U.S. rules altered for foreigners with HIV

Last Monday, for the first time in 22 years, foreigners with HIV were legally allowed to enter the United States without their infection status being considered.

Before that, even short-term visitors had to receive special permission -- or lie on their visa application -- to come here. A medical examination of people seeking to immigrate to the U.S. or who were already here but wanting to become permanent residents included an HIV test. Now, a person’s HIV status does not prevent him or her from entering the U.S., and testing is no longer required for immigration.

Advocacy groups for immigrants and people with HIV, human rights organizations and public health officials applauded the change. They also bemoaned the fact that the policy was ever put into place to begin with.

Only a handful of other countries, such as Russia, Yemen and the United Arab Emirates, have similar restrictions. “It wasn’t great company,” says Dr. Michael Saag, who directs the Center for AIDS Research at the University of Alabama at Birmingham. “Why is it that the U.S. had this rule, when most of the Western world doesn’t?”

Here’s a closer look at the history and justification behind the HIV travel and immigration ban, and its removal.

Why are immigrants screened for disease?

Throughout history, the U.S. has required medical screening of people wanting to move here or who may already be here but want to become permanent residents. The main purpose is to control diseases that might spread throughout the U.S. population, says Dr. Drew Posey, a medical officer in the Division of Quarantine and Migration Health at the Centers for Disease Control and Prevention in Atlanta. For that reason, there is a list of conditions -- termed “communicable disease of public health significance” -- for which entry into the U.S. can be denied, including new diseases such as severe acute respiratory syndrome (SARS) and old ones such as tuberculosis. Other diseases on the inadmissible list include syphilis, gonorrhea and leprosy. HIV was formerly on this list.

“Over time, the regulations have evolved, as we’ve learned more about disease and as we review the scientific data,” Posey says.

Even those who opposed the HIV ban agree that restricting movement of people across borders may be warranted by some diseases at critical times, such as infection with SARS, which emerged as a new disease in 2003 and killed 774 people before fading away, or extremely drug-resistant tuberculosis, which has crept around the globe ever since a large outbreak in South Africa in 2006. These are examples of highly communicable diseases that are genuine public health threats, Saag says -- hard to contain, difficult to treat, with high rates of mortality or illness.

When and why was HIV/AIDS put on the list?

HIV/AIDS was added to the list in 1987 by congressional mandate, and foreigners with the disease were barred from entering the country. The reasoning was that AIDS was a contagious, life-threatening disease and, therefore, a danger to Americans.

However, the action was not supported by the scientific evidence, says Saag, who is also the national chairman for the HIV Medicine Assn., a professional group of researchers and healthcare workers. “We knew by 1987 that it was only transmitted by intimate contact -- by either sexual exposure, mother-to-child transmission or through the blood supply,” he says. (Testing of the blood supply began in 1985.) In addition, the virus was already widely prevalent in the U.S. That made HIV very different than most other conditions on the list, such as tuberculosis, which can be transmitted through the air, or leprosy, which is very rare. “The decision in 1987 to create a travel ban was generated mostly, in my opinion, out of a political perspective,” Saag says.

Dr. James Curran, now dean at Emory University’s Rollins School of Public Health in Atlanta, headed the CDC’s AIDS program in 1987 and remembers Dr. James Mason, then the director of the CDC, seeking input on the ruling. “He held a consultation with the senior scientific staff who were almost uniformly against adding HIV to the [list],” Curran says. Those objecting included AIDS researchers and scientists at the agency’s quarantine division. “It was hardly a threat to the population of the U.S. It was a political decision that people with HIV should be banned from the country,” Curran says.

International groups also weighed in. “The World Health Organization said in 1987 -- the same year that this ban was proposed -- that screening international travelers for HIV was not an effective strategy to prevent its spread,” says Rebecca Schleifer of the organization Human Rights Watch in New York. And, Schleifer adds, the United Nations High Commissioner for Human Rights pronounced any restrictions on HIV-infected people as discriminatory and not justifiable by public health concerns.

Why was HIV/AIDS taken off the list?

“There has been pressure on the U.S. government for years to lift this ban,” Schleifer says. Human rights groups, AIDS groups and immigration groups have all lobbied to change the policy.

Because of the ban, the International AIDS Society has refused to hold its conference in the U.S. since the early 1990s -- this after holding three of the first six conferences here. After President Obama announced the intended change in November, AIDS 2012 was promptly scheduled for Washington, D.C.

“In fairness, we do know a lot more about HIV than we knew back in that time period, in the first few years after it was discovered,” Posey said.

How was the change made?

Two things had to happen to remove HIV from the list. First, a clause in the Immigration and Nationality Act, which explicitly specified HIV infection as a reason to deny admission to the U.S. and was added by Congress in 1993, had to be changed. Congress struck the language in mid-2008, thereby allowing the CDC to take another look at whether HIV should be included in its list of inadmissible diseases.

In July, the CDC proposed removing HIV/AIDS from the list -- and received more than 20,000 public comments, the overwhelming majority in favor of the change. The rule was finalized in November.