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Dangerous Direction on AIDS

July 17, 1988

The AIDS reporting initiative, Proposition 102, has now qualified for California's November ballot, stirring deep concern among many doctors and public-health workers. The concern is appropriate. This is a dangerous and potentially costly proposal that would undermine the present effective strategy for controlling AIDS.

There are two major provisions of the initiative:

--Requiring that all persons who test positive to the presence of the human immunodeficiency virus (HIV) that causes AIDS report themselves or be reported to public-health officials. The change would amend the elaborate rules of confidentiality now in place and terminate anonymous testing that has proved to be an effective control strategy.

--Ordering public-health officers to pursue the at-risk contacts of those who are infected, a project that could cost billions of dollars while serving, in most cases, only limited public-health purposes.

In limiting provisions for confidentiality and substituting mandatory for voluntary testing, the initiative challenges a basic finding of the Presidential Commission on the HIV Epidemic. "Rigorous maintenance of confidentiality is considered critical to the success of the public-health endeavor to prevent the transmission and spread of HIV infection," the commission concluded. "Current public-health strategies for fighting the spread of HIV infection are entirely dependent on voluntary cooperation."

In commanding an extensive program of partner tracing and notification, the initiative would impose a diversion of money from other more urgent needs identified by public-health officials in the areas of education and treatment. Indiscriminate tracing would cost millions, probably billions, of dollars. The wholesale-notification provisions contrast with the carefully crafted recommendations on notification of unsuspecting partners of infected persons developed by the American Medical Assn. and the presidential commission.

There appear to be many motives behind Proposition 102. Some doctors who are supporting the initiative are frustrated by existing laws restricting the ability of doctors to share AIDS test results with other health-care providers. That problem is now being addressed with legislation. Some of the sponsors, believing that AIDS has become a "politically protected" disease, argue that the existing policy is "ill-conceived and self-defeating," and that it is high time that HIV infection should be treated like other communicable diseases. That is the view of one sponsoring organization, California Physicians for a Logical AIDS Response, headed by Dr. Lawrence J. McNamee. He is a member of the Los Angeles County Medical Assn. AIDS Committee, but the committee itself has voted to oppose his initiative. Another sponsor, Rep. William E. Dannemeyer (R-Fullerton), has been a vigorous critic of proposals to protect AIDS-infected persons from discrimination on grounds that these are programs that encourage homosexuality and intravenous drug use because a majority of AIDS victims in the United States are male homosexuals and intravenous drug users. In making their criticisms, unfortunately, the sponsors of the initiative have offered no evidence that their sweeping proposals in the initiative would strengthen the efforts to contain the disease. In fact, they would not.

The careless, counterproductive proposals of the initiative are particularly evident when its provisions are compared with the constructive proposals of the presidential AIDS commission, headed by Adm. James D. Watkins. Taken as a whole, the initiative would do great harm to the basic strategy supported by the presidential commission. The breaches in confidentiality alone could destroy the voluntary cooperation of high-risk populations that the presidential commission cited as essential. There are, no doubt about it, problems and imperfections in the AIDS program. The presidential commission identified two basic shortcomings in the present approach: an absence of anti-discrimination laws that would protect victims of the deadly disease, and inadequate funding of efforts to control the disease, including treatment for drug users. But the initiative addresses neither of these problems. Indeed, if adopted, Proposition 102 would exacerbate them. Dannemeyer has emphasized his opposition to anti-discrimination legislation. And the mandates for wholesale contact tracing would squander the already limited resources available.

It is not surprising, in the face of such flagrant defects in the initiative, that the California Medical Assn. and the California Nurses Assn. have gone to court seeking to bar the initiative from the ballot. Proposition 102 would appear to violate constitutional restrictions that initiatives be limited to a single subject. Regardless of the outcome of the suit, the challenge at least makes clear the depth of opposition by many of the best-informed health-care professionals, including most of those directly involved in the effort to contain the AIDS pandemic.

"The initiative is bad medicine and bad public health," according to Dr. Laurens White, president of the California Medical Assn. We agree.

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