Writing on World AIDS Day in the OpEd pages of the Washington Post, Sanford Kuvin opines that Mandatory testing and treatment can end the AIDS epidemic. I find that conclusion both highly questionable and morally ambiguous, and I suspect there may be ulterior motives at work behind Kuvin's opinion.
Kuvin takes as his starting point that more than half of the persons in the United States who are living with AIDS or HIV are black--which is about the only thing in this piece that I'm not quibbling about. There were any number of places I would have expected his column to go after such an opening, but Kuvin went to none of them. Instead, he chose to bash the Centers for Disease Control and Prevention. Then things got really weird:
Any time blood samples are taken from U.S. residents ages 13 to 64, such as in an emergency room, physicians should have the right to scan for HIV. For those who don't regularly visit a doctor, blood tests could be scheduled, with the results recorded by states and the CDC.
There are all manner of things wrong with this idea. First, while I wasn't able to find any sources online for the number of routine blood tests that are run every year in the United States, I would imagine it is quite substantial. Virtually every time you go to the doctor anymore, they want a blood sample for something. Second, according to the 2007 American Community Survey (the latest readily available demographic information about the U.S. and its population from the Census Bureau), the population that Kuvin wants to test comprises approximately two-thirds of the U.S. total population of some 301.6 million. That's more than 200 million people. (The groups from ages 15 to 64 comprise 67.2% of the total population; without more detailed statistics, I can't get a hard number for the 13-to-64 set that Kuvin referenced. It's still an awful lot of blood tests.) Thirdly, a standard HIV test costs around $50 on average. Assuming, arguendo, that perhaps a third of the 13-to-64 population goes to a doctor and gets a blood test in an average year, that's around 68 million blood tests. At $50 a pop, the bill comes to about $3.4 billion--just for the testing.
For the purposes of comparison, I'll point out that the Senate's proposed expansion of the SCHIP program to cover uninsured children and families would have cost about $7 billion more per year than we were already spending--and the Republicans and all the conservative think-tanks (if that's not an oxymoron) argued that it was far too expensive. SCHIP currently covers approximately 7 million people. There are, by contrast, just over one million people living with AIDS or HIV in the U.S. today. With an annual incidence estimated at around 56,000 new cases of HIV infection per year, cost-benefit analysis suggests that the costs involved in Kubin's proposal far outweigh its benefits.
There is also, of course, a huge privacy issue involved. It is not normally the case that doctors can just go ahead and do whatever they want with a patient--or a patient's tissues, bodily fluids, or other biomedical materials. There is a presumption of informed consent--if not by the patient, then by someone who is responsible for the patient, either in a parental or a custodial role. I would have to say that deciding to get an HIV test would definitely be something that should fall under the informed consent rules.
It appears, from a quick Google search, that mandatory HIV testing is a bit of a bugaboo for Dr. Kuvin, who wrote this letter to the editor of the International Herald Tribune in 1998, and this article, which has marked similarities to the piece in the WaPo today, in Ha'aretz this past July. That fact might go a long way toward explaining his abject and utter failure to acknowledge the cultural factors involved: specifically, the pervasive homophobia in the black community which results in phenomena such as the "down-low" lifestyle.
It certainly seems to me that a far more effective strategy for reducing the incidence and spread of AIDS and HIV in the United States--and especially in the black communities in the U.S.--would be targeted, frank, factual education. That has been in short supply during the eight years of the notoriously anti-gay, anti-sex, abstinence-only Bush administration which is, thanks be to God, about to come to its horrific end. Education can work, if it is done properly--there is ample evidence to support this conclusion in all areas of sexuality education, and also in AIDS/HIV specifically. I suspect that the reason more black people don't get tested for HIV is because there is an incredible stigma associated with an HIV or AIDS diagnosis, and, especially within the black community, an equally incredible stigma associated with having (or even being interested in having) gay sex. As that is one of the more common means of HIV transmission, it's not hard to understand the resistance.
This is clearly an area where we're going to have to do some work under the Obama administration. We have got to start giving realistic information to young people and teaching them how to make responsible decisions about their own bodies and what they do with them. That's the first priority. Then we've got to start some serious dialogue between the gay community and the black community--on this issue, to be sure, but also generally. I am thoroughly sick to death of being told that the struggle for gay rights is in no way similar to the struggle for black civil rights, for example, and I am dismayed both at the fact that black voters in California overwhelmingly supported the heinous Proposition 8 and at the racist backlash that resulted (born largely, I sincerely hope, from the frustration and disappointment attendant upon that close-but-crushing loss, and not from any deep-seated racism within the gay community) in certain parts of the gay community.
Education will almost certainly be less expensive than mandatory testing would be. It is also far less intrusive of a person's privacy and does not infringe upon his/her right to make medical decisions for him/herself. Its results are far more likely to be lasting, and the benefits of an increased dialogue between the gay community and the black community will, it is sincerely to be hoped, bear fruit in other areas as well.
So I'm sorry, Dr. Kuvin, but I think we're going to pass on your idea. It just doesn't make the cut in this day and age.