The Lancet was correct. The February 14 cover calls for contact tracing to control the Ebola virus epidemic. “To get to zero new infections means identifying every case and every contact.. .Ebola is not yet under control.” An accompanying editorial emphasizes the devastating effect of the spread of Ebola on regions, communities, economies and health systems.1 The need for contact tracing is further emphasized by Frieden, Director of the U.S. Centers for Disease Control and Prevention in an article appearing in the New England Journal of Medicine. “Three core interventions have stopped every previous [Ebola] outbreak and can stop this one as well: exhaustive case and contact finding, effective response to patients and the community, and preventive interventions.”2 Indeed, getting to zero through contact tracing should be the goal of all public health approaches for controlling infectious disease epidemics.
HIV stands out as a public health exception. Early in the AIDS epidemic there seemed to be good reasons for not conducting contact tracing—stigma, discrimination and even violence were associated with HIV disclosure. Further there was no treatment for HIV. But as devastating and stigmatizing as the Ebola epidemic was with more than 22,000 individuals infected and over 10,000 deaths, it is dwarfed by the HIV epidemic which in just one year is estimated to have resulted in more than 2 million new infections and 1.5 million deaths. The Ebola virus epidemic has stopped – the far greater HIV epidemic has not.
It can be argued that the failure to identify the millions of individuals who are exposed to HIV without knowing it and the estimated 19 million people living with HIV who do not know that they are infected is a form of discrimination of a far greater magnitude, denying millions of individuals of their right to know that they are either being exposed to a potentially lethal infection or are already infected. It would seem de facto that they are denied their right to health (and life) through known methods of HIV prevention and treatment.
The failure to employ contact tracing for HIV is an outlier in public health policies for controlling communicable diseases—HIV remains the only sexually transmitted infection that does not utilize contact tracing to identify individuals who might be exposed to infection. While the right to privacy is an important individual right, there is both an ethical obligation on the part of individuals who know they are infected to identify individuals who might be exposed to infection, and an ethical and legal obligation of healthcare providers to warn individuals who might be exposed to HIV of their risks, and if warranted, to recommend HIV testing. (The duty to inform in relation to HIV will be discussed in a subsequent commentary.)
The failure of major public health institutions to recommend contact tracing for HIV at this time in the epidemic demands an explanation. When organizations such UNAIDS set a goal of zero infections for HIV and call for 90% of people living with HIV knowing their HIV status and 90% of people who are HIV infected placed on treatment by 2020—they need to be called on to explain just how that will be possible without contact tracing—nowhere mentioned in their publication.3 As both the Lancet and the New England Journal of Medicine point out, contact tracing is a foundational public health tool for controlling infectious disease epidemics. Obstacles to implementation for HIV need to be solved now. HIV can no longer be an exception. In 2015 the denial of life saving public health measures is a severe form of discrimination for the millions of individuals who are exposed to HIV and are unable to protect themselves from infection and the millions who are already infected but unaware of their infection and therefore unable to access life-saving treatment
1- Ebola in west Africa: getting to zero. Lancet 2015;385:578.
2- Frieden TR, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014–new challenges, new global response and responsibility. N Engl J Med 2014;371:1177-80.
3- Getting to zero. 2014. at https://www.unaids.org/sites/default/files/sub_landing/files/JC2034_UNAIDS_Strategy_en.pdf. (Accessed March 1, 2015).