Stigma, Hysteria, and HIV

Among the many news items buried in the dog days of summer was the repeal of legislation banning travel into the United States by nonresidents who are HIV-positive. The repeal marked a triumph for the advocacy groups that have fought for the ban's dissolution. Unfortunately, their victory remains only partial.

Twenty-seven years into the HIV epidemic, it is difficult to recall the fear, hysteria, and outright bigotry that was all too common at the epidemic's onset. People with AIDS—or people who were merely thought to be infected with HIV—were shunned, evicted from their homes, fired from their jobs, and kept out of their schools. Not surprisingly, already marginalized groups—gay men, intravenous drug users, and immigrants, especially from Haiti—bore the brunt of the fear and antipathy, as preexisting prejudices mixed with loathing of disease to produce a toxic brew of discrimination and stigma.

For the most part, public health officials and medical professionals quickly realized that discrimination and stigmatization were not only unethical, but also undermined efforts to educate the public about the disease and to encourage individuals to be tested. As early as 1988, the President's Commission on the Human Immunodeficiency Virus called for the enactment of antidiscrimination measures. That call seemed to be realized in 1990 when Congress enacted the Americans with Disabilities Act, whose legislative history clearly indicated that Congress intended it to prohibit discrimination on the basis of HIV status. In 1998 the Supreme Court appeared to agree, affirming that the ADA could apply to an individual who was HIV-positive.

U.S. policy concerning individuals who are HIV-positive, however, has not always been so enlightened. Early on, both the military and the foreign service decided to bar infected individuals from joining their ranks. (The military ban remains; the state department, after losing the first round of litigation, repealed its ban last February.) Even more troubling was the government's treatment of Haitian immigrants. Long before Guantanamo Bay became infamous for the detention of "enemy combatants," the United States housed HIV-positive Haitian refugees there. The abysmal treatment of these desperate people continued until courts intervened.

The ban on travel and immigration by HIV-infected foreign nationals is a slightly less toxic example of the same phenomenon. It was instituted in the late 1980s by the Reagan administration and fixed into federal law by congressional action. In 1990, it drew widespread condemnation when would-be participants to the Sixth International AIDS Conference, held in San Francisco, were barred from entering the country.

The repeal was contained within the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR). By bringing antiretroviral treatment to millions in developing nations who would otherwise have gone without it, PEPFAR and its repeal of the travel ban show the positive HIV policy. They foster treatment and side of U.S. HIV policy. They foster treatment and respect rather than discrimination and stigmatization.

Unfortunately, U.S. policy remains riddled with contradictions. For example, PEPFAR requires that organizations receiving its funds sign an oath opposing commercial sex work, and it pushes recipients to spend 50 percent of funding for prevention on programs that promote abstinence and marital fidelity. Both provisions undermine prevention and reinforce stigma. Within the United States, 12 percent of new infections are caused by intravenous drug use, but federal funds do not support needle exchange programs, here or abroad, despite powerful evidence of their utility. And in spite of the ADA, legal protections for people who are HIV-positive have proven both more fragile and less comprehensive than they were once thought to be.

Even travel restrictions remain. Despite the repeal of the statutory ban, HIV is on the Department of Health and Human Services' list of excludable diseases, and nonresidents with HIV may still be denied entry into the country. More broadly, public health officials still all too often assume that public health protection requires vigilant action against those who are ill. In short, stigma is as enduring as HIV.