Comment re: E d i t o r i a l b y G . G . F r 6 s n e r : " W h a t I n f e c t i o n 15 (1987) 1-2

Can Be Done Against the Further Spread of AIDS?"

Professor Fr6sner has written a thoughtful editorial outlining his opinions about how the spread of AIDS can be prevented. I agree virtually completely with his "conclusions" (really, the premises upon which his subsequent arguments are based): AIDS is spread by the same routes as hepatitis B, a large proportion of infected persons will develop some disease, the number of diseased persons in a population gives no information about how fast the infection is spreading, and a vaccine will not be available in the immediate future. However, both I (and virtually all public health authorities and AIDS experts in the United States) disagree categorically with his proposal that mandatory serologic testing coupled with legal restrictions on behavior are the best way to control spread of the disease. I am not saying that such measures will be completely ineffective; I am arguing that the economic, social, and political disadvantages of such measures outweigh the advantages. Control measures for AIDS must take into account the fact that transmission virtually always necessitates consenting behavior by both the infected party and the recipient of infection (with the sole exception of blood-product related transmission, now largely controlled by serologic testing of blood donors), and that any control measures will have an impact on society which must be assessed and compared with the estimated value of the control measures. Let us critically examine each of the putative advantages that Professor FrOsner attributes to mandatory universal serologic testing. It is true that such testing would provide reliable information about the prevalence of Human Immunodeficiency Virus (HIV)infection, but selective anonymous testing can provide the same information without compromising individual liberty and privacy. It is not necessary to know who is infected to provide information about preventing the spread of HIV infection - in fact, since transmission requires consenting behavior by both infected and uninfected parties, the consensus opinion in the USA is that everyone should be informed about high-risk behavior. The central means by which Professor Fr6sner proposes to control AIDS is by identifying those persons spreading the disease using repeated universal mandatory serologic testing coupled with contract tracing of newly infected persons; those individuals spreading infection would then be counseled or dealt with by legal action (the nature of which is not specified). This method of control is flawed for both economic and social reasons. A single serologic test for HIV antibody costs 10-30 DM, depending on the effort required to obtain the sample; presuming some reasonable testing interval, say every six months, the cost of the screening program would be a minimum of 1200 million DM per year in Germany alone. A truly universal 160 / 10

program of testing with efficient contact tracing would probably be much more expensive. Even with the best of programs, some anonymous sexual contacts would remain elusive. The restrictions of personal liberty and privacy imposed by such a program would be enormous particularly with respect to the legal actions necessary to prove that private acts actually resulted in transmission and to ensure that such acts did not occur again for the lifetime of the infected, irresponsible carrier. Are such restrictions of personal liberty and privacy warranted by the circumstances? I think not. It is not clear to me that AIDS represents a greater risk to Western society than some other unhealthy behaviors such as alcohol or tobacco abuse. (In the USA alone, tobacco consumption presently is estimated to cause about 300,000 premature deaths per year - about the cumulative total anticipated for AIDS by the year 1991.) It is therefore impossible to justify greater restrictions on personal liberty and privacy than those presently imposed for control of these other unhealthful behaviors. A more serious objection to Professor FrSsner's proposal is that implementation of such a program does not carry a guarantee of success. Governments have been notoriously unsuccessful in restricting or preventing many similar human activities thought to be undesirable, including prostitution and drug abuse. What hubris makes us think that legal restrictions will provide definitive control of the spread of AIDS? We have not successfully eradicated any communicable disease (other than smallpox), and even the most Draconian sanctions have had minimal impact on other unhealthy activities such as drug abuse. Sexually-transmitted diseases in particular have been notoriously difficult to control legislatively, and there is no reason to think that AIDS will be different. Suggesting that we can control AIDS by legal sanctions is holding out false hope. In summary, the potential benefits of the compulsory/legal approach to the control of AIDS (mandatory serologic testing, contact tracing, and imposition of quarantine or other legal sanctions on those transmitting the disease) are speculative, and are far outweighed by the economic costs, social disruption, and restriction of individual liberty and privacy such a program would entail. Control of AIDS is best achieved by using extensive education and intensive peer pressure to alter human behavior, and utilizing those public health statutes already enacted to deal with the unusual case of continued actions harmful to public health. J. Mills J. Mills, M.D., AssociateProfessorof Medicineand Microbiology,Uni-

versityof California,San Franciscoand San FranciscoGeneralHospital, Medical Center, 995 Potrero Street, San Francisco,CA 94110.

