Testing Dilemma

By Richard Stengel

Public policy, like medicine, is an inexact science, and when it comes to fighting a frightening, mystifying disease, policymakers, like doctors, are often uncertain how to proceed. For more than a year, as anxiety about AIDS has spread across the nation, the Reagan Administration has been paralyzed by a debate about whether to advocate widespread, mandatory testing for antibodies to the AIDS virus. Secretary of Education William Bennett has been outspoken in arguing that testing is the only way to track and ultimately contain the spread of the fatal virus, which has been detected in nearly 36,000 Americans but may already have infected as many as 1.5 million. Opposing him have been medical professionals led by Surgeon General C. Everett Koop, who contends that mandatory testing would have the undesirable effect of causing many possible carriers of the virus to hide their condition for fear of being stigmatized.

This week Ronald Reagan, who has mostly been silent about AIDS, finally offered his opinion -- and the result could mean that blood tests will be requested from millions of Americans. During a meeting of the Domestic Policy Council attended by both Bennett and Koop, the President expressed bewilderment about objections to testing. "Why should we handle this any - differently than we handled any other epidemic?" he asked. "We have an obligation to protect innocent people." The President's remarks, said one participant, "were in the form of an inquiry, but it was obvious he was making a statement."

Reagan's intercession spurred a decision disguised as a compromise: while avoiding the inflammatory words mandatory testing, the government will soon require "routine" AIDS tests for immigrants and federal prisoners and "routine voluntary" tests of patients in federal and Veterans' hospitals. Routine voluntary testing, explains White House Domestic Policy Adviser Gary Bauer, means "we wouldn't turn away somebody needing hospital care if he refused to take the test, but testing would presumably become the rule." State governments will be urged to require AIDS tests for couples seeking marriage licenses and to conduct such tests in hospitals, drug and venereal- disease clinics, and prisons.

The resolution on testing comes as the Reagan Administration's AIDS policy is about to undergo microscopic examination. This week Washington will be host to the third International Conference on AIDS, a five-day colloquium for 5,000 scientists and researchers and hundreds of journalists. On Sunday, the day before the AIDS conference was to begin, the President was expected to unveil the Administration's new policy at a glitzy fund raiser for the American Foundation for AIDS Research.

The President's exhortation, however, would be unlikely to win over an audience of AIDS researchers. While Reagan has pressed for testing, most public health professionals believe the best way to contain AIDS is through education about how to prevent exposure to the virus. Moreover, the new guidelines are being written at a time when many experts are suggesting that the threat to the general public from AIDS has been exaggerated. Says Harold Jaffe, chief AIDS epidemiologist at the Centers for Disease Control in Atlanta: "We really have not seen much evidence for the spread of the virus into people who are not in risk groups . . . For most people, the risk of AIDS is essentially zero."

At the same time, the danger to specific risk groups -- particularly intravenous drug abusers and their sex partners -- has been seriously underplayed. "The people who really need to be concerned," says Jaffe, "are the 15-year-old black and Hispanic girls who have IV drug-abusing boyfriends. I really wonder what they know about this and who is looking out for them."

Until the Administration reached its policy regarding testing, Washington's principal weapon in the battle against AIDS had been fear. Health and Human Services Secretary Otis Bowen has likened the disease to the black death, while Koop has preached about the dangers of AIDS for every sexually active heterosexual. Such alarmist warnings have caused an epidemic of anxiety, and many scientists and researchers are claiming that such widespread fears are unfounded. Koop admits that his dire statements about AIDS are not universally accepted in the medical community. But, he argues, "as a health officer, I have to say that. If I were to spread the word that you don't have to worry much about this, I could really besmirch the office of the Surgeon General."

But the spread of the AIDS epidemic as a whole appears to be slowing; the CDC estimates that 75% of those who will get the disease during the next five years have already been infected. Those most at risk of infection are homosexual and bisexual men, intravenous drug users and their sexual partners. But with the gay community now well organized to fight AIDS, the rate of infection among homosexuals appears to be declining. The CDC's Jaffe does not want the public to decrease its vigilance, but he would like to mute the hysteria. AIDS, he says, "is a fairly discrete problem . . . Why it isn't getting out beyond the immediate sexual partners of risk-group members, I don't know. Is the disease going to sweep into the heterosexual population, like Africa? I don't see it."

