Counseling Needs Considered for Any Mandatory AIDS Test

The young woman, married and the mother of a 6-month-old child, had just learned that she had AIDS, contracted from a transfusion several years earlier. While absorbing the tragic news, her husband asked her physician whether he should take the AIDS antibody blood test to see if he had become infected.

Experienced in treating AIDS, the doctor told him yes--that it was important for him to know. But he advised him first to examine his insurance policies to be certain that they were complete and up to date, so that he would not be denied coverage in the future if his test was positive.

This scene, which occurred last week in a large hospital in the Northeast, vividly illustrates the kind of counseling that results from a necessary awareness of the deadly disease’s political and social ramifications--and that many say should accompany the controversial procedure at all times.

Suggestions Criticized

But critics of suggestions made by federal health officials to vastly expand mandatory AIDS testing, among other proposals, to patients routinely admitted to hospitals and couples applying for marriage licenses, warned that it will be impossible to conduct appropriate counseling on such a massive scale. And others predicted that widespread mandatory testing eventually would create a “caste” society between the infected and the uninfected, with little impact on curbing the epidemic.

Federal health officials considering whether to recommend the proposals to the states, which ultimately will decide the issue, argue that individuals who know their status will be motivated to engage in “safer” sex practices--either to remain uninfected or to avoid transmitting the virus to others. Further, they say, it will enable the public health community to get a firmer grasp on the epidemic.

“We need to know what’s going on, community by community, to track this epidemic,” said Dr. James O. Mason, director of the Atlanta-based federal Centers for Disease Control. “How would you like to drive down the road with a blanket over the windshield? In our desire to protect the rights of individuals, we don’t have enough public health information to know what’s working or what isn’t working.”

A Diagnostic Tool

The test, which determines whether an individual has been exposed to the AIDS virus--but not whether he or she will contract the disease--has been the subject of intense controversy since it was introduced in 1985 to ensure safety of the nation’s blood supply.

During its two years of use, the test has also gained increasing acceptance as a diagnostic tool to identify whether an individual is infected and infectious to others. However, there is no medical treatment for infection.

Mandatory testing has already been adopted by the military, the State Department and the Labor Department’s Job Corps program.

But many medical and public health personnel, gay rights and civil liberties groups have argued against its widespread and mandatory application, fearing that test information--unless kept confidential or anonymous--would result in stigmatization and be used to discriminate in such areas as employment, life insurance and medical insurance.

Insurers Want Tests

In fact, many insurance companies have fought for the right to require applicants for coverage to undergo the procedure, and the Justice Department has ruled that federally funded employers who fire people with AIDS based on fear of contagion cannot be challenged under U.S. civil rights laws protecting the handicapped.

“To say an individual’s rights shouldn’t be considered in the public health interest is a very dangerous precedent to set,” said Dr. Robert T. Schooley, an infectious diseases specialist who treats AIDS patients at Massachusetts General Hospital in Boston. “I think there are a lot of situations in which testing is useful. But this sort of mandatory testing will create a caste system in which there will be a large group of ‘untouchables’ who could lose their jobs and their insurability.”

But Dr. Walter Dowdle, AIDS director for the Centers for Disease Control, said that “what we’re trying to do is keep this in the health setting and out of the legal setting.”

‘Less a Gay Disease’

Moreover, he said: “We have got to get away from considering this a gay disease. As more and more groups become infected, it is less and less a gay disease. Let’s consider it in its proper perspective: a sexually transmitted disease. The disease has got to now be considered for what it is as it spreads more and more into the heterosexual population.”

One knowledgeable public health official said he believes that the proposals--which will be debated during a public meeting in Atlanta on Feb. 24 and 25--resulted from a growing public anxiety about AIDS that has put increasing pressure on the government to take some kind of “tangible” action.

“There is nothing ‘tangible’ about public service announcements or AIDS education brochures,” said the official, who requested anonymity. “People want to know: ‘What are you doing about this?’ I think there’s a risk that federal health officials may be pushed into action, feeling they’ve got to do something.”

Kristine Gebbie, administrator of the Oregon health division and chairman of the AIDS committee of the Assn. of State and Territorial Health Officials, said the plan could contribute little to public health because of the high rate of false positives that result from using the test, known as ELISA. A positive ELISA test must usually be confirmed with a more sophisticated and expensive procedure known as a Western Blot.

‘False Positives’

“When you talk about screening, you want to use the test in populations where you have reason to think you have infected people and where most of the positives you get will be true positives,” Gebbie said. “If you use this test on thousands of people who are uninfected, most of positives will be false positives. . . . I think the test should be used in conjunction with education programs.”

Those opposed to wide-scale testing long have argued in favor of education, saying that most people at risk for AIDS in this country--homosexual and bisexual men, intravenous drug users and their sexual partners--already assume that they are positive and behave accordingly to protect themselves and others.

The CDC’s Dowdle, however, said he does not believe this assumption really works.

“You can act as if you’re positive when you’re thinking about it, coldly, without emotion or three drinks,” he said. “But once the events are upon you, you could say: ‘Well, I don’t really know I’m positive.’ It’s one thing to act as if you’re positive--and it’s another thing to know you’re positive.”

But Schooley, who is concerned that individuals will avoid any hospitalization, even for non-AIDS problems, because they fear the consequences of the test, said: “If the stated reason is to provide more people with information to decrease the spread of this disease to other people in society, why choose hospitals? Why not go to singles bars and demand people be tested before they have their second drink?”

AIDS, or acquired immune deficiency syndrome, destroys the body’s immune system, leaving it powerless against certain cancers and otherwise rare infections. It is transmitted commonly through anal and vaginal sexual intercourse, through the sharing of unsterilized hypodermic needles, and by woman to fetus during pregnancy.