HIV test~ill inth - Europe PMC

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been reported to Health Canada,6 and 42500 to. 45 000 more ... reported since 1984.12 Public health officials have .... the local medical officer of health.
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Anonymous

HIV test~ill inth

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SUMMARY Reported numbers of acquired immunodeficiency syndrome

ALICE LIN-IN TSENG, PHARMD

cases among Canadian aboriginal peoples are currently relatively low. However, any increase in

these numbers could have devastating human, social and economic costs. Education and prevention of human immunodeficiency virus transmission are the most efficient and cost-effective measures available today. This paper discusses the role of anonymous HIV testing in effective HIV prevention in the Canadion aboriginal population.

RESUME Actuellement, le nombre de cas de syndrome d'immunodeficience acquise rapportes dans les populations autochtones canadiennes est relativement faible. Toute augmentation de ce nombre pourrait toutefois avoir des effets devastateurs en termes de couts humains, sociaux et economiques. L'education et Ia prevention de Ia transmission du virus de l'immunodeficience humaine constituent les mesures les plus efficaces et les plus rentables disponibles aujourd'hui. Cet article discute du r8le du depistage anonyme du VIH pour prevenir efficacement le VIH dans Ia population

autochtone canadienne. Con hFm Physician 1996;42:1734-1740.

role of anonymous HIV testing as an THE PAST DECADE, increasing numbers of important component of effective human immunodeficiency HIV prevention in the Canadian virus infection and ac- aboriginal population. quired immunodeficiency syndrome cases have become international and Historical perspective national health concerns. Currently, Acquired immunodeficiency synthe number of AIDS cases in drome is the end stage of infection Canadian aboriginal peoples is rela- with HIV' The human immunodefitively low. However, these numbers ciency virus can be transmitted sexucould increase, with potentially devas- ally, by contact with blood or blood products or other bodily fluids, or tating consequences. Because HIV infection can be pre- perinatally from mother to infant.2 vented, the most efficient and cost- Infection with HIV leads to broad effective strategies for coping with the suppression of cell-mediated immuniepidemic include measures aimed ty. This in turn results in an increased toward education and preventing incidence of life-threatening opporHIV transmission. Through HIV test- tunistic infections and neoplasms.2 ing programs, seropositive individuals Since 1980, HIV infection and can be taught to modify risky behav- AIDS have become important global iour, thus preventing the spread of health problems. As of June 1994, HIV to others. However, many peo- more than 985 000 cases of AIDS ple, including members of the worldwide were reported to the World Canadian aboriginal community, are Health Organization.3 This figure is reluctant to be tested for fear of being considered to be underestimated, identified. This paper discusses the because reporting standards are inconsistent throughout the world. Dr Tseng is an HlVPharmacist at the The World Health Organization estiClinic in the of mates that about 4 million AIDS Immunodeficiency Department Pharmacy Services at The Toronto Hospital and cases have occurred worldwide and is a Lecturer in the Facul4 ofPharmacy at the that approximately 16 million people Universiy of Toronto. have been infected with HIV since VER

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the start of the pandemic.3 Long-term projections of HIV prevalence to the year 2000 have been calculated to be as high as 20 million cases.+ In Canada, more than 2000 people have died of AIDS-related causes over the last decade.' As of December 1994, 10 689 cases of AIDS had been reported to Health Canada,6 and 42500 to 45 000 more Canadians were estimated to be infected with HIV5 As ofJanuary 1994, 93 cases of AIDS had been reported among aboriginal peoples in Canada, representing 1.6% of the total number of AIDS cases in the country.7 This number is believed to be underestimated, because before 1988 physicians were not required to record ethnic origin on reports.8 Between 750 and 1500 aboriginal Canadians are currently estimated to be infected with HIV'

