The Sixth International AIDS Conference in San Francisco next week is being boycotted because U.S. policy restricts travel and immigration of foreigners infected with the AIDS virus. All persons applying for permanent residence must be screened for HIV. Temporary travelers must declare their HIV status and are tested if there is suspicion that they are infected. "Suspicion" has in the past been triggered by the possession of antiviral medication, a medic alert bracelet for hemophilia or the intention to attend an AIDS conference.
The Immigration and Naturalization Service has granted waivers to all persons attending the San Francisco meeting. But this has not reduced the implacable international opposition to U.S. law. Remarkably, the INS recently"The U.S. program actually causes people to avoid testing and to falsify their results." announced that it would strictly enforce current regulations that prohibit entry of homosexuals to the United States even if they are only going to briefly attend the San Francisco AIDS Conference.
The INS is conducting one of the largest HIV screening programs in the world. More than 3 million foreigners trying to enter the United States have been tested. Yet the program is both ineffective and unjust. Even under optimistic assumptions, the U.S. screening program results in one false positive result for every 15 infected persons detected. Thus, hundreds of persons not actually infected with HIV are being unfairly denied entry to the United States without any mechanism to rectify this serious error.
From a global perspective, the testing and exclusion of international travelers is a specious public health policy. The only potential global effect of restrictions might be to shift the geographic distribution of the epidemic marginally. It is ironic that the United States -- with one of the highest prevalences of HIV in the world, and with citizens who travel widely -- restricts the travel of persons infected with HIV to our country.
The U.S. policy is harmful to the public health. Certainly, no effort is made to provide people with the education and counseling needed to help them avoid high-risk behavior. Indeed, the U.S. program actually causes people to avoid testing and to falsify their results rather than promoting testing and changes in behavior. Persons infected with HIV are advised by immigration lawyers to go underground rather than apply for permanent residence, because no waivers are available on humanitarian grounds.
In the xenophobic context of testing "outsiders," it is all too easy to forget that the HIV test is a clinical test designed to promote the health and well-being of the patient. A positive HIV test does not lead to any health services. Indeed, U.S. regulations specify that foreigners may not be a financial burden and that they are ineligible for Medicaid.
Restrictions based upon infection rather than risky behavior are discriminatory and overly inclusive. The U.S. program penalizes those who behave responsibly, as well as those who do not. It is also arbitrary, because it does not include hundreds of millions of people who come to the United States who do not need a visa and returning nationals.
Even the Centers for Disease Control has argued that the policy is ineffective and has recommended its repeal. Recently Rep. J. Roy Rowland (D-Ga.) introduced a bill to empower the CDC to amend the regulations so that foreigners infected with HIV could travel and immigrate freely.
Wide support in favor of a change in the law is evident in the Bush administration and in Congress. But the issue is so politically unpopular that none of the key players is willing to take action. The Rowland Bill is bogged down in the House. Sen. Ted Kennedy (D-Mass.) and Sen. Alan K. Simpson (R-Wyo.), majority and minority leaders on immigration, are sympathetic, but neither will take the lead. It appears that the House will act only if the Senate acts first, the Senate will act only if the House acts first.
In the meantime, there is a strong possibility that the 1992 international AIDS meeting (scheduled for Boston) will not take place at the Harvard AIDS Institute. It is possible that after next week, no formal international AIDS meeting will take place in the United States until the law is changed.
Rather than arbitrarily restrict the movement of a subset of infected people, the U.S. government should dedicate itself to the principles of justice, scientific cooperation and a global response to the HIV epidemic. Larry Gostin is executive director of the American Society of Law and Medicine. Paul Cleary is an associate professor at Harvard Medical School. This article is also appearing in the New England Journal of Medicine.