners.(25) When Williams started giving the names of the women with whom he had sex prior to learning of his HIV positive status, health officials used their clear power under the 1988 law to contact the women.(26) However, after providing those names, Williams continued to have unprotected sex with women after testing positive.(27) It was not until almost a year later that the Chautauqua County health investigator learned that Williams continued to expose women and girls to the HIV virus.(28)

   In the spring and summer of 1997, several women who were tested at local STD and family planning clinics were HIV positive and all described a partner who fit one description but used various street names.(29) Chautauqua County health officials, and the State Health official working with them, realized that the man at the center of this controversy was the same man they had dealt with months before, Williams.(30)

   At the suggestion of the health officials, many of the women identified Williams to law enforcement officials, who were brought in largely because some of the women were...