HIV Prevention Act would require HIV reporting
AMA’s support of Coburn bill called shocking’
Health officials have argued for years over the pros and cons of treating HIV disease differently from other infectious diseases. Until recently, the stigma and discrimination brought on by HIV have tipped the balance in favor of voluntary testing, anonymous HIV reporting, and limited partner notification. The "HIV Prevention Act of 1997" recently introduced in Congress proposes mandatory, confidential reporting of HIV infection, mandatory partner notification, and a provision that would allow providers to refuse invasive treatment to patients who won’t agree to an HIV test.
The bill has won the endorsement of the American Medical Association, but is harshly criticized by AIDS activists as punitive and detrimental to existing HIV prevention strategies.
Introduced in mid-March by Rep. Tom Coburn (R-OK), the bill would require states to:
• report all HIV cases to the Centers for Disease Control and Prevention (currently, all states must report AIDS cases but only 26 states voluntarily report HIV cases);
• notify partners exposed to HIV (the CDC now requires states to notify partners for AIDS cases only);
• require medical associations to design policies that would require patients to undergo HIV testing before they receive invasive procedures, and determine whether HIV-positive health care workers can perform those procedures;
• require HIV testing for people accused of sexual crimes;
• require insurance companies to provide test results to applicants, as well as permit parents to know the HIV status of adopted children.
Coburn, a physician, wrote the bill with the intention of "returning sound medical practices" to the way HIV is treated and prevented, protecting those not infected and assuring that those infected know their HIV status as soon as possible.
The American Medical Association strongly supports the bill. In a letter to Coburn, John Seward, MD, executive vice president of the AMA, wrote: "In the interests of preventing the spread of HIV disease, the AMA has long supported the concept of confidential reporting of all HIV-positive people, including physicians and other health care workers. Similarly, we have also recommended that a system for contact tracing and partner notification for unsuspecting sexual or needle-sharing partners who might have been HIV-infected be established in each community. This is in keeping with our belief that those infected with HIV and AIDS be treated in the same manner as other infectious and contagious diseases."
The AIDS community’s two largest national organizations strongly oppose the bill. The National Organizations Responding to AIDS (NORA), whose membership includes medical, pediatric, legal, civil rights, and religious organizations, claims the bill adds nothing to the effective prevention of HIV and undermines successful community-based HIV prevention strategies, says David Harvey, co-chair of NORA.
Miguelina Maldonado, also co-chair of NORA, found the AMA’s endorsement "alarming and shocking," considering that the bill is opposed by other national public health partners, including the American Public Health Association, the National Alliance of State and Territorial AIDS Directors, and the Association of State and Territorial Health Officials.
Coercion discourages testing, treatment
NORA finds the bill’s proposal to allow providers to refuse to treat untested patients particularly onerous. Patients could be tested without consent or subjected to unnecessary delays or denials of critical medical procedures, NORA states, adding that coercive measures only discourage people at risk of HIV from seeking testing or treatment.
AIDS Action Council, the nation’s leading AIDS advocacy organization, also denounces the bill, calling it an attempt to "federalize policies that do nothing but stigmatize and punish people living with HIV."
"Rep. Coburn is promoting a hodge-podge of coercive testing-related policies, under the pretense that identifying people who are HIV-positive, in and of itself, will somehow prevent others from being infected," says Aimee Berenson, AIDS Action Council’s director of government affairs. "Every public health and medical professional knows that the only way to protect from accidental exposure to HIV is to comply with the universal precautions’ guidelines when treating all patients."
Based on a multicenter study of hospital-based physicians, however, compliance with universal precautions may be low. Answers to confidential questionnaires from 322 physicians found that while glove use (94%) and needle disposal (92%) were high, 45% did not wear protective clothing and 43% recapped needles, according to results published in the most recent issue of the Journal of Environmental Medicine.
Coburn’s bill requiring medical associations to set guidelines regarding which invasive procedures HIV-positive health care workers should avoid isn’t likely to have much impact, says Robert Wood, MD, director of the Seattle-King Country AIDS Prevention Project. "Those societies struggled with that a few years ago and didn’t come up with any recommendations because there really is no solid epidemiologic evidence to say which procedures are dangerous," he says. "So frankly, I don’t think putting it in law will force them to come up with any recommendations."
In a similar move to mandate HIV reporting, Puerto Rico’s department of health has proposed new HIV regulations that require HIV-positive persons to report the names of their sexual partners to the government. The proposal also creates a mandatory name reporting system, requiring hospitals and medical laboratories to send HIV-positive test results to the government.
The American Civil Liberties Union testified against the proposed regulations. "If they are enacted, HIV will spread more quickly in Puerto Rico," says Michael Adams, JD, staff attorney with the ACLU’s AIDS Project. "Study after study has shown that mandatory name reporting discourages people from being tested for HIV."
San Juan, Puerto Rico’s largest city, had the eighth highest AIDS rate among U.S. cities in 1996.
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