Risk factors for HIV transmission Several factors increase the risk of becoming infected with HIM These include engaging in unprotected sexual activity, lack of awareness, psychosocial and cultural barriers, and economic limitations. Most of these risk factors exist in both nonaboriginal and aboriginal groups.9'"' For this review, data specifically regarding the Canadian aboriginal population are presented whenever available. Failure to engage in safer sex practices is one of the strongest risk factors associated with transmitting HIM More than 40% of the men surveyed in the Ontario First Nations AIDS and Healthy Lifestyle Survey reported having sex with two or more partners during the previous year, often without using a condom." A high incidence of sexually transmitted diseases (STDs) is evidence of unprotected sexual activity. In 1989, the incidence of chlamydia in the Sioux Lookout Zone was 10 times the provincial average, while the incidence of gonorrhea was twice the provincial average.'0 In addition, genital inflammation and ulceration associated with many STDs could facilitate HIV transmission. Unsafe homosexual and bisexual practices are considered important risk factors for HIV infection. Intolerance of divergent behaviour exists in many cultures, including the Canadian aboriginal population. Cultural, societal, or religious pressures force many individuals to hide their sexuality

and lead a double life, placing their heterosexual partners at risk. General patterns of male and female prostitution are assumed to apply to individuals of all ethnic origins. Teenagers who run away to large cities often wind up on the street and resort to prostitution to survive, thus placing them at high risk of acquiring HIV Return of these individuals to their communities can then serve as a means of introducing HIV to even the most remote, isolated areas. Another facet of this issue is that people who travel to larger urban areas might engage the services of prostitutes and then infect their partners upon returning home. Once HIV is introduced to a community, transmission of the disease can be rapid. One recent example is Conception Bay north, Nfld (population 50000), where 41 cases of HIV infection have been reported since 1984.12 Public health officials have suggested that HIV was introduced into the community by a local man currently serving a jail sentence for knowingly infecting two young women via unprotected sex despite a court order. A false sense of security, of being "safe" from HIV in a rural setting, combined with the failure of some residents (including teenagers), to engage in safer sex practices, probably contributed to the propagation of HIV in this small community.'2 In the First Nations survey, 450% of respondents in northern Ontario had never heard of AIDS. " Many also perceive AIDS as a "white man's disease," and 710% of those surveyed felt certain they were at no risk of contracting HIVM' These misconceptions discourage people from practising safer sex. Sexually transmitted diseases mostly affect people younger than 30. Many risk-taking behaviours are linked to adolescent experimentation, such as alcohol or drug use, although this was not found to be the case in the First Nations survey11 In addition, younger people often believe they are less vulnerable to acquiring HIM Approximately 67% of the Canadian aboriginal population is younger than 30.8 Therefore, AIDS could have a huge effect on this relatively young community. Failure to recognize HIV as a threat could be in part because targeted HIV education and prevention programs are currently unavailable.

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In Canada, the largest groups affected by HIV have been homosexual and bisexual men and injection drug abusers. However, the number of AIDS cases attributed to heterosexual activity continues to rise faster than cases attributed to any other cause.'3 Consequently, the number of women and children diagnosed with AIDS is also increasing. In the aboriginal community, most people affected by HIV have been heterosexual. Currently, aboriginal women appear to have a greater incidence of AIDS (ie, as a proportion of all aboriginal AIDS cases) than Canadian women in general (25% versus 6.3%).'° Birth rates among aboriginal people are more than twice the national average; the number of teenage pregnancies is increasing.8 Since prevention programs to date have not specifically targeted heterosexuals, many people (both aboriginal and nonaboriginal) are not receiving full benefit from these programs. When studying the potential impact of HIV, the general health of the population must be considered. Evidence suggests that, after infection with HIV, the disease is more rapidly expressed among individuals whose immune systems have been chronically activated.9 A high incidence of seriously debilitating disease, such as anemia, diabetes, gallbladder disease, infectious and parasitic diseases, and lung disease, has been observed among aboriginal Canadians.8"' In general, life expectancy for this group is 10 years less than the national average.8 Finally, many rural communities lack information as well as access to appropriate health care; these factors could obstruct intervention for HIV diagnosis and management.

