Health care policy: what lessons have we learned from the AIDS pandemic?

• Author: Pratt, David
• Position: Symposium on Health Care Policy: What Lessons Have We Learned from the AIDS Pandemic?

I want to congratulate the editors of the Albany Law Review for scheduling this symposium a week after the Nushawn Williams case hit the headlines.(1) That was really very prescient of them. The Nushawn Williams case illustrates some of the dilemmas that we face in developing appropriate public policy for HIV reporting and testing. Mr. Williams actually went to a clinic voluntarily to receive treatment for a sexually transmitted disease.(2) He was tested voluntarily for HIV and when he was found to be positive he voluntarily disclosed, with some pride I believe, the names of many of his partners.(3) There is a question as to whether he would have done so if he had not been guaranteed the confidentiality to which he is entitled under current law.(4) Perhaps the most distressing aspect of the Nushawn Williams case is the fact that his partners, although obviously on one level aware of the danger of unprotected sex, thought it simply could not happen to them. Some of his partners were quoted by the doctor who treated them as saying that Mr. Williams was respectful and did not have the look of an infected person.(5) After all these years of dealing with AIDS and trying to develop AIDS education programs, it is distressing that these young women were so cavalier about their own safety.

In terms of AIDS statistics, there is some good news, but the good news has to be viewed with some caution because it is not uniformly good. In 1996, for the first time since the AIDS epidemic became a matter of concern in the early 1980s, both the number of AIDS deaths and the number of new cases diagnosed dropped.(6) The number of deaths dropped by 23%(7) and the number of new cases diagnosed with AIDS dropped by more than 6%.(8) There were some populations, however, where the number of new cases actually increased. The number of heterosexual men diagnosed was up by 10%(9) and the number of women was up by 7%.(10) Moreover, there has been a significant shift in the population which is infected with AIDS. Today about 52% of all Americans living with AIDS are either African-American or Hispanic.(11)

The issue of testing has come to the fore for a couple of reasons. As Ronald Bayer has pointed out, the AIDS epidemic has been treated somewhat differently than most epidemics.(12) He attributes this to the fact that the original people identified as suffering from the disease were largely white gay men who were vocal in defense of their hard won civil rights.(13) The civil rights of people infected with HIV, therefore, were given much more protection than has been the case with epidemics in the past.(14) There was also a feeling that, as long as there was nothing much that could be done to alleviate the condition, it was difficult to enforce mandatory reporting.

There are now, however, some strong reasons to think that reporting people who are HIV positive is important and has significant public health benefits. Some of those arguments are developed in an Article by Larry Gostin and James Hodge which is included in this volume.(15) First, reporting gives us a better chance of providing counseling for people who are infected with HIV. Second, there are now drugs which, if used early enough, can actually arrest the development of the disease, lengthen life expectancy for patients and, therefore, may lower the risk of transmitting the disease to others.(16) Presently there are twenty-nine states that have HIV reporting statutes.(17) Three of the five states with the highest population of persons living with HIV or AIDS(18) do not have an HIV name reporting statute.(19) Proposed legislation in New York, one of those five states, has repeatedly failed.(20) Today there are an estimated 250,000 Americans living with HIV who are unaware of their infection.(21)

One of the major concerns that I have in connection with AIDS and HIV infection generally is access to health care for the population that is affected. A 1993 report estimated that the lifetime annual cost of care after an HIV diagnosis averages $119,000.(22) My guess...