AIDS Panel Drafting Guidelines on Isolation : State Health Officials Take Aim at Patients Deemed ‘Recalcitrant’ in High-Risk Behaviors

A committee of California health officials is quietly drafting guidelines for counties that may want to isolate “recalcitrant” AIDS patients who seem intent on continuing to engage in high-risk behaviors that may infect others with the AIDS virus.

The emerging guidelines, based on existing state laws that empower health officials to protect the public from communicable diseases, would affect only those who are actually sick with acquired immune deficiency syndrome or ARC, the equally deadly AIDS-related complex.

The guidelines would not affect the far larger number of people who are merely infected with the virus, as shown by a positive blood test for AIDS antibodies.

Among the severest isolation steps--most likely to affect some prostitutes and intravenous drug users--are confinement to one’s home, a hotel, a hospital or a jail. The recommendations, as currently written, would provide due process safeguards, such as legal representation.

“These are guidelines of last resort,” said Dr. Carl Smith, chairman of the disease and epidemiology committee of the California Conference of Local Health Officers, which advises state and county public health officials.

About 15 members of the committee spent five hours discussing the guidelines at an airport hotel here Wednesday and, despite the objections of gay rights activists, said it would continue drafting the guidelines for eventual presentation to the board of the conference. The committee’s next meeting is March 19 in San Francisco.

The latest draft of the recommendations, made public for the first time, would apply to “recalcitrant AIDS and ARC patients who, despite counseling and education, continue to engage in all kinds of dangerous activities,” Smith said.

The controversial guidelines have been drawn up in the aftermath of the defeat in November of Proposition 64. That ballot initiative would have compelled health officials to strictly enforce the state’s Health and Safety Code against AIDS by taking measures that its opponents said would have led to unnecessary restrictions on personal liberties on a broad scale.

Proposition Foes

Public health officials were among the strongest opponents of the proposition, and they set out after its defeat to apply current state law to the increasing number of instances where prosecutors, physicians and the public are reporting alleged “recalcitrant” individuals to health authorities.

According to Martin Finn, director of the AIDS program of the Los Angeles County Department of Health Services, the county is receiving about 15 such allegations a month, most of which turn out to be unfounded.

During Wednesday’s meeting, about 10 representatives of the gay community urged the committee to abandon its effort because, they argued, the guidelines would do more harm than good by driving AIDS patients underground.

‘Witch Hunt’ Feared

“It is a system where people will engage in a witch hunt,” said Keith Griffith of Citizens for Medical Justice in San Francisco.

“Public health clinics may become clinics for self-incrimination,” added Bruce Decker, chairman of the California AIDS Advisory Committee. “We may be creating kangaroo courts above the law which (can be used to) incarcerate patients for the rest of their lives.”

The 23-page draft document includes procedures to guide county health officers who investigate allegations of dangerous behaviors by AIDS and ARC patients, such as willfully exposing others to the virus through sexual contact or sharing drug needles.

It calls for a series of increasingly severe isolation orders if, for example, such patients disregard educational and health counseling. These steps include confinement and perhaps denial of visitors.

Other Measures

The less restrictive measures being contemplated are mandatory counseling or prohibition of high-risk behaviors, such as sharing needles or having sex without condoms.

While isolation has not been ordered by health authorities in California, such action has been reported in other states, including Florida and Mississippi.

According to the current version of the recommendations, all isolation orders would have to be reviewed by a county health officer every 30 days. Violations would be a misdemeanor.

The guidelines include a policy for emergency isolation for up to 72 hours without a hearing if a health officer determines “the general safety of the public health is in imminent danger.” They do not specify what such situations might be.

In non-emergency situations, AIDS patients suspected of endangering others would first be ordered to appear at an examination hearing and a subsequent isolation hearing, if necessary, both to be conducted by a county health officer.

Legal Representation

At these hearings, individuals would have the right to be represented by lawyers and could introduce evidence and question witnesses. Individuals would also have the right to an independent medical examination by a physician of their choice.

In investigating allegations, the guidelines advise health officers not to use the results of blood tests for exposure to the AIDS virus, because the confidentiality of these results are protected by current state law and they are not reported to health authorities. In contrast, cases of AIDS and some cases of ARC are required by law to be reported.

As currently written, the guidelines do not recommend surveillance of people under isolation. “This is a passive system,” said Smith, who is the committee chairman and the health officer for Alameda County. “We are not attempting to circumvent laws related to AIDS confidentiality.”

Word of Caution

Some committee members, such as Dr. Shirley Fannin of Los Angeles County, cautioned that focusing on the guidelines could divert attention from more effective and important measures to control the spread of the disease, such as education and counseling.

AIDS, which attacks the body’s immune system, can be transmitted through the blood, by sexual contact and from an infected pregnant woman to her fetus. Those who become infected with the AIDS virus are considered infectious to others, although medical experts say that not all those who are infected will necessarily go on to develop AIDS or ARC.

As of Monday, 31,306 patients had developed AIDS in the United States, of whom 17,851 had died.