Sexual Risk-Takers Need More Than Tests

AIDS thrived for years with scant attention from politicians, reflecting the scant interest of the general public. Now, suddenly, Americans rank AIDS third on their list of worries--right behind war and the economy. They want the country’s leaders to “do something,” and to do it quickly; fear of the epidemic is not calmed by talk of education and research whose results may not be seen for years. Increasingly that “something” is testing--mandatory testing--for the presence of the AIDS virus.

It was sad to hear Paul Gann this week saying, “Those who have AIDS or who might have AIDS want to keep it all a big secret so they can keep doing what they want and keep spreading the disease to others . . . . I am for testing everyone and telling everything.” Gann said that he had contracted AIDS through a blood transfusion during surgery. Since that’s a socially acceptable way of becoming infected, he will never know the incredible stigma that most AIDS patients face. It’s a stigma that many feel so strongly that they try to keep the diagnosis secret even after death to protect their families.

Inherent in the politicians’ view is that public health officials have been negligent in not calling for mandatory testing and other measures, so politicians must do it for them. A more subtle belief, widely held but only occasionally articulated, is that public health officials have either put civil rights first or yielded to the political pressure of the gay community on the testing issue.

This is a total misstatement. I and most public health officials support the concept of more widespread testing--provided it is voluntary, with anonymity or ironclad protection of confidentiality. And it absolutely must be accompanied by education and counseling. Anything less will be counterproductive if the goal is to stop the spread of AIDS.

Premarital testing is probably the most common form of mandatory testing favored by Americans--more than 80% in most polls. The idea is to find the men who are carriers of the AIDS virus and prevent the infection of women and babies. Public health officials know that premarital testing isn’t the answer. In one study reported by the Centers for Disease Control, of 567 women infected with AIDS, less than one-quarter were married. And in a survey of pregnant intravenous drug users, only 15% were married.

What the political palliatives ignore is human nature. People who want to be tested can be tested now. Those who are most likely to need testing are also most likely to resist the idea, and, if coerced, to find a way out. If premarital testing for AIDS is made mandatory, people who are reluctant will simply choose to live together--and to continue high-risk sexual activity.

Regrettably, test results alone do not necessarily stop high-risk behavior. This is especially true among loving couples, both heterosexual and gay male, where one of the partners is known to be infected; many persist in intercourse without condoms.

For most people, changing sexual behavior will require repetitive counseling. That would be done primarily by health-care providers, most of whom currently have neither the desire nor the expertise to do so.

Certainly everyone who is about to be married has the right to know if his or her partner is infected with AIDS or any sexually transmitted disease. They should want to be tested, but not only in connection with marriage. The average American is sexually active by age 17, long before marriage. Given the incidence of premarital--and extramarital--sex, it is crucially important to know that a partner is free of AIDS before intercourse, especially unprotected intercourse. Until that is known, the proper approach is abstinence or intercourse with condom and spermicide. If unprotected intercourse is considered, both partners should be tested twice--three to six months apart--to be as certain as possible that they are not infected.

Instead of testing all people about to be married, testing should focus on critical areas: in clinics for drug use and sexually transmitted diseases, and in prenatal and family-planning clinics.

But putting the AIDS antibody test in the same category as the premarital syphilis test is absurd. There are no disadvantages attached to the syphilis test--no social stigma, no emotional complications, no opportunity for discrimination--as there are in the AIDS test. Politicians have the power to remove the major disadvantages by enacting anti-discrimination legislation, by funding programs to teach health-care professionals how to counsel, and by funding mental-health and similar support services for those who test positive.

When political leaders, from the President on down, urge widespread testing, they also should guarantee that this will not constitute punishment. It would cost the government nothing to remove such barriers as the Justice Department’s opinion that fear--no matter how unjustified--is reason enough to allow an employer to fire an employee who tests positive for the AIDS antibody.

As we work toward eradicating AIDS, the imperative remains to change the behavior of tens of millions of Americans with continuous counseling and education. Until there is good post-test counseling as well as anti-discrimination legislation, wide-scale testing will result in despair and tragedy with very little effect in slowing the spread of the virus. And such testing will have the additional ill effect of lulling Americans into believing that nothing will happen to them because “something” is being done, somewhere, to others.

Of course, marked increases in funding for education, counseling and programs for drug users are a politically unpopular prescription. But it is the politician’s responsibility to govern, not to make health decisions for political expedience.