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The death toll from AIDS is mounting daily. Prof. Stephen Jay Gould of Harvard warns that 25 percent of the human race could be swept away by the AIDS-causing human immunodeficiency virus (HIV) that wipes out the immune system and leaves the body vulnerable to a vast number of horrible diseases. Dr. William Haseltine, also of Harvard, has called the syndrome "species-threatening," and Dr. John Seale, a British Member of Parliament, informed that body that AIDS is "clearly a serious threat to the entire population." All of which has caused government and other leaders to demand that something, anything be done to slow the spread. It's the "anything" part that should have us worried.
So far, aside from research funds, most AIDS-targeted government money has gone for education. But the next big push is for mandatory testing to detect infection with the AIDS virus. Generally it is conservatives who advocate mandatory testing, although a few liberals have also joined the chorus.
The first problem with the rush to testing is that the threat it addresses has been grossly exaggerated. Contrary to popular belief, fueled by interests as disparate as scientists seeking greater research funds, gay rights groups, chastity-pushing conservatives, and headline-happy publications, AIDS is not "exploding" into the general population. It remains confined almost exclusively to homosexuals, intravenous (IV) drug users, recipients of blood products prior to 1986, and their steady sexual partners.
According to the Centers for Disease Control (CDC) in Atlanta, only about 2 percent of all diagnosed AIDS cases in this country have been attributed to heterosexual transmission in native-born Americans, a figure that has held steady for several years now. In New York City, the heterosexual AIDS capital of the United States, only 359 females out of 14,294 cases have been identified as having gotten AIDS from heterosexual intercourse; some partners in these cases are, of course, IV drug users or bisexuals. Even more dramatically, AIDS has been traced to heterosexual sex in only eight males. And if other health departments interviewed patients as carefully as New York does, screening out those who claim sex with women as their only risk when in fact they have had sex with men or shared needles, it's quite possible they'd find less than a score of such heterosexual men in the entire country.
Blood tests also indicate that the problem remains tightly confined to a few groups. The CDC estimates the prevalence of HIV infection in military recruits at 0.15 percent or less; excluding high-risk groups, at 0.02 percent or less. In first-time blood donors, CDC puts the figure at 0.04 percent or, excluding high-risk groups, an estimated 0.006 percent. Most importantly, both of these figures have held steady the last two years.
An article in April in the Journal of the American Medical Association estimates that people who avoid sex with a member of a high-risk group have only a one-in-five-million chance of infection per act of intercourse—about the same as one's chance of dying in an automobile accident in 10 miles of driving. Using a condom is estimated to reduce this risk to one in 50 million.
AIDS has been, and will continue to be, a problem for people who engage in those few acts—primarily needle sharing and anal intercourse—that allow transmission of the virus. Why should millions of others be physically violated through mandatory testing in order to reduce the riskiness of those risky activities?
While testing proponents invoke the procedure as a talisman, in their rush to do so they rarely stop to ask what the results will be used for. In fact, they even have trouble deciding on the ground rules. The term mandatory is regularly eschewed in favor of the pleasant-sounding routine, but what's in a name? Gary Bauer, assistant to the president for policy development, says routine testing means that individuals can refuse to be tested; but columnist William Safire has quoted him as admitting that "routine testing at the federal level does not include the right to opt out. "
Wholesale testing, whether mandated or routinely suggested, doesn't make sense. In the screening test that will be used, the enzyme immunoassay (EIA), a blood sample is mixed with a chemical that reacts to antibodies created by the body in reaction to HIV, usually within about six weeks of exposure. (Infrequently, individuals may not develop antibodies for more than a year, or not at all.) The test is intentionally oversensitive, to reduce the possibility of false negatives. If the EIA shows positive once or twice, indicating the presence of HIV, a far more accurate test, called a Western Blot, is applied.
Studies in both the United States and West Germany, along with observations of the effects of an AIDS-like virus in sheep, are leading to a consensus among researchers that virtually everyone infected with the AIDS virus will eventually become ill. It may not be wrong, then, to see a positive HIV test result (seropositive) as tantamount to a death sentence.
Because there is no known cure for AIDS, nor a confirmed preventative treatment that will keep HIV infection from developing into AIDS, testing in and of itself cannot save the lives of infected people. The test is useful only to the extent it can prevent new infections.