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R e p l y to c o m m e n t f r o m J. Mills on: E d i t o r i a l , G. G. Fr6sner, " W h a t C a n B e D o n e A g a i n s t the Further Spread of AIDS?" I n f e c t i o n 15 (1987) 1-2. Dr. Mills claims that control of AIDS is best achieved by extensive education to alter human behaviour. However, this has been attempted without success in homosexuals from New York (JAMA 255, 2167-2172 [1986]) and San Francisco (MMWR 34,573-577 and 613-615 [1985]). In spite of "safer sex", leading to a decline in gonorrhoea rates since 1981; the incidence of serologically proven new HIV infections in susceptible individuals has not decreased. For the San Francisco cohort study an incidence of 26% can be calculated for susceptible individuals in 1985! Reduction in the number of sexual partners is inefficient if the next sexual partner is already infected in more than 50%. The use of condoms is inefficient if there is an occasional failure and an infected person is infectious for on average ten years. On the other hand, with the increasing prevalence of HIV in the population the probability of infection is increasing. From the available data it can be concluded that the majority of still sexually active homosexuals will die of AIDS in the U.S. We should start now to think of how part of the coming holocaust can be prevented. I agree with Dr. Mills that legal restrictions can never provide complete control. However, in European countries mandatory screening of prostitutes, as well as regular screening of hospital patients and pregnant women, proved highly efficient in reducing the prevalence of syphilis in the general population. On the other hand, the abolishment of legal restrictions for certain forms of drug abuse in Amsterdam considerably increased the number of deaths due to this cause. There would be no laws if we were really convinced that laws were useless in controlling human behaviour and in protecting rights. In computer simulations of the AIDS epidemic the knowledge of an individual on its infectivity was shown to be one of the most important parameters for the prevention of the further spread of HIV in a population. Only if infected persons know about their infectivity Can they protect their sexual partners in an optimal way, and also the sexual partners can protect themselves best. Unfortunately, in Germany about 90% of infected persons refuse to participate in voluntary testing because it is of no benefit (no treatment is available) for them. In this situation a government which feels responsible for the lives of its citizens has to start mandatory screening tests. Identification of the sources of infection is an essential rule in fighting every epidemic. Another basic rule is prevention of transmission from the identified sources of infection. Here we are in a rather

bad situation because no efficient treatment is yet available. Our best weapon is the repeated oral and written information of an infected person on the behaviour necessary to prevent transmission to others. A medical doctor has to explain over and over again that the infected person is responsible for the lives of his or her sexual partner(s), family members and other persons (i.e. dentists, medical personnel). The infected person should also know that a failure may be detected at the next screening of the population. If only half of the identified HIV-carriers behave responsibly an estimated 15,000 new infections could be prevented in Germany each year. A cost benefit calculation clearly shows that it is much cheaper to test the adult German population twice a year than to treat preventable infections. If serological testing is done in newly founded, highly automated public health service centers the yearly costs would be less than 250 Million DM (less than three fighter planes). This calculation includes the costs of drawing and testing the blood, of confirming positive specimens and of educating infected persons (personnel, test materials, buildings, administration, equipment). Assuming a manifestation rate of 75% and treatmefit costs of 200,000 DM a case, a positive costbenefit calculation can already be reached after the prevention of 1500 new infections. Countries having the above amount of money available should start screening now to prevent the bankruptcy of the medical system in the near future. There should be no doubt that repeated mandatory serological testing of the whole adult population will give the most reliable information on the prevalence and incidence of HIV infection. Anonymous testing of volunteers is difficult to evaluate and has an unpredictable selection bias. I am aware of the fact that the compulsory/legal approach to the control of AIDS is very difficult to accept for the more liberal US population. Moreover, in the U.S. such screening could only be done on a very inefficient volunteer basis because there is no registration at the place of residence as in Europe. European countries really should consider whether it is desirable to reach a similar situation as in the U.S. in some years' time. In New York and San Francisco, 1 out of 1000 inhabitants is already ill with AIDS and probably more than 1% are infected. Other urban areas are not far behind these figures. Democracy includes the responsibility of the individual for the whole of society. The life of the majority should be counted as more valuable than some individual rights of a small minority. Our children will ask us what we have done against AIDS. G. Fr6sner Dr. reed. G. Fr6sner,Professorfor Virologyat the Ludwig-MaximiliansUniversit/it, Mfinchen,Arzt ft~rMikrobiologieund Infektionsepidemiologie, Max-von-Pettenkofer-Institut,Pettenkoferstr.9a, 8000 Mfinchen 2, FRG.

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