Need for prevention Acquired immunodeficiency syndrome is a very costly disease. In addition to exacting a very high toll of human lives, AIDS places a great financial burden on our health care system. Direct medical costs incurred in treating and preventing HIV infection and AIDS include costs associated with inpatient and outpatient care, drugs, home care, and health professionals' services, as well as screening, counseling, education, administration, and research.

The direct medical costs of caring for an AIDS patient for the duration of the illness is currently estimated to be $100000.1' These costs will continue to increase as newer and more expensive drugs are developed and prescribed earlier in the course of HIV disease. The indirect cost to society takes into account lost opportunity and lost productivity, and is roughly equivalent to a patient's productive capacity. Most people currendy infected are between 20 and 49 years old.5 Thus, the indirect losses to Canada are high and are estimated to cost the economy $300 000 to $800 000 for each HIV-infected person.'3 In some areas of the United States, AIDS has become the leading cause of premature death among people between 25 and 44 years.'5 Unfortunately, no medical solution to AIDS is available. As with any other STD, education and prevention remain the primary methods of limiting the spread of HIM If 1000 new cases of HIV infection were prevented, a minimum of $100 million in direct medical costs would be saved.

Seropositivity testing Currently available tests can detect HIV antibodies. In Canada, there are generally four purposes for HIV testing: to identify and reject blood, tissues, or organs donated by infected persons; to establish a differential diagnosis; to identify persons who should be counseled about HIV; and to gather epidemiologic data. For those who are HIV-negative, obvious benefits of testing include decreased anxiety and freedom to engage in unprotected sexual activity with uninfected partners. Negative test results also enable women to become pregnant without fear of transmitting HIV perinatally. Negative results can also motivate people to avoid exposure to HIV in the future. Individuals diagnosed with HIV infection can be referred to appropriate medical and support services. Often, HIV testing serves as the entry point to the health care system. Individuals might be motivated or persuaded to seek out their previous contacts to notify them of potential infection. Seropositive individuals should be counseled to avoid engaging in activities that could pose a health risk to them or transmit HIV to others.

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An HIV test can be performed under three formats: nominal, nonnominal, and anonymous. Privacy, autonomy, and individual rights are protected to varying degrees depending on the testing format. With nominal testing, results can be linked to the person tested by a personal identifier (ie, code or name). If test results are positive, physicians are legally obliged to report the patient's name to the local medical officer of health. Under the Health Protection and Promotion Act, the medical officer of health is legally obliged to safeguard the person's confidentiality. The medical officer of health is also legally responsible for ensuring the person's sexual and drug use contacts are notified. With nonnominal testing, a code without personal identification is used to link the results to the person tested. The code is known by that person and the physician, but is not reported to public health authorities. The physician and patient both take responsibility for notifying partners who have been exposed. The local medical officer of health will check with the physician about the case and, if satisfied that partners have been notified, will not ask for the person's name. Anonymous testing is the least intrusive method of testing. Results can be linked to the person by a code known only to that person. That person is then responsible for notifying partners but can ask a counselor for assistance. The anonymous testing program is based on several principles. The first is that people who are at very high risk of acquiring HIV are often the most reluctant to seek testing because of fears of losing confidentiality. It is hoped that the guarantee of anonymity will encourage high-risk individuals to come forward for testing. Kegeles et al'" demonstrated via self-administered questionnaires that all sexual orientation and identification groups were reluctant to obtain testing if anonymity were not assured. In fact, believing that one was infected with HIV was associated with a slightly decreased inclination to obtain testing if anonymity could not be guaranteed. People who know that they are HIV-positive are more likely to practise safer sex than those who do not know their HIV status. Once infected individuals present themselves, they can receive appropriate education and counseling. Decreased

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high-risk behaviour has been observed in people who have sought anonymous or confidential HIV-antibody testing accompanied by counseling. Finally, by encouraging testing among high-risk populations who otherwise would have avoided testing, more reliable seroprevalence data can be collected and reported. This in turn allows more precise monitoring of the HIV epidemic, more accurate measurement of the effects of intervention programs, and more appropriate allocation of future health care resources. Table 1. Increasing AIDS awareness among the Canadian aboriginal population: Programs with thefollowing characteristics have greater chances ofsuccess. Holistic: Adopt a holistic approach; educational programs should be directed not only toward those likely to become infected with HIV but also toward members of aboriginal communities who will be required to lend support. Positive: Approach should be positive, rather than critical of past behaviour.

