A dramatic change has quietly occurred in the testing of Americans for the virus believed to cause AIDS. ``Voluntary testing is the name of the game now,'' says Peggy Gault, staff director of the Presidential Commission on AIDS, which has heard hours of testimony on the subject.
Across the United States, calls for mandatory testing have gone from a shout to a whisper. States are retreating from the extreme positions, either in favor of widespread mandatory testing or insisting that no mandatory testing be permitted.
In Illinois and Louisiana, the states with laws that require mandatory AIDS testing for marriage applicants, pressure for repeal is building.
A report by the National Academy of Sciences says AIDS testing should not be a requirement for getting a marriage licence. The report encouraged more voluntary testing and said mandatory testing ``is currently appropriate only for blood, tissue, and organ donations.'' But the academy also said that Americans infected with the AIDS virus should be considered as suffering from a disease.
The states have been taking the lead in deciding what policy should be on AIDS-virus testing, Ms. Gault says. This year they have been independently coalescing around more moderate positions.
Mandatory testing is now ``targeted toward convicted sex offenders'' and toward intravenous drug users, as well as blood donors, says Connie Thomas. She is a research assistant at George Washington University's Intergovernmental Health Policy Project, which watches state action on AIDS.
There are several reasons for the move to carefully targeted testing. The costs of widespread testing are enormous - as much as $30 million annually to provide mandatory screening for couples in Illinois, for instance. There is also concern that in a broad program many people would erroneously test positive and that results might not be kept confidential. Finally, most AIDS experts say testing millions of Americans not likely to have the disease would waste resources that could be better used in dealing with AIDS.
Yet, as Peter Fischinger says, surveys find that Americans want to know how many people have the AIDS virus, how many now ``are becoming positive,'' and how many are likely to do so. Dr. Fischinger, who directs the national AIDS program office of the US Public Health Service, says the challenge to policymakers is to answer these questions without mandatory testing.
One approach may become controversial. The government ``is in the process'' of surveying 15 groups of Americans in 30 cities, according to Harold Jaffe, chief of the epidemiology branch of the AIDS program for the Centers for Disease Control (CDC).
The studies, which Dr. Jaffe says ``will go on over the next year,'' check for the AIDS-causing virus in the blood of people, most of whom will be sampled anonymously.
Among the groups are college students - that has ``already started,'' says Jaffe. Also being tested are prison inmates, women of child-bearing age, and newborn infants. The CDC wants ``to test more than 1 million children,'' Jaffe says.
If doctors have their way, one more group will be tested - people being admitted to hospitals - says M.Roy Schwarz, assistant executive vice-president of the American Medical Association. Among physicians there is ``a growing conviction and desire that it should be done,'' Dr. Schwarz says.
He cites a survey of physicians in New York that found 48 percent in favor of mandatory testing of patients before nonemergency surgery. That figure, he says, is up dramatically from a year ago.
The commission is expected to recommend that America continue along the general middle ground on testing that the states have followed. Adm. James D. Watkins, the commission's chairman, is to present its recommendations today; the group's final report will be made public June 24.
A few continue to call for widespread mandatory testing. Rep. William Dannemeyer (R) of California says the US ought to test ``about 50 million people a year'' to determine how many Americans harbor the virus.
Unless this information is known, it is ``very difficult'' to design AIDS education programs that can prevent spread of the illness, Health and Human Services Secretary Otis Bowen says.
Until two months ago some experts had believed there was a secondary purpose for testing. It involved a concern that people who harbored the AIDS-causing virus might, as one study had indicated, have episodes of dementia.
But in mid-March the World Health Organization's Global Program on AIDS concluded that people with the virus are no more likely to have such problems than anyone else. Thus it found no evidence to suggest that testing would be useful in forecasting dementia.
No new test now seems necessary to find out how many Americans have the disease AIDS, since doctors are already required to report to the government the number (but not the names) of the patients they treat who have AIDS.
US health officials say some 60,000 Americans are reported by physicians to have the disease. Officials are far less certain of the number of Americans with the virus; they estimate perhaps 1.5 million.
Most commission witnesses who have discussed testing favor restricting mandatory tests to targeted groups.
For instance, Arthur Di Salvo told the panel that ``mandatory testing on a wide scale ... seems unnecessary since all indications still [show] strongly that the epidemic is focused in particular small segments of the population where special targeted testing and prevention programs are more appropriate.
``In this regard, targeted use of testing in such increased-risk populations as [people with sexually transmitted diseases] ... or drug-abuse clinic patients is receiving increasing attention.'' Dr. Di Salvo is chief of the bureau of laboratories of the South Carolina Department of Health and Environmental Control.