Aware of the growing challenge for public health authorities represented by a new and severe health hazard, the Human Immunodeficiency Virus (HIV) infection, transmissible by sexual intercourse, through the blood, during pregnancy and perinatally, and which can induce a variety of conditions such as AIDS, Aids Related Complex (ARC), various cancers, neurological and other disorders, as well as some problems with respect to healthy carriers;

Conscious that there is at present neither vaccine nor cure for AIDS;

Considering that, under these circumstances, HIV infection will dangerously increase and spread in the population if no immediate and effective preventive action is taken;

Considering that such an epidemic will represent a very heavy burden for health services and social security systems, and will have serious economic consequences;

Considering that it may also pose ethical, legal and social problems in terms of stigmatisation and discrimination;

Bearing in mind the Convention for the Protection of Human Rights and Fundamental Freedoms;

Recalling its Recommendations No. R (83) 8 and No. R (85) 12 concerning the screening of blood donors for AIDS markers;

Judging that the implementation of a harmonised comprehensive preventive policy at European level may effectively limit the spread of the disease,

In the light of present knowledge, recommends the governments of member states to:

I. declare the fight against AIDS an urgent national priority;

II. carefully devise, in the light of socio-cultural contexts, the most appropriate public health policy for the prevention of AIDS by drawing up a comprehensive strategy consisting of programmes and measures which:

- are scientifically justified and expedient to impede the spread of the infection with a view to the protection of the health of citizens, and

- do not interfere unnecessarily with their individual rights to objective information, freedom and private life;

III. follow to this end the guidelines set out in the appendix to this recommendation;

IV. intensify co-operation within Europe in pursuing studies on specific aspects of the control of AIDS with a view to :

1. assisting national health administrations in continuously adjusting their public health policy to actual requirements;

2. optimising the effectiveness of such policies by avoiding duplication of efforts through exchange of information, comparison and assessment of strategies;

3. identifying common areas of research in the field of AIDS prevention, diagnosis and treatment, for which specific funds should be allocated;

4. achieving a concerted harmonised European policy in the fight against AIDS.

Appendix to Recommendation n� R (87) 25

Guidelines for the drawing up of a public health policy to fight AIDS

1. Co-ordinating committees

Those governments which have not yet done so, should urgently set up co-ordinating committees at national, regional and local levels in keeping with the size and administrative structure of the country.

1.1. Task of the committees

The task of the national committee should consist in the drawing up of a public health policy for the prevention of AIDS taking into account the complex implications at strategical level (for the essential elements of this policy, see Item 2 hereafter).

The appointment of regional and local committees should serve as a means of ensuring a regular flow of information and vertical and horizontal co-operation in the implementation of the policy and co-ordination of actions.

The national committee should monitor the implementation of the policy by instituting an appropriate feedback system for permanent revision and adaptation of the policy.

Resources should be made available, both in terms of finance and personnel, to implement the nationally agreed policy at regional and local levels.

1.2. Membership of the committees

Membership of the national committee should include, for example, representatives of relevant governmental sectors: health, social affairs, social security, education, research, etc.

The national committee should seek the advice of experts in various fields, interested parties, health staff, associations and organisations, whether public or private, whose work is relevant to AIDS prevention.

The membership of regional and local committees should include the same representatives at the corresponding level so as to reflect all concerned interests.

The committees, whether national, regional or local, should be set up in such a way as to :

- ensure a balanced approach integrating the various aspects and issues involved;

- facilitate the drawing up of a consensus policy taking into account the various interests and allowing for an optimal use of scarce resources.

2. Formulation of a public health policy : essentials

The national AIDS committee should draw up a comprehensive policy based on an agreed strategy consisting of a series of coordinated and consistent programmes in a variety of complementary fields, combining :

- prevention:

. health information programmes directed at the general public;

. health education programmes targeted on groups at particular risk;

. health promotion programmes;

- public health regulatory measures;

- strengthening of health care services;

- training of staff;

- evaluation and research.

2.1. Prevention: health information, education and promotion

National health administrations should concentrate their efforts on preventive measures aimed at behavioural change to control the epidemic since these are of singular importance as long as a vaccine and cure have not been found.

To this end, a health communication strategy should be devised at the national level taking account of the views of health education, mass communication and social science experts, professional advertisers, etc. ; such a strategy should be based on the following programmes which will respectively bear short-, medium- and long-term effects:

- health information programmes directed at the general public with a view to maintaining awareness, avoiding panic reactions and preparing for targeted health educational activities;

- health education programmes directed at groups particularly at risk with a view to achieving behavioural change;

- health promotion programmes with a view to helping individuals in choosing healthy life-styles.

2.1.1. Health information programmes directed at the general public

The objective should consist in counteracting misinformation, prejudice and fear by raising the level of knowledge about the modes of transmission, the spread of the infection and the risk associated with behavioural patterns. The public should be informed of measures to prevent infection and, in particular, that sexual transmission may be prevented by careful selection of sexual partners, by avoiding casual sexual contact and by the use of condoms.