In this light, screening the blood supply makes sense: each infected pint screened may prevent several new infections, since whole blood is usually broken down into several components, and one infected recipient could infect others. With such a clear benefit, no organization today opposes such testing.
A good case can be made for testing of military recruits, as well. It relieves the armed forces of having to pay substantial medical costs and of the prospect of screening blood in field hospitals during the heat of battle. No other situation, however, is so clear.
Premarital testing is a microcosm of the mandatory testing debate. Vice-President George Bush, former Education Secretary William J. Bennett, White House aide Gary Bauer, and numerous other national figures have signed onto the mandatory premarital testing bandwagon. Bills introduced into the Senate and the House seek to force the states to mandate such testing, and two states—Illinois and Louisiana—have done so on their own. Surveys show that up to 85 percent of Americans favor premarital HIV screening.
Advocates give several reasons for such testing: Premarital testing was part of the broad national plan that helped break the back of the syphilis epidemic in the early part of the century. It will be cost-effective, because every new infection prevented will save tremendous amounts of money. It will prevent children from being born with the virus. Finally, it will give us a good idea of the extent to which the infection has spread beyond the drug-using and gay populations. None of these rationales, however, stands up to scrutiny.
• The syphilis analogy. One of the most revered myths of the pro-test lobby is that premarital testing for syphilis was a key in reducing the incidence of this crippling venereal disease. In fact, as Dr. Allan Brandt of Harvard Medical School notes, premarital testing was extremely cost-ineffective, detecting less than 1 percent of all syphilis cases found, with a tab as high as $250,000 per case detected.
With this poor cost-benefit ratio, on top of a general drop in the syphilis rate (a result attributable more to penicillin than to aggressive testing), 22 states have repealed their premarital blood test requirements since 1980 alone.
So far, the detection rate of HIV in premarital screening has paralleled the results of syphilis testing. In Illinois, of over 75,000 marriage-license applicants tested by the end of July, only 10 proved seropositive. Tests cost from $30 to over $100; assuming an average of $50 a test, this comes to $375,000 per case detected.
Those who justify this incredible expense in part by asserting that "none of the costs are borne by taxpayers" would be hard-pressed to explain how this is not a tax, and a very unwelcome one at that. In fact, marriage-license applications in Illinois are down 40 percent this year, while applications in Indiana and Wisconsin from Illinois residents are way up. Perhaps some individuals just don't want to know it if they're infected with the HIV virus, but according to an official at the Illinois Department of Health, most are seeking to avoid not the results but the expense.
The idea that premarital screening can be cost-effective in terms of cases prevented is based on one false assumption and one naive one. The false assumption is that health care for the remaining life of each AIDS patient can cost as much as $150,000 per case. In fact Blue Cross/Blue Shield, one of the nation's largest health insurers, is using the estimate of $80,000 per case.
The naive assumption is that somehow cases detected translate into additional cases prevented: the virus carrier, once notified, will take action to reduce the chances of passing it on. But even among those who have sought out testing, a disturbing percentage of victims of infection continue to engage in high-risk activity. One study reported in January in the Journal of the American Medical Association indicated that among homosexual and bisexual men voluntarily being tested, over 12 percent would not inform their primary partners if they proved seropositive and over 25 percent would not inform nonprimary partners.
Those who avoid testing until it is forced upon them are likely to act even less responsibly. Jim Johnson, an AIDS hospice director in Long Beach, California, testified in congressional hearings that 60 percent of the several hundred seropositives he's worked with—many of whom did intentionally remain ignorant of their status until they were diagnosed with symptoms—continued to engage in high-risk activity.
To ensure a preventative result from testing, a positive test result would have to result in permanent quarantine. But a virus that is so difficult to transmit—that literally has to be invited in—hardly justifies the loss of liberty involved in isolation of its carriers.
• Preventing AIDS babies. A study in New York City, the site of the scary figures we've been hearing on the high percentage of newborns with AIDS, found that 75 percent of HIV-infected infants are born to unwed mothers. Further, many women, married or not, choose to give birth even knowing they are seropositive. In neither case does premarital testing offer hope of prevention.
