Mischan also points out that the existing system already encourages, though doesn't mandate, patients and their doctors to initiate confidential partner notification. "[If notified,] the doctors in the health department can contact a person and say, 'We have reason to believe you may have been exposed [to] a communicable disease' and encourage that person to come in for testing. That system is in place."
Mischan says he's not involved through self-interest. "I've been [HIV] positive for about 20 years and clinically diagnosed [with AIDS] 7 years. I'm considered a long-term survivor. My name has been surrendered to the CDC [as are the names of all patients diagnosed with fully developed AIDS]. I personally have nothing to lose. I'm trying to protect those people who we want to encourage to come in for testing. We want to protect their confidentiality."
Mischan wants San Diego -- and California -- to use the state of Maryland's model. Under that system, doctors of HIV-positive patients would forward a 12-digit number to public-health authorities. The first four numbers would be the last four of the person's social security number, the next six would be date of birth, and the last two would indicate race/ethnicity and gender, using a code already established by the CDC. The patient then talks to public-health workers and, identified only by that number, gives them names of partners to notify.
It works, says a December 1997 study by the American Civil Liberties Union AIDS project. "Maryland's increasingly successful experiment with unique identifiers suggests that effective HIV case reporting can occur without name reporting."
For Mischan, the main benefit is that more people will come forward. People forget, he says, the emotions that such a diagnosis can generate. "Since the epidemic has crossed over into the heterosexual community, we've heard many cases of domestic partner abuse, against people who even suggest [to partners] there might be a need for testing. People say they're afraid to be tested because if you go in and notify their partner, using their name, you're putting them at risk of violence."
But for Savitch, cryptic codes will just create more obfuscation, when clear leads to partners are top priority. And with up to 900,000 Americans living with HIV (100,000 of them Californians, an estimated 9000 of them San Diegans) and 40,000 more being infected every year, the time has come to go beyond education to more strident measures. The need, he says, is to curb the actual behavior that spreads the disease in the first place.
"The World Health Organization tells us how bad the disease is and that we need more education, but when it comes down to practicing public health, they're gutless. We support education, of course, but it's got to be more than that. The most educated group in our country is gay men, and they have the highest rate of infection. I think that many people live their lives honorably and would not dare infect anyone else, but there are people who don't care how many people they infect. Some of them are called the AIDS Kamikazes; others AIDS Gifters. They need to be restrained, period. The fact is that drugs may prolong people's lives. But what does that mean to the epidemic if you don't live honorably? People have a longer time to spread the disease."
Savitch says a Brown University study claims over 40 percent of HIV-infected individuals do not alert their sexual partners. But how far can public- health authorities go to stop such behavior?
"I don't like Big Brother. Nobody can prevent you from engaging in dangerous activity. But if I knew that you were intentionally infecting others, then I would definitely recommend that you be restrained, whatever that took. Because merely infecting someone is taking their life. If you were wielding a gun at people, we wouldn't think twice. I'm going to a funeral tomorrow of a wonderful guy who would never have infected anyone else. But somebody infected him. He had the most miserable last six months. Nobody could suffer the way this guy did. Do you think this man was concerned about whether this was a reportable disease or not? All he wanted to do was get rid of the headaches and the constant vomiting.... We add to HIV's stigma when we make it so different. The life expectancy of a gay man in the United States is 42 years. That needs to be stopped. But the control of this disease is in the hands and the hearts of those who are infected. And it's sad that AIDS activists like Mark Mischan don't see it that way, that they see everybody who opposes them as some sort of homophobe."
For his part, Mischan worries that the county's feasibility study is a political smoke-and-mirrors game. "They say, 'Trust us. Trust us.' How can we? This study at least should have gone out to a third party who could be neutral about the topic. You cannot trust the people who are already in the system and pushing for these issues."
Michelle Ginsberg says she expects to have the study ready to present at a public meeting on February 3.