Empowering: The program must support the community and individuals in their efforts to take responsibility. Sensitive: Educators must be cognizant of and sensitive to different views of sexuality. Accessible: Programs must cnsure equity of access for all aboriginal individuals and communities.

Community based: Activities should be designed and delivered within the community using common language, customs, and traditions. Integrated: Programs for HIV and AIDS education should include messages about preventing other STDs.

Linked with existing AIDS activities: Io help develop some of these ideas, linkages should be established with other AIDS groups. Audio-visual media: Campaigns should make maximum use of audio-visual media to accommodate different literacy levels and languages among aboriginal gToups.

Culturally transportable: As much as possible, messages should be adaptable and culturally transportable to meet the information needs of many. Ongoing: General awareness campaigns should be ongoing rather than on a one-time basis. Adaptedfrom the Joint National Committee on? Aboriginal AIDS Education and Prevention.9

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So far in Ontario, anonymous testing programs account for about 5% of specimens received for testing. The first results of these programs indicate that they attract individuals with risky behaviours (particularly bisexual men). Also, the prevalence rate among anonymous specimens is significantly higher than among specimens collected under other formats (ie, 3.3% positive with anonymous versus 2.5% nonnominal and 0.7% nominal).'7 These preliminary observations suggest that anonymous testing is successful in attracting high-risk individuals who otherwise would not come forward for testing. Table 2. Developing, maintaining, and evaluating anonymous HIV testing programs for Canadian aboriginal people: Programs with tle following characristics are likely to have greater chances ofsuccess. Facilitative: Assist and support those who will assume day-to-day responsibility for running the anonymous HIV testing program. Long-term, consistent, and periodic: Ensure that long-term efforts are planned with consistent messages, and incorporate periodic updates to generate continuous interest. Visible: Aboriginal leaders should be seen and heard to support HIV testing (as part of the overall AIDS education and prevention strategy).

Supported: Once anonymous HIV testing has been identified as a required service, the necessary support for responsiblc staff (ie, training and resources) should be available. Adaptedfrom the Joint National Committee on Abonrginal AIDS ELducation and Prevention. 9

Anonymous testing in the aboriginal population Anonymous HIV testing is suitable for the Canadian aboriginal population because it ensures patient confidentiality, and thus encourages individuals to undergo testing. However, several challenges currently exist: increasing overall AIDS awareness and implementing anonymous testing programs. Many aboriginal communities do not view AIDS as a priority, in part because of other day-to-day health and social problems. A member of the First Nations Steering Committee stated, "First Nations communities are still facing

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contaminated water supplies similar to Third World conditions."" Other factors, such as unemployment, poverty, poor housing, poor sanitation, and [lack of] running water, are given priority over disease prevention. Attention must be directed toward improving the overall standard of living in aboriginal communities and correcting social problems experienced by members of this population. Once the basic determinants of health have been addressed, efforts can be concentrated on HIV and AIDS. Another reason HIV and AIDS are often not regarded as a priority in aboriginal communities is the misconception that HIV is a "white man's disease." Educational programs to increase awareness of HIV among aboriginal people need to be developed, ideally in keeping with the principles suggested by the Joint National Committee on Aboriginal AIDS Education and Prevention (Table 19). These principles include encouraging a holistic, community-based approach to increase HIV awareness, in a nonjudgmental, culturally sensitive manner. Whenever possible, activities should be integrated with other public health programs and linked to existing AIDS service organizations.

