Interim report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic: Chairman's recommendations--Part I.

PIP: The Presidential Commission was created in September 1987 with the mandate to advise the White House "on the public health dangers including the medical, legal, ethical, social, and economic impact, from the spread of the HIV and resulting illnesses including AIDS, AIDS related complex, and other related conditions." This paper covers the Commission's interim policy recommendations as of March 15, 1988, in the areas of intravenous drug abuse, patient care, and basic research and drug development. The scope of recommendations in the area of intravenous drug abuse includes provision of treatment services, treatment research, drug abuse prevention, and outreach education. There must be a national policy of "treatment on demand" for drug users. An expanded program of drug treatment research must include research on cocaine as well as heroin addiction treatment. Drug abuse prevention should coordinate efforts at all levels of government as well as community and religious organizations and schools. Outreach education, which is especially difficult with drug users because drug use is illegal, will cost roughly $126.5 million a year over current funding. Outreach programs should train and utilize street outreach workers, including former addicts, and should have special focuses on adolescents, minorities, and women of childbearing age. The scope of recommendations in the area of patient care includes health care provider education, health care systems, psychosocial needs, nursing care, minorities and underserved populations, and information coordination and exchange. AIDS needs to be integrated into the educational curricula of medical and all other health professional schools. In the area of health care systems, the recommendations emphasize the need for integrated community-based services for people with HIV infection. 22 AIDS Service Delivery Demonstration projects are currently being conducted in the US, 13 funded by the US Public Health Service and 9 funded by the Robert Wood Johnson Foundation.^ieng

Pharmacologic modification of psychosexual dysfunction.

Sixty female and male outpatients with psychosexual dysfunction (sexual aversion/inhibited sexual desire, inhibited sexual excitement, and/or inhibited orgasm) participated in a comparison of the efficacy of bupropion hydrochloride vs placebo. Eight weeks of single-blind treatment with placebo was given at the outset to establish a baseline of sexual ratings/behavior and to eliminate placebo responders. Patients were then assigned randomly to 12 weeks of double-blind treatment with bupropion, 225-450 mg/day, or matching placebo. The onset of therapeutic sexual effects was gradual, but by the end of 12 weeks of treatment, significantly greater improvements were noted on the libido and global assessments of sexual functioning in the bupropion group. Sixty-three percent of the bupropion-treated patients reported themselves much or very much improved, compared with 3% for placebo. Changes in the frequency of sexual behavior, however, were much less dramatic and consisted largely of trends toward more sexual activity. To our knowledge, these results represent the first demonstration in a well-controlled clinical trial of an improvement in the psychological aspects of sexual dysfunction due to pharmacologic treatment.

The sexual aversion syndrome.

Sexual aversion is a widespread, poorly recognized syndrome occurring in both males and females. Once diagnosed, it is relatively resistant to conventional forms of therapy. Aversion is characterized by an unwillingness to get involved in sexual activity, with avoidance of any touching or communication that might lead to sexual involvement. This syndrome usually presents as a lack of libido, low sex drive, inhibited sexual desire or arousal dysfunction. Aversion may be seen along with other sexual dysfunctions, as a precipitating cause or as a consequence. However, aversion can also be the only dysfunction present. Once aversion is correctly diagnosed, identifying the type of aversion present is a prerequisite to appropriate therapy. Primary and secondary aversion are treated differently and have a different prognosis. This article describes the Sexual Aversion Syndrome, and distinguishes between primary and secondary aversion for the purpose of treatment and prognosis.

Initiation of erection and semen release by rectal probe electrostimulation (RPE).

Instrumentation and methodology are described for rectal probe electrostimulation (RPE) in human males to elicit erection and allow semen collection. This system virtually eliminates shock hazard; the simultaneous monitoring of current, voltage and impedance ensures reliability and repeatability. It was tested with 8 neurologically intact subjects, and 12 paraplegic patients with lesions between T4 and L2. Platinum electrodes delivered current (density never exceeding 0.37 mA per mm. at the electrode) at frequencies of 60 Hz, 20 Hz, and 0.25 Hz. Erection was elicited repeatably in only 1 of the intact subjects, and no seminal emissions or ejaculations occurred. Discomfort prevented current delivery beyond levels even 50 per cent of those safely acceptable. Six of 10 paraplegic patients (2 others had penile implants) developed erections with 20 Hz; the other 2 frequencies were much less effective. The extent of RPE-induced penile tumescence varied directly with electrode surface area and applied current intensity. Discomfort was minimal. Retrograde seminal emission in 5 of the 12 paraplegics was verified by post-stimulation recovery of sperm via voiding or bladder irrigation via catheter. Although motility was very low, 4 of 8 recovered bladder-urine/seminal fluid specimens indicated sperm counts and morphology consonant with use in artificial insemination. Thus, RPE, if combined with techniques to allow antegrade semen collection, may be a useful technique for spinal cord-injured men who, as part of their sexual rehabilitation, are interested in siring children.