Call for Tests, ‘Contact Tracing’ : AIDS Specialists’ Views Challenge Current Ethics

A top AIDS specialist predicted Wednesday that medical records increasingly will list the fact that a person has been exposed to the AIDS virus--a controversial practice currently barred under California law as a violation of confidentiality.

Dr. Paul Volberding, chief of medical oncology and AIDS activities at San Francisco General Hospital, spoke here Wednesday at a cancer symposium attended by about 700 cancer specialists from throughout the world.

Also at the meeting, sponsored by the Cancer Center of Scripps Memorial Hospital, a bioethicist called for widespread “contact tracing” to notify the sexual partners of infected people--a policy that has been opposed by some civil libertarians and groups representing AIDS patients.

A ‘Failure of Nerve’

“That this, with some few exceptions, has not been done across the country represents a failure of nerve and a dereliction of professional responsibility on the part of public health departments,” said Ronald Bayer, a bioethicist with the Hastings Center in New York.

Their comments appeared to challenge the efficacy of public-health practices in California and elsewhere, in light of what they described as the increasingly complex problem of controlling the spread of acquired immune deficiency syndrome.

Traditionally, the researchers who have worked most closely with AIDS patients and the experts who have studied the ethical questions posed by AIDS have been among the strongest advocates of measures to ensure the privacy of people infected with the AIDS virus.

“We are at a critical point in the epidemiological curve of AIDS in America,” Bayer said. “There can be no doubt that the rising toll . . . will place great strains on our commitment to the principles that define a liberal democracy.”

And Volberding, speaking as a member of a panel on AIDS, called the prohibition on listing exposure to the AIDS virus on medical records “a temporary aberration.” Later, he predicted that the state law barring a physician from listing a patient’s AIDS-test status would be changed.

Volberding also said he is “evolving my position . . . in favor of much more (AIDS-antibody) testing in the hospital.”

Basis for Criticism

“I think we can be fairly criticized by avoiding identification of the virus infection in a person,” Volberding said. Noting that hospital tests aim to identify problems, he said, “Certainly, HIV (human immunodeficiency virus) infection has got to be problem No. 1.”

The AIDS antibody test determines whether a person has been exposed to the virus.

People who have been exposed can spread the virus although it may take them as long as 10 years to become ill with the disease themselves.

Researchers still do not know what percentage of people infected with the AIDS virus will come down with the disease.

Advocates for AIDS patients and civil liberties groups have expressed concerns about the use and abuse of AIDS test results, noting that tests can produce false positives and that people could be subject to discrimination should test results become public.

‘We Need a Better Test’

“I think it’s a mistake to put so much weight on the antibody test in the first place,” Lance Clem of the San Diego AIDS Project said in an interview Wednesday. “The antibody test is going to mean less and less because of the limitations of the test itself. We need a better test.”

Bayer and Volberding both stressed the need for federal and state laws barring discrimination against people who test positive. Volberding said the absence of such laws is “frankly appalling.”

Bayer, who has a Ph.D in political science and has done work in bioethics for 10 years at the Hastings Center, called it “a matter of the highest moral and public health importance” that public health departments begin trying to contact the sexual partners of infected people.

He further contended that in some cases private physicians may have to violate confidentiality if an infected individual refuses to inform sexual partners or to change his or her sexual behavior.

“The duty to warn, the right to know and the protection of public health all seem to indicate in this carefully defined situation that confidentiality be breached and the third party be notified about the risks of infection,” Bayer said.

Ramifications Feared

Bayer added, however, that he foresees one “ironic twist”: If it becomes known that physicians might violate patient-doctor confidentiality, then patients who have tested positive but have no symptoms may hide that fact from their doctors and lie about their sexual behavior.

He also warned that increased testing in hospitals and that identifying HIV-positive patients on medical charts--a step that some health-care workers suggest might help the workers protect themselves from exposure--might have another effect.

“It’s my sense that the subtext is not, ‘Give us more information so we can be more cautious,’ ” Bayer said. Rather, “the subtext is, ‘We want to know who’s infected so we can avoid that person.’ ”

Bayer said he has observed “a remarkable and disturbing resurgence in reports of the refusals of physicians to care for those with AIDS as well as those who are simply HIV-infected but asymptomatic.”

Asked for details, he and Volberding cited three instances in which, they said, prominent surgeons in respected hospitals said they would not treat or were worried about treating people infected with AIDS.

They also discussed another problem: Whether patients in surgery could be exposed to the virus by an infected surgeon or aide. They said there are no documented cases of such transmission and that the risk is considered extremely low. Still, “lots of people have been operated on by infected surgeons, I’m certain,” Volberding said. “I’m not aware, at least, of any documented case of transmission. So you’re in the position of making policy decisions that are based on fear rather than fact.”

The conference was the 11th annual cancer symposium sponsored by the Cancer Center of Scripps Memorial Hospital.