Even when communities recognize the issues and potential threat of AIDS, lack of resources and government funding are important obstacles. Because aboriginal people make up a small proportion of the total Canadian population, the number of reported cases of HIV is relatively small. Governments could mistakenly perceive this as an indication that HIV is not a serious problem. Logistic, linguistic, cultural, societal, and financial issues affect implementing anonymous HIV testing programs in aboriginal communities. Accessibility to testing facilities is limited for many people because many aboriginal communities are quite isolated. Traveling to another community for anonymous testing often involves considerable time and expense; anonymous testing programs could operate in conjunction with existing STD clinics or other health facilities. Mobile public health units could also be equipped to handle requests for HIV testing. Another barrier is the limited number of health

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care workers in rural communities. Appropriate incentives could encourage health care professionals who are adequately trained in HIV and AIDS therapy to practise in the isolated, rural areas of the country. Reluctance to use a testing centre can stem from language barriers, cultural nuances, or preference for traditional healing options. Aboriginal languages tend to be limited and conservative in their vocabulary for-describing sexual activities. Difficulty in communication hinders pretest and posttest counseling, which are mandatory elements of the anonymous testing service. Language barriers can be minimized by training and recruiting people who are fluent in aboriginal languages. Medical personnel should also be sensitive to aboriginal cultural nuances and traditions. Professionals can adapt the characteristics outlined in Table I9 to one-to-one communication. Physicians also need to keep an open mind about the use of traditional healing in conjunction with Western medical therapies. Although anonymous testing programs are designed to preserve patient confidentiality, anonymity can be difficult to maintain in small communities. Active participation in and support of HIV testing by influential community leaders will help to acknowledge the threat of HIV, reduce cultural prejudices, and encourage acceptance of individuals infected with HIV In this way, high-risk individuals will be encouraged to come forward for testing. Finally, federal, provincial, and municipal governments need to work closely with leaders of aboriginal communities in ceveloping, maintaining, and evaluating anonymous HIV testing programs. Coordination between different levels of government will ensure efficient use of manpower, appropriate allocation of resources, timely institution of programs, .and rapid identification and correction of problems (Table 29).

Conclusion Human immunodeficiency virus infection could spread quickly through the relatively young Canadian aboriginal community, with potentially devastating consequences. Through HIV testing programs, seropositive individuals can be

identified and then educated to modify their risky behaviour, thus preventing the spread of HIV to others. Many people, however, especially those in high-risk categories, are reluctant to be tested because they fear being identified. Anonymous HIV testing is appropriate for the aboriginal population. Yet the cultural, social, political, geographic, and language differences that separate the aboriginal community from mainstream Canadian society must be addressed before anonymous testing is feasible. Correspondence to: Dr A. Tseng, Immunodeficiency Clinic, Toronto Hospital, General Division, College Wing G-315, 101 College St, Toronto, ON M5G 2C4; telephone (416) 340-5077, fax (416) 340-4890

References 1. Revision of the CDC surveillance case definition for AIDS. _AMA 1987;258:1 143-9. 2. Redfield RR, Burke DS. HIV infection: the clinical picture. SciAm 1988;259:90-8. 3. World Health Organization. WHO global AIDS statistics. MOly Epidemiol Rec 1993;68:9-10. 4. ChinJ, Sato PA, MannJM. Projections of HIV infections and AIDS cases to the year 2000. Bull World Health Organ 1990;68: 1 -1 1. 5. HIVand AIDS: Canada's blueprint. Ottawa, Ont: Health and Welfare Canada, 1990. 6. Division of HIV/AIDS Epidemiology, Bureau of Communicable Disease Epidemiology, Laboratory Centre for Disease Control, Health Canada. Quarterly surveillance update: AIDS in Canada. Ottawa, Ont: Health Canada, 1995. 7. AIDS Information and Education Services, Health Services and Promotion Branch, Health and Welfare Canada. Facts about AIDS and aboriginal peoples. Ottawa, Ont: Health and Welfare Canada, 1995. 8. AIDS Information and Education Services. Facts about AIDS and aboriginal peoples. Ottawa, Ont: Health and