Special attention should be paid to the media, whose role in shaping public opinion is crucial; a strategy should be adopted to favour responsible reporting on the subject; to this end dossiers should be regularly prepared and made available to the press.

2.1.2. Health education programmes targeted on groups particularly at risk

Such programmes should be planned on a medium-term basis, as their main objective, behavioural change, cannot be reached overnight.

Three overriding principles should permeate health education activities :

- behavioural change depends on the attitude of the individual;

- the individual is responsible for the outcome of his behaviour towards himself, others and society;

- the individual must be treated with dignity and respect.

No health education programme (primary prevention) should be initiated if not backed up by secondary and tertiary prevention facilities (that is, sites for voluntary testing, counselling, treatment and psycho-social support services).

Target groups to be considered may vary in size from country to country and programmes and activities should reflect this variability; however, in view of the transmission modes, the following should in any case be taken into account:

- intravenous drug users,

- men with homosexual contacts,

- prostitutes,

- customers of prostitutes,

- "sex tourists", coming from or travelling to ares where AIDS is endemic,

- haemophiliacs,

- people staying in or travelling to areas with a high prevalence of AIDS,

- the prison population,

- adolescents.

2.1.3. Health promotion programmes

Sex education should be integrated in a wider reflection on life-styles and human relationships. Such programmes should encourage individuals to assume responsibility for their health by becoming aware of risks and benefits inherent in various life-styles.

2.2. Public health regulatory measures

In the light of present knowledge, given the absence of curative treatment and in view of the complexity of the epidemic, the implementation of the following public health measures is to be considered essential to limit the spread of HIV infection.

2.2.1. Screening

- systematic screening programmes should be fully implemented in respect of donations of blood, mothers' milk, organs, tissues, cells and, in particular, semen donation in compliance with the usual strict requirements of informed consent and regulations for confidentiality of data; for greater security, heat-treatment or other inactivation procedures of plasma products should continue to be enforced; self-exclusion from donation should continue to be strongly recommended to individuals with high-risk behaviour;

- there should be no compulsory screening of the general population nor of particular population groups;

- health authorities should instead invest resources in the setting up of sites - when these do not already exist - for voluntary testing fully respecting confidentiality regulations, and for arranging under the same conditions contact tracing of partners of seropositives;

- voluntary testing should be backed up by counselling services which should be readily accessible or even free of charge;

- the identification, where necessary, of groups to whom to recommend voluntary testing should be decided upon by health authorities in close co-operation with experts in the field; the identification on the basis of risk factors of cases to whom to recommend voluntary testing should be the task of medical staff;

- quality of testing should be ensured through the appointment of reference centres.

2.2.2. Other measures

- public health regulatory measures such as health controls, restriction of movement or isolation of carriers, should as a general rule not be introduced on a compulsory basis;

- in the light of present knowledge, discriminatory measures such as control at borders, exclusion of carriers from school, employment, housing, etc. should not be introduced as they are not justified either scientifically or ethically.

2.2.3. Information relating to seropositivity

- individuals, whether donors or not, should be informed of a confirmed positive result of a blood test; they should be referred to competent medical and counselling services to be informed of precautions to be taken to protect their own health and to avoid spreading the infection to other individuals;

- if they take appropriate measures, health staff can usually avoid contamination; patients should, therefore, themselves be left to advise health staff of their seropositivity unless the patient has specifically authorised a doctor to pass on this information.

  2.2.4. For the purposes of gaining insight into the epidemiology of HIV infection

- the reporting of AIDS cases in strict compliance with confidentiality regulations is strongly recommended;

- where implemented, the reporting of seropositivity should also be carried out in strict compliance with confidentiality regulations;

- the setting up of epidemiological studies of representative samples or cohorts of the general population and groups with risk behaviour on a voluntary basis and in compliance with regulations of confidentiality and anonymity is to be considered essential in identifying risk factors associated with seropositivity and changing patterns of the disease.

2.3. Strengthening of health care services

Flexible plans consistent with the epidemiological projections and capable of efficiently meeting increasing needs should be drawn up; in this respect the responsible health authorities should :

- ensure adequate in-patient facilities or reinforce existing in-patient units for the treatment of AIDS and related conditions, staffing them with multidisciplinary teams;

- organise out-patient facilities supported by community care services allowing patients to maintain as much as possible a private and a social community-integrated life;

- organise psycho-social support services for in- and out-patients as well as for asymptomatic carriers, their partners and families.

2.4. Training of staff

Appropriate training programmes should be organised for all categories of health staff, especially for those working in the field of diagnosis, treatment, control of transmission of infections, psychological support and terminal care.

Staff in the social services should be trained in the implementation of policies and regulations, as well as in patient and family assistance and psychological support.

Staff who may have occupational exposure to infected fluids and secretions should be kept informed of sensible hygienic precautions to be taken both for themselves and for their clients.

Training for teachers should be organised to allow them to integrate AIDS prevention in health education.

2.5. Evaluation and research

Development of research and co-operation at European level through the designation of reference centres in all AIDS-related fields is an urgent priority to combat AIDS, would be of great benefit both in terms of effectiveness of programmes and costs, and should therefore be strongly supported by national health administrations.