Confrontation and concern about AIDS

JOHN BARBER June 15 1987

Confrontation and concern about AIDS

JOHN BARBER June 15 1987

Confrontation and concern about AIDS


Entertainment was not on the agenda last week as Elizabeth Taylor prepared to address a crowd of 450 people at the National Press Club in Washington. Indeed, Taylor spoke on a grim subject—acquired immune deficiency syndrome. And the stage was set by a burly gatecrasher holding a sign at the front of the room that read “Quarantine Manhattan Island, the AIDS capital of the world.” That unwelcome message underscored the urgency that marked all the speeches at the city’s Third International Conference on AIDS, a weeklong gathering of 6,350 researchers and health officials, including U.S. specialist Robert Gallo and, from Paris, the Pasteur Institute’s Luc Montagnier. Their presentations —ranging from the latest analysis of the spread of the disease among heterosexuals to ominous news of the appearance of a new AIDS-like virus in Africa—represented the pinnacle of international expertise on the epidemic. Still, it was Taylor who sounded the week’s keynote. “The fear of AIDS threatens to tear apart the very fabric of our society,” she declared, “and the crisis tests our ability to call ourselves civilized.” The warmth with which the audi-

ence received Taylor’s plea for understanding contrasted with the scattered jeers that greeted U.S. Vice-President George Bush’s address to the opening session of the conference. Bush apparently angered some members of the audience by endorsing President Ronald Reagan’s proposal that prisoners, immigrants and people planning to marry should be subject to AIDS testing. At the same time, outside the White House, half a kilometre away, police wearing rubber gloves were arresting demonstrators protesting against those proposed measures. The announcements and their reception— Reagan was also booed by members of the audience at an AIDS fund-raising dinner—focused international attention on the deep and troubling ethical issues generated by the epidemic. But the hard facts presented for the first time at the conference also gained immediate attention, especially those concerning the still-relentless spread of the disease around the world.

Jonathan Mann, director of AIDS programs for the Geneva-based World Health Organization, opened the conference on a sobering note: he announced that as many as 10 million people are already infected with the

virus that causes AIDS. “This epidemic has just started,” he declared. He added that, although WHO officials had tabulated 51,535 reports of full-blown AIDS cases in 113 countries, the actual number of AIDS victims could be more than twice as high. In the same way, Dr. James Curran, director of the AIDS program at the Atlanta-based Centers for Disease Control (CDC), contrasted the 35,980 reported AIDS cases in the United States with an estimate that 1.5 million U.S. citizens are infected with the virus, a frightening statistic that may include one out of 30 men between the ages of 20 and 50. It is not known yet how many of those AIDS car-

riers will eventually succumb to the fatal disease, but Curran said that by 1991 AIDS will be second only to accidents as the leading cause of premature death among U.S. men.

Several conference sessions focused on the spread of the disease through heterosexual intercourse. In general the experts were reassuring: one reported that in the United States at least, a woman’s chances of contracting the AIDS virus during a single sexual encounter with an infected man were no more than one in 1,000. For his part, CDC chief epidemiologist Harold Jaffe said that, although AIDS is a serious threat, research shows that its

spread among heterosexuals is slow. Indeed, Health and Welfare Canada officials say that of the 1,052 confirmed AIDS cases in Canada to date, 867 have occurred among homosexual or bisexual men, and 26 among heterosexuals with partners in such highrisk groups as bisexual men and intravenous drug users. Among the other cases are 28 of unknown origin and 65 that have occurred among people from Haiti and other parts of the world where the disease is endemic.

Still, many researchers at the Washington meeting said that those statistics should not cause heterosexuals to become complacent about AIDS. “The reality that heterosexual contact is an efficient mode of transmission is established,” said Dr.

Robert Redfield of the Walter Reed Army Institute of Research in Washington. “It is the major mode of transmission in the world, and it will become the major mode in this country.” In a recent U.S. study of heterosexuals, in one group of 25 couples in which one partner had advanced AIDS,

Redfield found that 14 of the uninfected partners eventually

became infected. He also cited another U.S. study involving AIDS victims who engaged in vaginal intercourse. Its conclusion: the disease was transmitted to the uninfected partner in 81 per cent of the cases.

Ultimately, however, most delegates said that intravenous drug use was a

more worrisome method of AIDS transmission. Declared the CDC’s Dr. Timothy Dondero: “The typical person at risk for heterosexual transmission is not the 35year-old white suburban professional woman who does aerobics and worries about fitness. It’s more likely to be a disadvantaged black teenager whose boyfriend is a drug addict.” So far in Canada, only four people

have acquired the disease exclusively after using infected needles, but a quarter of U.S. cases involved people who abused intravenous drugs.

Tragically, researchers have identified infants as being the most frequent victims of so-called tertiary transmission. That is one reason why Reagan announced his support for what he called “routine testing” of selected populations for AIDS infection. Indeed, his most farreaching recommendation was that state governments demand such tests of

all couples planning to marry. Added Reagan: “It is time we knew exactly what we were facing. And that is why I support routine testing.”

Despite the President’s appeal, the overwhelming majority of U.S and Canadian AIDS experts say that they are opposed to any form of mandatory

testing, even so-called routine testing that people can decline if they are strongly opposed to it. Indeed, Reagan voiced his proposal in the face of strong opposition from Surgeon-General Everett Koop. Declared Dr. David Roy of Montreal’s Institute of Clinical Research: “It is impractical, it is not cost-effective, it is ineffective in stopping the spread of infection, and it would seriously wound the rights and social status of people who will be branded by false positive

results. In short, it is stupid.” And according to Greg Smith, co-ordinator of Canada’s National AIDS Centre, such tests would have to be repeated continuously to be effective— and even then would fail to protect the general population from infection. Declared Smith: “You can get a card Friday declaring yourself to be AIDS-free, and depending what you did on the weekend it might be worthless by Monday.” And many experts put forward ethical arguments for their oppo-

sition. Said Roy: “Once we have identified the carriers, what do we do about them? Attempting to control their behavior would be terribly fascistic and completely impractical.” Added Smith: “Mandatory testing alone doesn’t protect people from infection. In order to achieve that, once you find the infected people you have to remove them from the social fabric.”

In contrast to Reagan’s stance, federal Health and Welfare Minister Jake Epp maintains that Canadian government policy is still in harmony with scientific and medical opinion on the subject. According to Epp, that position encourages voluntary testing, ensures confidentiality and seeks to provide counselling before and after

testing. “At the present time there is no advice that I have received that we should change our policy,” Epp told Maclean’s last week. Still, Epp acknowledged that federal health officials were discussing the possibility of requiring prospective immigrants to undergo mandatory AIDS tests. And he refused to rule out other changes in future. Declared Epp: “As other countries consider some form of mandatory testing, there will have to be public explanations as to why Canada has not moved in the same direction.”

But even if opponents of mandatory testing prevail, the seemingly inexorable spread of AIDS threatens Taylor’s plea for tolerance and civilized behavior. Many of the researchers at the conference are working hard to make her request unnecessary—by finding a cure for the disease. But as paper after paper demonstrated, that longed-for breakthrough is not yet at hand.