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A strategy to prevent the spread of AIDS.

Dr. Burke's strategy, presented in Nashville to the Presidential Commission on the HIV Epidemic, met with resounding support from most members.

Editor's note: Colonel Burke, currently the chief of the Department of Virus Diseases at the Walter Reed Army Institute of Research in Washington, D.C., received his M. D. from Harvard Medical School. After junior and senior residencies in internal medicine on the Harvard Medical Services at Boston City Hospital and Massachusetts General and training as a research fellow in infectious diseases at the Walter Reed Army Institute of Research, he spent six years in Thailand conducting medical research on epidemic tropical diseases. Today his duties at Walter Reed include responsibility for the design, conduct, and quality control of army HIV screening programs. He also serves as an attending physician, providing medical care to patients with AIDS and other manifestations of HIV infection.

The Presidential Commission on the HIV Epidemic has heard ample opinion ftom witnesses on the theoretical adverse effects of HIV screening programs. I would like to directly address, and thereby refute, some of the more common misconceptions and concerns about HIV screening:

Misconception #1: "False-positive test results are common."

Fact: The false-positive error rate in the army HIV screening program has been measured to be only I out of every 135,000 persons tested. The fact that falsepositive rates are unacceptably high in some private-sector laboratories is a direct consequence of the feeble quality-control programs implemented by civilian public-health authorities. The problem of false-positive test results is eminently correctable; it does not reflect any inherent technical limitations of the testing methods.

Misconception #2: "HIV screening is not cost-effective."

Fact: Laboratory test costs are $4 per person screened in the army program. Among civilian applicants for military service, the cost per case detected is about $2,500 nationwide. The cost in the New York, Washington, and San Francisco areas is about $300 per case detected.

Misconception # 3"The logistical problems of setting up a program for HIV screening are insurmountable."

Fact: On August 30, 1985, Deputy Secretary of Defense Mr. Taft directed that all applicants for military service would be tested. Within six weeks, the program was in full operation with 60,000 persons tested each month.

Misconception #4: "Suicides are commonplace when wide-scale testing is implemented."

Fact: Among the 1.8 million applicants for military service who have been screened during the past 2-1/2 years, there have been 3,000 persons found to be HIVinfected. All have been informed of their infected status. No one has committed suicide as a consequence of learning of the test results.

Misconception # 5"The requirement for pretest counseling renders routine testing programs prohibitively expensive."

Fact: For civilian applicants for military service, "pretest counseling" consists of distribution of a one-page fact sheet. Individualized, one-on-one counseling is provided only as posttest counseling to persons who have tested seropositive.

Misconception #6: "Because there is no cure for HIV, testing is useless."

Fact: HIV-infected persons are directly benefited by knowledge of their infected status. First, they can be assured of prompt diagnosis and effective therapy of opportunistic infections. Second, HIV-infected persons who know their infected status may be able to slow progression of AIDS by careful attention to diet, physical fitness, and avoidance of other infectious diseases. Third, HIV-infected persons can avoid the guilt and pain of having unwittingly transmitted potentially fatal HIV infections to their lovers or spouses.

Misconception #7: "Wide-scale screening for HIV will drive the epidemic underground."

Fact: To date only 75,000 HIV-infected persons have been diagnosed as HIV-infected through the alternative-test-site programs. This represents only about 5 percent of all HIVinfected persons in the United States. Restated, 95 percent of HIV-infected Americans remain totally unaware of the fact that they can transmit a fatal communicable disease to their sexual partners. As a direct consequence of a national failure to encourage widescale routine testing, the epidemic is already underground.

I reject the passive and fatalistic attitude, championed by some, that effective routine HIV testing is beyond the capability of the U.S. publichealth machinery. The means are in hand today to establish an accurate diagnosis in each and every case of HIV. We as a society must abandon th "strategy of ignorance." We can no longer systematically deny the rights and benefits of painful but critically important knowledge to the 1.5 million members of our society who carry a fatal infectious disease. We must set, as a clear goal, wide and free availability of high-quality HIV testing.

How do we achieve this goal of accessible, high-quality HIV tests? I suggest that the commission should make the following four fundamental recommendations to the President:

Recommendation I: Rigorous quality control of HIV testing must be implemented immediately throughout the United States. This should include (a) establishment of guidelines for licensure or certification of all laboratories that perform HIV confirmatory tests and (b) creation of a national HIV proficiency test program in which substantial numbers of difficult test serum samples are sent on a regular basis to testing laboratories. Satisfactory performance in this program should be a requirement for continued certification.

Recommendation II: New, "second generation" diagnostic tests for HIV should be put on the fast track for licensure. Regulatory control of confirmatory tests for HIV should be removed ftom the Division of Blood and Blood Products of the FDA and placed instead in the Division of Medical Devices. This step would speed the availability of highly accurate yet low-cost HIV diagnostic tests, particularly those which are based on molecularly cloned and expressed HIV antigens.

Recommendation III: Clear and compelling legislation should be enacted at a national level to ensure the continued rights of HIV-infected persons to housing and employment. National leaders of high public visibility, such as the President and the Surgeon General, should forcefully denounce acts of irrational discrimination-such as the recent burning of the house of the three hemophiliac boys in Florida-and should frequently praise, in public, acts of compassion and understanding. Strong and sustained leadership is necessary to destigmatize HIV.

Recommendation IV: Public-health policies at the local, state, and national levels should include routine HIV testing as an important strategy for infection control. Infected persons detected in routine screening programs should be the focus of intensive yet compassionate counseling to ensure that they fully understand the fatal and communicable nature of the virus infection they carry.

If these four recommendations are implemented, I believe that the goal of epidemic control through widescale HIV testing and counseling of seropositives can be achieved.
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Title Annotation:Dr. Donald S. Burke
Author:Burke, Donald S.
Publication:Saturday Evening Post
Date:May 1, 1988
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