27. Memorandum From the Domestic Policy Council to President Reagan1
SUBJECT
- AIDS Testing
ISSUE—What additional steps should be taken by the Federal Government to prevent the spread of the HIV virus in America.
BACKGROUND—Since 1981, when AIDS was first recognized as a fatal disease, there has been increasing discussion about the best way to stop the spread of the disease. The Federal Government has been in the forefront of the fight against this deadly virus. Through the efforts of the Public Health Service, the HIV virus that causes AIDS was discovered, the ELISA screening test to detect the AIDS antibody was developed, approval of treatment agents such as Retrovir (AZT) has proceeded, and work has progressed on AIDS vaccines. The blood supply has become safer because of blood bank testing procedures. [Page 75] The Department of Defense has been testing recruits and active duty personnel for HIV virus.2
The State Department has begun testing Foreign Service employees and their dependents for HIV as part of their routine physical examinations.3 The Peace Corps is also testing volunteers who are assigned to overseas posts.
AIDS is now the 10th leading cause of lost years of life in the country and is rapidly becoming the leading cause of death for males ages 20 to 39. As of May 1987, approximately 35,000 cases of AIDS have been reported and more than 20,000 AIDS-related deaths have occurred.
Accurate HIV tests are widely available, but since AIDS itself is always fatal, there continues to be concern about confidentiality and discrimination against individuals who test positive for the HIV virus. However, public health practices have always dictated that in order to control an infectious disease spread by direct person-to-person contact, every effort must be made to limit the encounters between those who are infected and those who are susceptible.
DISCUSSION—In February 1987, the Centers for Disease Control (CDC) sponsored a conference in Atlanta on the role of testing in the prevention and control of AIDS. Although no final agreement was reached, there was a consensus that more testing should be done.
The public is also very concerned about AIDS, as news of the epidemic continues to be reported. In a Washington Post/ABC Poll, conducted in March 1987, 98% of all those polled believed a test for the AIDS antibody should be available for everyone. 83% believed physicians should check for AIDS on all routine examinations, and 85% believed testing should be required for all people about to be married. Many health professionals believe that counseling should be required whenever a person tests positive or negative for AIDS. The [Page 76] cost of this counseling is estimated to range from $22 to more than $100 per person.
The screening test for the HIV antibody costs less than $1.00; however, a confirmatory test is always performed to eliminate false positives. After two positive ELISA tests, a further check is done using the Western blot test. With the incidence of the HIV virus so low, less than one in 50,000 people will falsely test positive on the Western blot test, if quality control such as the Department of Defense (DOD) currently employs is used. DOD indicates that this multi-stage test costs an average of $5.00 per case. Charges may run higher for tests conducted in the private sector. Some claim that there is an extremely high percentage of false positive HIV tests. However, this claim lies only against the ELISA tests and not the complete multi-stage testing procedure.
A new test is being developed by a laboratory in Cambridge, Massachusetts, that would be similar to the home pregnancy test and would be nearly 100% accurate. The Army is currently using this test on an experimental basis. FDA is considering this test, and it may be approved within the next year or sooner.
There are various ways in which HIV tests can be administered. In self-initiated tests, an individual could voluntarily request an HIV test from his physician or any medical clinic. Routine/voluntary tests are done when a health care provider routinely recommends testing on the basis of information provided by a patient who may have an increased likelihood of HIV infection. In this case, the individual understands that the test is strictly voluntary. Routine/required testing could be done where individuals are in high risk groups, in prison, donating blood, organs or tissues, or using the services of a sexually transmitted disease clinic (STD) or drug abuse clinics. There has also been concern expressed by some about the possibility of “mandatory” testing where individuals in the general population would be identified, sought out, and required to be tested.
All HIV infected individuals are potentially infectious, and since most, if not all, infected persons can be detected by currently available diagnostic tools (HIV antibody screening), it is important to consider ways in which wider testing can be done, consistent with established public health procedures that protect confidentiality. These tests could be self-initiated, routine/voluntary, or routine/required.
[Omitted here is material unrelated to AIDS.]
Issue 2: Regulations requiring AIDS testing of aliens and immigrants (routine/required). The Immigration and Naturalization Act authorizes the Secretary of Health and Human Services (HHS) to issue through regulation a list of dangerous contagious diseases for which immigrants and aliens seeking permanent residence in the United States could be [Page 77] denied entry. The regulation is ready to be issued in final form and be made effective immediately.
The Administration could simultaneously issue a proposed rule for public comment that would go even further. Such a rule would substitute HIV for AIDS on the list of dangerous contagious diseases.
All Council members support Option 1, with the exception of the State Department which has concerns about the costs of testing, implementation procedures, and quality control in overseas facilities.
Option 1: Issue the final AIDS rule and the HIV notice of proposed rulemaking simultaneously, with an adequate comment period to take into account cost benefits, implementation, and quality control in overseas facilities.4
Option 2: Issue the AIDS rule only.5
[Omitted here is material unrelated to AIDS.]
- Source: Reagan Library, Bledsoe, Ralph: Files, 320—AIDS Policy (Jan–Jun 1987). No classification marking. A stamped notation on the memorandum reads: “The President has seen” with 5/27 filled in on the line provided.↩
- In October 1985, the Department of Defense adopted a policy to screen enlisted military applicants for exposure to HTLV–III: “The rationale for this policy is that the condition existed prior to service, the Department avoids potential medical costs and the possibility that the individual shall not complete his or her service commitment, clinical evidence indicates that pre-AIDS patients may suffer adverse and potentially life-threatening reactions to some live virus immunizations administered at basic training, an antibody positive individual is not able to participate in battlefield blood donor activities or other blood donation programs, and presently there is no way to differentiate between antibody positive individuals who will progress to clinical disease and antibody positive individuals who will remain healthy.” (Department of State, AIDS, 1984–1987, Lot 89D137, AIDS: Dept. Policy Guidelines/Press) In April 1987, the Department of Defense refined its screening policy, stating that HIV positive individuals “are not eligible for appointment or enlistment for military service.” (Washington National Records Center, OSD Files: FRC 330–91–0033, 907.05, AIDS Research)↩
- See Document 20.↩
- The President initialed the approve option.↩
- There is no indication of approval or disapproval of Option 2.↩