Visa Restrictions: Policy Change Comes, Though Slowly

Change is in the air. By the time this column is published, the nation will know who will next occupy the White House; many appointees of the departing administration will most likely have already moved on to new positions; and potential appointees will be polishing their rsums and pressing the wrinkles out of their good interview suit. Policy changes will creep into existence-usually at a pace far slower than advocates desire. And such is the case with our government policy on visa requirements for entry to the United States.

The stimulus for this month's column was a recent New York City theatrical event: the closing of the musical Rent, which had been playing on Broadway for the past 12 years. The play is set 2 decades earlier, and it is the story of New York City's Lower East Side and the men and women with HIV/AIDS who live there. Specifically, it is the story of a group of young people who have come to New York to make it one way or another and then find themselves developing symptoms of a terrible disease, without health insurance, afraid, striving, reaching out to one another. This play is a story of the beginnings of hope; the setting is when the first therapeutic medication (remember AZT?) had become available. We are reminded of the challenge to adhere to early treatment with its requirements to take multiple doses timed around meals or no meals: In one scene, the simultaneous sounding of alarms and wristwatch buzzers signifies medication time; the play's characters rush to open their pill bottles. Back then, AIDS seemed to have appeared out of nowhere (although the latest analysis suggests a 100-year span of infection¹). The show is set at a time when the earliest, most irrational fears of the virus had begun to subside, at least in ordinary circumstances. But the rule-writing process for federal (and, for that matter, state) agencies remained locked in fear.

HIV AND TRAVEL
The United States has had a rule since the 1980s that makes it difficult for anyone with HIV infection to travel to this country-a Department of Health and Human Services (DHHS) rule placing HIV infection on the list of diseases that bar entry to the United States. The rule was born out of fear-fear that HIV-infected persons might come here and engage in risky practices that would increase the burden of disease in the United States; fear that those with HIV/AIDS might come to the United States seeking care and become a burden on our resources; or simply fear of the different and the unknown. The first fear-the introduction of disease into the United States-was laughable. The rates of infection in this country were at levels that would take an immense immigration of HIV-infected persons to substantially raise. Further, travel by Americans, who have huge disposable income compared with persons in the highly infected parts of the world, was more likely to lead to either us spreading the disease elsewhere, or Americans traveling abroad returning home infected.

The second fear had, perhaps, some basis in reality because the United States does have a far more extensive medical care system than that of most of the countries with high infection rates, and it was likely that new therapies, as developed, might be available here first. For permanent migrants, requirements for sponsorship and for support mitigate the problem, although it is possible that a sponsor might be fooled into making guarantees without understanding the potential costs. For visitors, it is also possible that someone might come as a tourist or student and then stay indefinitely, using care resources here. We know from the various recent efforts to more strictly monitor visa holders that such overstaying has not been rare. However, once again economics play a role: infected persons from the economically developed world have more comprehensive and less expensive medical care available at home than anyone in the United States has. And those most in need of care, from sub-Saharan Africa for example, would have great difficulty in finding the funds to even purchase an airplane ticket to here.

Although the original rule was almost absolute, changes to the law in 1993 allowed limited exceptions, which many believe have been granted only to friends of whichever administration was in authority or to those whose friends and supporters were able to make sufficient noise and create enough press attention that they become an embarrassment. The heightened screening process initiated after the transfer of immigration au­thority to the newly created Department of Homeland Security (after 9/11) has not changed. While the new "frightening other" of the authority's imag­ination (ie, the person to be excluded from entry for our protection) is more likely to be a potential terrorist from the Middle East, the specter of the disease-carrying, resource-draining AIDS patient has not vanished from our minds. It is not un­usu­al to hear of horror stories related to our visa pol­icy, such as that of an infected African woman making 3 trips to the US embassy before receiving a visa to attend a church-related meeting in the United States, although others in similar situations simply gave up before finding a sympathetic ear.

CHANGE IS POSSIBLE
The bill reauthorizing the President's Emergency Plan for AIDS Relief (PEPFAR), the successful extension of AIDS services to a number of countries, includes a provision for rewriting the HIV-related travel provisions in the Homeland Security rules. And Homeland Security has done so, although only part way to a completely unrestricted status preferred by many.² Homeland Security's new rule allows any HIV-positive person who meets all other usual requirements to receive a nonimmigrant visa from a consular office overseas. Persons applying for this visa are required to show that they are not a current transmission risk and that they are traveling with sufficient medication and funds to prevent a drain on US resources. This still sounds like a great deal of paperwork with the potential for delay or discrimination. The agency in question is currently fully occupied with building a fence along our southern border; man­aging the huge number of detainees who have been stopped at our borders or brought in through raids on employers; monitoring terrorist threats around the globe; and monitoring and responding to all sorts of national emergencies, such as damaging hurricanes. Will there be adequate attention to training all offices internationally to appropriately adopt this slightly more relaxed rule? The lame duck Bush administration has no track record on HIV/AIDS that would suggest any interest in rapid change.

The inclusion of HIV/AIDS on the DHHS's "do not admit" list is also in need of attention. Given that the lame duck administration is reported to have told agencies "no more rule changes," the responsibility rests with the new administration. That could take a while, even if whoever is elected makes commitments before his inauguration. The transition process requires enormous energy, new staff need time for orientation, and the list of priorities is long. Campaign promises to make changes quickly related to HIV/AIDS issues have not turned out well in the past. (For example, the Clinton pledge about military policies on sexual orientation, which subsequently frightened a new administration about the risks associated with any issues involving sexual orientation, such as being HIV-positive.) The only way change in any HIV policy will be on the new administration's agenda during its first 6 months is if the ongressional sponsors of the statutory paragraphs authorizing change and the community-based organizations committed to removing all ill-founded HIV and AIDS regulatory limitations join together in a continuing chorus demanding action.

The play Rent continued to resonate with young audiences throughout its 12-year run. Those who had not been born when the ravages of HIV infection were recognized may simply have liked the music or the sense of rebellion in the stories portrayed. But I wonder if they also found compelling the stories of those who lived with and through those early days of the AIDS epidemic, supporting as best they could those who were dying. And in finding the stories compelling, did they also recognize the commonality of the human condition, with or without a particular disease taking its toll on health and life.

This column is not advocacy for ignoring necessary travel restrictions on persons who have active airborne infections, such as tuberculosis (TB); those with HIV infection who also have TB need to have their TB effectively treated before traveling. That's common sense. But there is no sense continuing the current HIV-related travel restrictions-even in part. It's time for change.

References:

References1. Worobey M, Gemmel M, Teuwen DE, et al. Direct evidence of extensive diversity of HIV-1 in Kinshasa by 1960. Nature. 2008;455:661-664.
2. U.S. Department of Homeland Security. Streamlined Process Announced for Otherwise Eligible HIV-Positive Individuals to Enter the United States. Press release, September 29, 2008. http://www.dhs.gov/xnews/releases/pr_1222705590290.shtm. Accessed October 9, 2008.