In public health, contact tracing is the identification and diagnosis of people who may have come into contact with an infected person. Historically contact tracing has been the mainstay for controlling epidemics caused by infectious agents regardless of the means of spread. However, contact tracing for HIV has not been universally employed to prevent the spread of the HIV epidemic. Initial arguments against the use of contact tracing for HIV focused on issues of confidentiality and discrimination and for good reason. Early in the epidemic AIDS was viewed as a “gay disease” and resulted in unacceptable levels of stigma and blame. It was further argued that without treatment, there was no need to identify individuals who were exposed to HIV. Thus any benefit derived from contract tracing would be negated by the risks of stigmatization and discrimination. Although these arguments dominated public health policy for decades it was shortsighted as it focused solely on treatment and not prevention thereby allowing sexual transmission of HIV to millions of individuals who were unaware that they were being exposed to continue. It also resulted in a delayed diagnosis of HIV in those who were already infected, but unaware of their infection, and thus unable to access lifesaving treatment before their infection reached advanced and untreatable stages of disease.
By 1996 international HIV clinical experts were calling for the treatment all HIV infected individuals with combination antiretroviral drugs based on studies that had shown that combination antiretroviral drugs could halt disease progression and prevent HIV transmission. Tragically, the national and international public health community contained to ignore the urgent need for contact tracing as a means of bringing the HIV epidemic to a halt. The delay ensured on ongoing epidemic affecting millions of men, women, and children each year.
Today all modes of HIV transmission are known and are preventable. There are over 30 drugs and combination of drugs to both prevent and treat HIV infection. The failure to conduct tracing as a means to prevent new infections and identify those who could benefit from lifesaving treatment has resulted in the needless continuation of the global HIV epidemic, especially among vulnerable populations, a circumstance that of itself can be considered discriminatory. My view on the need to fully implement contact tracing for HIV has remained steadfast since 2005 when I called for universal HIV testing coupled with protection from discrimination. Clearly, without contact tracing the HIV epidemic will not end. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC545213/)
Women are particular vulnerable to the failure of public health agencies to conduct contact tracing. Following my presentation on HIV Prevention at the 2000 International AIDS conference in South Africa, a woman in the audience stood up and challenged me, ”Why do you keep talking about testing women for HIV? How do you think we get infected?” A provocative question, and the point she was making was valid. She was pointing out that most women who are HIV infected had no choice in the matter. The fact is that 30 years after AIDS was first described, the HIV epidemic, especially in women, has not been brought under control. An estimated 14 million women had become HIV infected since the year 2000 and some 3,500 women continued to be infected each day – sobering numbers that are far too great to dismiss.
It is almost certain that none of the women would have willingly undergone the risk of a fatal viral infection had they known that their sexual partner was HIV infected. And in almost all instances they had no choice―no one warned them that they were being exposed to HIV. As more and more women continue to become infected many are asking a very logical question, “How can anyone expect to stop the HIV epidemic that is infecting millions each year, causing the death of millions more, and costing billions of dollars for treatment and care without knowing who is infected and without telling individuals that they are being exposed to HIV so that they can protect themselves?”
The HIV epidemic is complicated by stigma and discrimination, two unacceptable social outcomes of HIV infection. That creates reluctance by many to reveal their HIV status lest it also result in violence. Yet, the objection that divulging one’s HIV status might result in stigma or harm while possible, cannot be weighed against the certainty that HIV infection is lethal unless treated. Even with treatment, which is lifelong, drugs are expensive and associated with significant side effects. Further, if undetected, HIV infection is transmitted from one sexual partner to another thereby multiplying the number of individuals who become infected. It can also be transmitted to infants born to HIV infected mothers resulting in a new generation of HIV infected individuals. Today, the scales are tipped in favor of contact tracing. Rather than accepting individual examples of sexual violence as sufficient evidence to keep us from protecting millions of individuals from HIV, we need to take seriously the evidence derived from the many clinical studies that conclude that HIV infection of women may be yet another manifestation of violence against them. If true, then we must, and should, develop international laws to protect women from stigma, unwanted sex, sexual violence of any form, and we must find a way to inform women that they are at risk of HIV infection.
There is a very straight-forward fix to all this: “Do ask. Do tell.”
- “Do ask” is asking your sexual partner if they have been tested for HIV and asking them for the result. Every individual has the right to protect themselves from a preventable infection.
- “Do tell” is telling your sexual partner if you have been tested for HIV and telling them the result.
Each and every life is too valuable to be shortened by an infection that can be prevented. Just how urgent is “Do Ask. Do Tell?” The number of individuals who do not know they are infected is likely to be over 300,000 in the United States and over 10 million worldwide! Imagine the lives that could be saved if all of those people got tested, knew their HIV infection status, and warned their sexual partner to protect themselves from HIV infection. As important, testing could also identify those who are already infected who could then benefit from early treatment and transform a uniformly fatal infection into one that can be controlled. For a woman knowing if she is being exposed to HIV or has HIV is the best way to prevent HIV infections and end the pediatric HIV epidemic. No matter what the experts say about the potential for controlling the epidemic, it cannot be controlled until everyone who is sexually active is tested for HIV and accepts the ethical responsibility of protecting their sexual partner from HIV by telling them of their HIV infection status.
Each year, the U.S. Public Health Service and advocacy organizations embark on an annual campaign to encourage HIV testing on National HIV Testing Day. Credit must be given to them for moving forward with this agenda and emphasizing that universal HIV testing, in all health care settings, can save lives and slow the HIV epidemic. Their “talking points” highlight the role that communities, doctors, public health agencies and individuals can play in increasing the acceptance of HIV testing. But strikingly absent from the recommendations is asking individuals to move beyond HIV testing and accept the ethical responsibility of telling their sexual partners if they are infected. Public health agencies cannot and should not force individuals to be tested. But this does not excuse individuals from their responsibility to protect others from HIV.
In an epidemic that has gone on far too long and has been too costly in human suffering and premature loss of life it is irresponsible to believe that we can continue to treat all those who are infected with increasingly complex and expensive drugs while ignoring other means of HIV prevention. It is time to question the current public health approach to controlling the HIV epidemic and deliver the message that it is the responsibility of individuals, indeed, their ethical duty, to protect themselves and others from HIV infection. Further, in an epidemic that disproportionately infects women and children who are kept from the knowledge that they are being exposed to HIV it is unconscionable to ask them to continue bear the burden of undisclosed HIV infections. Life is too precious to allow it to be destroyed by a preventable infection. “Do Ask. Do Tell” is an essential means to end this tragic epidemic.