• Survey purposes. This is one of the more bizarre arguments for mandatory testing of people about to get married. Accurate surveying is possible using blood submitted for other reasons (for example, syphilis or hepatitis B testing) and not informing the donors. To mandate testing is to cause the testing cohort to be self-selecting, as has been the case with the fleeing Illinoisans. So the survey value of the test group is destroyed.
All these arguments for mandatory premarital testing are, however plausible, specious. But there is also a disturbing problem with screening low-risk populations.
As the media were quick to note when HIV testing came on the scene, there is the possibility of false positives. Usually retesting, as in using the Western Blot, solves the problem. But some individuals will cause a biological false positive, meaning their tests will consistently show evidence of the virus no matter how often repeated.
One such case was reported recently in the Journal of the American Medical Association. A woman complying with the Illinois law obtained a blood test that indicated positive on the EIA and indeterminate on the Western Blot. Retesting and testing a second blood sample still left things up in the air. This woman, who was at virtually no risk for HIV infection—her fiancé tested negative and she had had only one previous sexual contact—was turned into a nervous wreck two weeks before her planned wedding day.
Needless to say, one false positive can ruin your whole day. Some individuals have taken their lives after receiving positive HIV results.
Still, false positives are a trade-off in any medical test, and by medical standards the HIV one is very accurate. The problem is that in an extremely low-risk population, there will be so few true positives that the chance of a positive being a false one is quite high. A team of Harvard scientists has concluded that mandatory testing of 3.5 million marriage seekers under optimal conditions would result in detecting 1,200 infected persons who had not already transmitted the virus to their partners. But as many as 380 persons—a quarter of the positives—would be told they were infected when they weren't. According to current data on the prevalence of HIV infection, if 3.5 million New York City IV-drug users were tested (and of course there aren't that many), there would still be 380 false positives, but there would be almost 2.5 million true positives detected—a far more acceptable trade-off.
Given all the other drawbacks, the few cases detected in testing low-risk populations can hardly be worth it. Such is the conclusion Louisiana officials finally reached. In July that state repealed its premarital testing requirement, all parties to passage of the bill having admitted it was a gigantic flop.
Other forms of mandatory testing would almost certainly be more effective than premarital screening, but most suffer from the same drawbacks of low yields, high costs, and no assurances that those identified as infected will take action to avoid infecting others. One apparent major exception to the stricture against mandatory testing is so because it isn't really mandatory. In cases of contract, one party should have the right to demand a test of the other. So concern for the sake of the uninfected partner in a new marriage is met by allowing a prospective spouse to demand a test. Insurance companies should be free to insist that applicants submit to an HIV test, just as they are screened for other major-risk factors. If a hospital wants to test nonemergency patients in the belief this will enhance employee safety, it may do so. This is true of government entities, as well. With a volunteer force, military testing, for example, is part of a contract.
Since requiring a test can scare off the potential party to a contract, the first party has a clear disincentive to avoid such a demand unless it is deemed truly necessary. This serves as a control—a control that is nonexistent when the government forces an individual to be tested and notified of the results in order to be married or perhaps to avail himself of medical services.
The contract theory even applies to illegal contracts. Aside from the fact that there is scant evidence that prostitutes are spreading the AIDS virus, why should the government test prostitutes when a prospective customer can reduce the chance of infection by using a protective condom or—lest the thought not occur—can avoid sex with prostitutes? Does the government have the responsibility to protect the prostitute's customer from his own follies? For that matter, does it have the responsibility to protect someone who marries a partner who hasn't been tested? One of the supreme ironies of the mandatory-testing debate is that conservatives who speak so often of "getting the government off our backs" want to substitute overweening paternalism for choice.
In a movie by the comedy troupe Monty Python, a group of knights finds itself defenseless against a deadly beast that blocks its path. Under assault, they flee the area. "Would it help if we ran away some more?" asks one of the knights. The call for mandatory testing is understandable, but like the reaction of the Python knight and like so much of the nation's reaction to AIDS, it borders on the hysterical.
Under assault by an enemy of unknown yet often exaggerated strength, we find ourselves with no real weapons for defense save testing in those situations in which it can reasonably lead to transmission reduction. But testing beyond this point to defeat AIDS is like trying to run away more to defeat the Python beast. It won't work. Rights will be violated, funds will be squandered, and the course of the epidemic will be affected not one whit. Whatever the question, mandatory testing is not the answer.