Welfare Canada, 1992. 9.Joint National Committee on Aboriginal AIDS Education and Prevention. Recommendationsfor a national strategy on aboriginal AIDS education and prevention. Ottawa, Ont: Health and Welfare Canada, 1990. 10. McCrimmon M, Hunter L. HI V/drug use needs assessment for northern Ontario. Toronto, Ont: Ontario Ministry of Health, 1991.

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ibuprofen

IDENTIFICATION Ibuprofen CLASS Non-steroidal Analgesic/Antipyretic

INDICATIONS Temporary relief of headaches, minor aches and pains, dysmenorrhea, dental pain, fever

CONTRAINDICATIONS 1. Hypersensitivity to the drug 2. Known peptic ulcer disease or GI bleeding 3. Known inflammatory disease of gastrointestinal tract 4. ASA hypersensitivity disorder 5. Patients on anticoagulant/or with intrinsic clotting dysfunction 6. Systemic lupus erythematosus - may cause aseptic meningitis 7. Preexisting asthma 8. Pregnancy, nursing mothers or children under 12

WARNINGS 1. Safety in pregnancy not established 2. Safety in breast-feeding mothers (for newborn) not established 3. Ibuprofen is not approved for use in children in Canada 4. As for other NSAIDs, serious GI side effects are possible, particularly at higher doses 5. Consider lowering dose for elderly or frail individuals 6. Should not be administered to patients with ASA-sensitive asthma and should be used with caution in patients with preexisting asthma

USE WITH CAUTION IN PATIENTS EXHIBITING: 1. Preexisting renal disease 2. Preexisting liver disease 3. Cardiac failure, cardiac dysfunction, hypertension 4. Renal dysfunction 5. Dehydration, severe debility, old age 6. Unusual visual effects 7. Preexisting gastrointestinal disease 8. Underlying hemostatic defects 9. Systemic lupus erythematosus POTENTIAL DRUG/DRUG INTERACTIONS 1. ASA/non-steroidal antiinflammatory agents GI toxicity 2. Corticosteroids - augmented GI toxicity 3. Antihypertensives - may interfere with BP control 4. Anticoagulants - may augment bleeding tendency 5. Alcohol - augmented GI toxicity 6. Methotrexate - may augment toxicity methotrexate 7. Digoxin - may elevate blood levels digoxin 8. Lithium - may elevate blood levels lithium 9. Diuretics - may interfere with effectiveness and BP control - augmented

ADVERSE EFFECTS 1. Gastrointestinal (4-16%) Nausea, epigastric pain, heartburn (3-9%) Diarrhea, abdominal cramps or pain, fullness of the GI tract (1-3%) Gastric or duodenal ulcers with bleeding and/or perforation, gastritis, GI haemorrage, melena (less than1 %) 2. Allergic (less than 1 %)Anaphylaxis, syndrome of abdominal pain, fever, chills, nausea, vomiting, bronchospasm, serum sickness, lupus erythematosus syndrome and Henoch Scholein vasculitis

3. Central nervous system (4-13%)Dizziness, headache, nervousness, depression, insomnia, confusion, emotional lability, somnolence, aseptic meningitis 4. Dermatologic (4-13%) Rash, pruritus, vesiculobullous eruptions, urticaria, erythema multiforme, alopecia, Stevens-Johnson syndrome, toxic epidermal necrolysis and photoallergic skin reactions 5.Cardiovascular (less than 1 %) Congestive heart failure, elevated blood pressure and palpitations 6. Special senses (2-4%) Tinnitus, blurred and/or diminished vision, scotomata and/or changes in colour vision 7. Hematologic (1-20%) Decrease in hemoglobin, anemia, leukopenia, hemolytic anemia, thrombocytopenia, neutropenia, agranulocytosis, aplastic anemia and eosinophilia 8. Renal (1-9%) - Decreased creatinine clearance less than 1 %: Acute renal failure in patients with preexisting significantly impaired renal function, cystitis, hematuria, polyuria, azotemia and interstitial nephritis, nephrotic syndrome and renal papillary necrosis 9. Hepatic (less than 1 %) Hepatitis, jaundice, abnormal liver function 10. Metabolic (1-3%) - Decreased appetite, edema, fluid retention 11. Miscellaneous (less than 1 %) Dry eyes and mouth, gingival ulcer and rhinitis

