Top Medical Journal Calls for Routine AIDS Testing : Health: Editorial reflects growing support for measures that critics say arise from new fears.
The opposition of many medical and health officials to routine AIDS-virus screening appears to be eroding--a shift made starkly apparent today in a top medical-journal editor’s unusual call for routine testing of hospital patients, pregnant women, newborns and health care workers.
The editorial in the New England Journal of Medicine, also calling for a federally funded AIDS-care program, comes at a time when physicians, public health officials and others seem increasingly willing to consider disease control measures that have been viewed as being problematic.
Those measures include reporting AIDS-virus infections to health departments, notifying infected people’s sexual partners, and routine testing of groups such as newborns and doctors for infection with the human immunodeficiency virus.
Observers disagree on what has prompted the shift. Some say that recent medical advances have made routine screening more justified: If drugs can delay the onset of the disease, the value of testing outweighs the risk of stigma associated with infection, they say.
Others, however, trace the shift to a resurgence of AIDS fear. They say that the highly publicized cases of three patients apparently infected by a Florida dentist, and last week’s announcement that others were infected through transplantation, are creating new pressure for more aggressive--some say coercive--measures to control the disease’s spread.
“I think (the change in opinion) is very widespread and I think it’s enormously significant,” said Ronald Bayer, an associate professor of public health at Columbia University, who wrote an article accompanying the journal editorial.
“The crucial point is going to be whether America as a political community is going to be willing to commit the resources necessary to provide care,” Bayer said. “. . . You don’t screen before the services are available.”
The shift in opinion has left many in the field uneasy.
Dr. June Osborn, chairwoman of the President’s Commission on AIDS and dean of the University of Michigan’s School of Public Health, flatly rejected the idea of routine screening in favor of public education and voluntary testing with informed consent and counseling.
“There’s nothing routine about an HIV test,” said Osborn, who added that it is unwise to screen with tests that have the power to change a person’s life. “. . . A positive HIV test is one of the most potent stimuli to suicide that mankind has ever invented.”
From the mid-1980s until recently, an alliance of AIDS activists, physicians, public health officials and others has argued successfully that tests for the infection should be strictly voluntary, with subjects giving their informed, written consent.
They also argued, mostly successfully, against reporting the names of infected people to public health authorities, as is done with other communicable diseases. They said such a policy would scare people away from testing for fear of violations of confidentiality.
But the emergence of new drugs that can delay the onset of symptoms in infected people and prolong sick patients’ lives brought greater interest in voluntary testing in 1989. Next, physicians began calling for more routine testing of patients in hospitals and offices.
In December, officials of the American Medical Assn. called for AIDS-virus infection to be treated like other sexually transmitted diseases--subject to routine testing in certain groups, like pregnant women, and reportable to public health authorities.
At about the same time, the U.S. Centers for Disease Control also came out in support of reporting infected people and notifying their sexual and needle-using partners. Partner notification has also been backed by several prestigious scientific groups.
And in a report to be published next month, one of the first national surveys of physicians’ and nurses’ attitudes has found a high level of support for routine testing, according to John Colombotos, a Columbia public health professor who performed the study.
Colombotos, whose study was funded by the federal Agency for Health Care Policy and Research, said Wednesday that three-quarters of those surveyed supported screening pregnant women and surgical patients, while more than half supported testing health care workers.
“I think society is moving in that direction because they’re sorting out this confusion between civil rights and the epidemic,” said Dr. Marcia Angell, the executive editor of the New England Journal of Medicine who wrote the signed editorial published today.
Others, however, offered different interpretations.
“The doctors feel threatened as the epidemic has grown,” said Thomas B. Stoddard, executive director of the Lambda Legal Defense and Education Fund, the country’s largest gay legal organization. “. . . So they promote exclusion and punishment, rather than assistance and voluntary cooperation. It’s quite scary.”
In the editorial, Angell called for routine screening of certain groups, as well as anti-discrimination legislation and “a nationally funded program . . . for the medical care of HIV-infected persons.”
Angell argued that such a program would give people an incentive to be tested. And more widespread testing would make it possible to effectively use traditional public health measures, such as partner notification, to control the spread of infection.
Parts of her proposal, at least, came under heavy fire.
Gunther Freehill, a member of the AIDS activist group ACT UP/Los Angeles, criticized the proposal on grounds of effectiveness. He argued that partner notification programs have not worked and that there is still too much discrimination to justify routine testing.
“While we like to say that AIDS should be treated like any other disease, AIDS isn’t seen like any other disease,” said Larry Gostin, executive director of the American Society of Law and Medicine and a professor of health law at Harvard University.
“People suffer much more greatly with AIDS,” Gostin said.
BACKGROUND
Since a test for AIDS-virus infection became widely available in 1985, the conditions of its use have been controversial--largely because of the serious implications of a positive result and the threat of discrimination against people found to be infected. Until recently, an alliance of AIDS activists, public health officials, physicians and civil libertarians had managed successfully to promote the policy that the test would only be used voluntarily and with specific informed consent. Now, health experts say that alliance may be eroding in the face of calls for routine screening of groups like pregnant women, newborns and health care workers.
