Failing the AIDS Test

While a cure for AIDS is still not in sight, in a country with Israel's level of literacy, and cultural and public-health sophistication, it should be possible to bring the level of new cases down to very low numbers.

As AIDS remains the No. 1 health threat in the world, it is also a growing problem in Israel. Last week, Haaretz and other news outlets reported on new data, collected by the Israel AIDs Task Force, suggesting an alarming rise in the number of new HIV-positive cases in the country last year, with a significant percentage of them among the gay population and intravenous drug users. The total of diagnosed HIV carriers in Israel is now estimated at about 5,500, and best estimates are that an equal number remain undiagnosed.

It needn't be this way. While a cure for AIDS is still not in sight, in a country with Israel's level of literacy, and cultural and public-health sophistication, it should be possible to bring the level of new cases down to very low numbers. So why is the number of new AIDS cases outpacing any gains in control, treatment or education among high-risk groups?

The answer lies in the unwillingness on the part of the Health Ministry to adopt control measures, including routine testing among selected, broad age groups. For example, any time a blood sample is taken from residents ages 13-64, up to twice a year, the ordering physician should have the right to scan for AIDS. For those who don't visit a doctor during a given year, blood tests could be scheduled, with the results recorded by the ministry.

When bird flu was a threat several years ago, strict mandatory testing measures were brought into play in various parts of the world, and a potential epidemic was avoided. Because AIDS is a slow virus, unlike bird flu, it can remain "silent" for years before symptoms appear, even though a simple blood test can provide a positive result. Because we do not test all risk groups mandatorily, AIDS has become a secret disease, with 20-40 percent of sufferers not being aware that they are infected, meaning they can pass it on unknowingly.

The AIDS epidemic is spread only by blood, sex, needles and during pregnancy, but within those parameters, everybody is equally susceptible to it, regardless of gender, age or social status. So, in 2006, when the U.S. Centers for Disease Control and Prevention did a major public policy about-face when it recommended that doctors offer AIDS tests not just to people at risk, but as part of routine medical care to all patients ages 13 to 64, it was a giant step forward. This was true even if the new policy lacks a mandatory element. Nonetheless, even this voluntary recommendation has not been adopted in Israel.

In fact, at present, not even pregnant women in this country are regularly tested for AIDS. Instead they must request to be tested, and one can understand that many people are not interested in receiving such potentially frightening information. Furthermore, when a case of HIV-positive blood is discovered, there is no mandatory treatment or counseling for the patient, nor does the law require that his or her partners be notified or tested. Any or all of these measures are taken on a purely voluntary basis.

Israel has consistently followed a dysfunctional U.S. AIDS policy in not invoking a policy of routine universal testing, tracing and treatment, and the result has been an increase in AIDS cases, many of which could have been prevented by simple public health initiatives. Blood testing should be mandatory once or twice a year when a patient visits the doctor's office or hospital. Mandatory testing already exists in blood banking and the military, and is a policy of many insurance companies. Many other routine blood tests are done without the patient's permission or knowledge when the doctor deems it advisable, and so it should be with AIDS.

The paradigm of excellent AIDS control can be found in Cuba, which first discovered this sexually transmitted disease - long before it was named - among its mercenary soldiers when they returned from Angola in the 1960s. Discrimination was never practiced against those who contracted the disease, and mandatory testing, tracing and treatment resulted in the lowest AIDS rate in the Western world.

A light unto all nations? Not when it comes to AIDS public policy in Israel, until there is universal testing and mandatory reporting, tracing and treatment. Until we have it, the government will not be fulfilling its obligation to protect the public health interests of the country's uninfected population.

To be clear: No Israeli need ever be quarantined for HIV/AIDS and no new immigrant should be refused entry to the country based on it or any other disease. However, all citizens are entitled to the same public health protection under the law that is afforded them already against tuberculosis or bird flu. And whereas quarantine has been used to fight deadly viruses like bird flu, which is spread by sneezing and coughing, it is not necessary with AIDS, which is spread via other means.

There will be no forgiveness when future generations look back to see what went wrong with medicine and public health during these last few decades, when universal testing, tracing and treating could have been put into place, and could have saved and prolonged uncountable numbers of lives. There is, however, an opportunity for Israel to lead and not follow poor public health policy.

Dr. Sanford Kuvin is founder and international chair of the Kuvin Center for the Study of Infectious and Tropical Diseases at the Hebrew University Medical School, and a frequent commentator on public health issues.