DOSAGE Adults and Children over 12: 1 or 2 tablets (caplets) every 4 hours, not to exceed 6 tablets in 24 hours. Should not be taken for pain for more than 5 consecutive days or for fever, if not improved, for more than 2 days without first consulting a physician. SUPPLIED Caplets: Each white, film-coated caplet contains: ibuprofen 200mg. Nonmedicinal ingredients: carbon black, carnauba wax, cornstarch, hydroxypropyl methylcellulose, pharmaceutical glaze, propylene glycol, silicon dioxide, stearic acid, titanium dioxide. Bottles of 24, 50 and 100. Tablets: Each white, film-coated tablet contains: ibuprofen 200mg. Nonmedicinal ingredients: carbon black, carnauba wax, cornstarch, hydroxypropyl methylcellulose, pharmaceutical glaze, propylene glycol, silicon dioxide, stearic acid, titanium dioxide. Bottles of 24, 50 and 100.

The Full Product Monograph is available to physicians and pharmacists on request from McNeil Consumer Products Company Geulph, Canada N1K 1A5

11. Myers T, Calzavara LM, Cockerill R, Marshall VW, Bullock SL, First Nations Steering Committee. Ontario First Nations AIDS and healthy lfrestyle survey, 1993. Ottawa, Ont: Ontario Ministry of Health and Health and Welfare Canada, 1993. 12. Bergman B, Welbourn K. Outport outrage: Newfoundlanders feel stigmatized by the Red Cross. Maclean's 1995 April 17:16. 13. The Canadian AIDS Society, The Canadian Association for HIV Research, The Canadian Hemophilia Society, The Canadian Public Health Association. No timefor complacency. Ottawa, Ont: The Canadian AIDS Society, The Canadian Association for HIV Research, The Canadian Hemophilia Society, The Canadian Public Health Association, 1993. 14. Kendall PRW. The Native Canadian communi_y in Toronto. Toronto, Ont: City of Toronto Department of Public Health, 1989. 15. Centers for Disease Control and Prevention. Acquired immunodeficiency syndrome - United States, 1994. MMWR Morb Mortal W/ly Rep 1995;44:64-7. 16. Kegeles SM, CataniaJA, Coates TJ, Pollack LM, Lo B. Many people who seek anonymous HIV-antibody testing would avoid it under other circumstances. AIDS 1990;4:585-8. 17. Major C. Lessons learnedfrom anonymous testing in Ontario. Toronto, Ont: Ontario Ministry of Health, 1993.

For further reading

® Registered Trademark of The Upjohn Company © 1996

Canadian Medical Association. Acquired immunodeficiency syndrome: a CMA position. Can Med AssocJ3 1989; 140:64A-64B. Health and Welfare Canada. National AIDS strategy. Phase I: significant highlights. Ottawa, Ont: Health and Welfare Canada, 1993.

PAAB

Royal Society of Canada. AIDS: a perspectivefor Canadians. Summary report and recommendations. Ottawa, Ont: Royal Society of Canada, 1988.

CCPP

(MCNEIL

McNEIL CONSUMER PRODUCTS COMPANY

Guelph, Ontario

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StrykerJ, Coates TJ, DeCarlo P, Haynes-Sanstad K, Shriver M, Makadon HJ. Prevention of HIV infection: looking back, looking ahead. JAMA

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