While heterosexual transmission is possible, it does not happen easily. In a CDC study of spouses of AIDS patients who were infected by contaminated blood transfusions, researchers found that wives became infected 16% of the time and husbands only 5%. Some 10% of the people studied had more than 200 sexual contacts with an infected partner and still did not pick up the virus.

Only 4% of all AIDS cases are classified as instances of heterosexual transmission. Nearly half of those cases actually have no identified risks of infection, but the victims were born in countries where heterosexual transmission is believed to play a major role. The CDC lists an additional 3% of AIDS cases as "undetermined" in origin. Most of these victims were people who died before being thoroughly interviewed. Says the researcher who investigates this category: "We still get a flavor that they are engaging in high-risk behavior."

If AIDS were creeping into the heterosexual population, it would most likely be doing so in New York City, which has one-third of the nation's AIDS cases. Yet Rand Stoneburner, director of the city's AIDS research division, says the spread of the disease has been surprisingly circumscribed: "In the most recent tests, we found less than 1% testing positive who were outside the high-risk category."

In a study of AIDS cases among military personnel, most instances of apparent heterosexual transmission turned out to involve classic risk behavior: homosexual activity or IV drug use. Says Denver Doctor John B. Muth, who performed the study: "Clearly heterosexual transmission does occur, but we should not buttress our feelings of extreme risk by using data that are almost certainly skewed."

Where heterosexual transmission is increasing, it is doing so among teenage black and Hispanic sex partners of IV drug users, particularly in New York City, New Jersey and Florida. Contrary to the notion often promoted in urban ghettos that AIDS is exclusively a white, homosexual male disease, blacks and Hispanics suffer disproportionately from AIDS. A recent CDC report shows that while blacks and Hispanics represent 11% and 8% of the population, respectively, they account for 25% and 14% of all AIDS patients.

Among women and children with AIDS, blacks and Hispanics comprise 73% of the women and 79% of the children. Intravenous drug users, not bisexuals, are the principal transmitters of the disease to heterosexuals. Yet for many minority women, says San Francisco Epidemiologist Judith Cohen, "the first time they learn about AIDS is when they're diagnosed with it, or when their baby is born with it."

Transfusing blood, by sharing dirty needles, for example, is the most efficient way of transmitting the AIDS virus. While the overall incidence of AIDS is slowing down, the rate among IV drug addicts and their sex partners is climbing. In New York, for example, it is estimated that more than half of the city's 200,000 IV drug users are infected. "As a nation," says Dr. Stephen Joseph, New York City's health commissioner, "we are perhaps slower than we might have been in realizing that AIDS has disproportionately affected ghetto areas, where drug abuse is high. For us, the future of the epidemic will be determined by what happens with the virus in IV drug users."

Yet at the moment, the young urban minorities most vulnerable to the disease are least likely to know much about it. Programs are just getting under way to focus attention on AIDS among inner-city drug abusers. The city of Chicago is putting up 20 billboards in an effort to reach chronic drug abusers who do not read newspapers. In New York City and northern New Jersey, the health departments have hired former addicts to visit shooting galleries to talk to drug users about the importance of sterilized needles. Volunteers in San Francisco are handing out bottles of bleach to addicts to clean their needles.

Some professionals argue that sterilized needles are as necessary as condoms to fight AIDS. "If we don't make needles available to addicts, we are denying them the opportunity to prevent AIDS," says Richard Chaisson of the University of California, who directed a study of IV drug abusers in the Bay Area.

Such prescriptions are likely to be even more controversial than the Surgeon General's insistence that the public be taught about condom use and other safe-sex techniques. Yet such radical proposals are directed precisely to where the danger is now greatest. The alarm over AIDS and its potential spread into the heterosexual population has served to warn the public of its virulence and concentrate government attention on research and prevention. But now it is important to calm the fears of those who are not at great risk and provide help and education to those who are.

CHART: TEXT NOT AVAILABLE

CREDIT: TIME Chart by Joe Lertola

CAPTION: AIDS VICTIMS IN THE U.S.

Totals since June 1981

DESCRIPTION: Number of adult and adolescent AIDS victims who are Intravenous drug users, Homosexual male drug users, Heterosexual, Blood transfusion recipients, Hemophiliacs, and Undetermined.

With reporting by David Beckwith and Dick Thompson/Washington