-Suzanne Marks, RPCV Togo
A question often asked of Peace Corps recruiters by participants at Gay Pride events is: “Can I serve as a volunteer if I am HIV positive?” Peace Corps’ official policy states that the agency does not discriminate on the basis of disability and that it must provide reasonable accommodation for persons with disabilities, in accordance with the Rehabilitation Act of 1973. (Note: The Americans with Disabilities Act of 1990 protects HIV-infected individuals from discrimination by private employers of 15 or more employees, and by state and local governments). However, to date, no HIV-infected applicant has been accepted for Peace Corps service. At a time when protease inhibitors have rendered HIV disease a manageable health condition for many and when persons with HIV disease can provide much needed health education about disease prevention and management to the ever-increasing numbers of HIV-infected in developing countries, the practice of excluding those with HIV disease from Peace Corps service, regardless of policy, is called into question.
To be offered a Peace Corps volunteer position, an interested individual must complete an application form and be medically qualified. While the Peace Corps application does not explicitly request HIV status, it does ask applicants to report their medical history, including infectious diseases. If an applicant responds that s/he has HIV disease, then the health condition of the applicant is assessed. If an HIV-infected person does not voluntarily disclose her/his status, then the required medical exam soon reveals that fact, since Peace Corps policy states that applicants must be HIV tested.
Since 1986, HIV testing has been performed on all applicants prior to service and again at close of service. One reason for this policy is to determine baseline medical status upon entry and post-service medical status to aid in determining valid workers’ compensation claims in the event of disability caused or exacerbated during Peace Corps service. As of 1998, approximately 20 cases of HIV infection have been documented among volunteers since testing began. Another reason for HIV testing is to enable Peace Corps to examine the health status of applicants, so that their medical qualification for posts can be realistically assessed and accommodations made, if needed. The primary motivation underlying the practices of the Office of Medical Services is to protect the health of US citizens serving in the Peace Corps. Medical qualification is based on an applicant’s medical prognosis and on Peace Corps’ ability to meet her/his medical needs, including an assessment of how quickly the volunteer can be provided emergency medical care, if the need arises, and an evaluation of a worst case scenario.
Peace Corps has quite a history of accommodating various disabilities, such as blindness and diabetes. For example, a diabetic volunteer required use of an insulin pump, an uninterrupted supply of insulin, and regular medical monitoring, including lab tests of specimens. When asked whether the cost of accommodating a medical condition figured into the qualification process, the Office of Medical Services stated that the costs of care were not among the determining factors for medical clearance. However, costs might be considered at a higher level in the Peace Corps application process, such as at a policy level. Currently, no policies exist barring expensive medical conditions. But theoretically, an accommodation for a disability may become an undue hardship when it becomes costly, extensive, disruptive, or fundamentally alters the nature or operation of the business. Since the current annual cost of anti-HIV medications is approximately $15,000, and since Peace Corps would be required to pay this cost (excluding the first six months of service, during which the volunteer would bring a supply of medications), resource availability and constraints may become relevant if substantial numbers of HIV-infected individuals applied to the Peace Corps. Costs of accommodating a medical condition are covered either entirely by Peace Corps headquarters, entirely by the post, or are shared by both entities.
Besides medical qualification for service, applicants must be considered “suitable” for their posts. Among considerations of suitability is the acceptability of the medical condition by the culture in which the volunteer would serve. For instance, some cultures do not accept individuals with seizure illnesses such as epilepsy. Given the high prevalence of HIV disease in many developing countries, cultural acceptance of those with HIV is likely to be higher than for persons with diseases that are rare or unusual. However, legal barriers to acceptance of persons with HIV disease exist in countries, like the US, that prohibit entry of HIV-infected individuals.
Peace Corps headquarters weighs the risks and the benefits of each applicant, before deciding to offer a position. Are the skills and abilities that an HIV-positive applicant brings to Peace Corps service worth the risks to that individual’s health? The opinion of a source in the Office of Medical Services is that, currently, the risks are greater than the benefits for most HIV-infected individuals. The high incidence of diarrheal, parasitic, and other infectious diseases among volunteers with functional immune systems suggests that Peace Corps service would be detrimental to the health of HIV-infected individuals. Other organizations and agencies, such as CARE, CDC, USAID, and WHO, are also formulating policies and practices vis-a-vis HIV-infected applicants. Of interest would be the consistency in policies/practices and the actual experiences of HIV-infected employees placed in long-term positions in developing countries. The net risks/benefits depend greatly on the health status of the applicant and on the circumstances of the post. Access to high quality water, food, and needed medications are essential. Also to be considered are prophylactic medications that may lessen an individual’s risk of acquiring diseases. Tuberculosis (TB) is the most common opportunistic infection determining AIDS in the developing world. However, prophylactic medications exist to prevent TB disease. And, if disease develops, TB is as curable in HIV-infected persons as it is in non-infected persons. Peace Corps will help applicants make informed risk/benefit calculations regarding their decisions to continue with the Peace Corps application process. HIV-infected persons who are considering applying for Peace Corps service may contact the Office of Medical Services at 800-424-8580, extension 1500.
The many facets of the decision to send HIV-infected US citizens into developing countries as Peace Corps volunteers highlight the challenges and realities that millions born and living in developing countries face daily in their struggle to survive HIV infection. The developed world has been criticized for their two-tiered approach to preventing and managing HIV disease: with the provision of anti-HIV medications, intensive medical monitoring, and needle exchange in the US and Europe compared with the focus on condom use and partner reduction in Africa, Asia, and Latin America. Since one of Peace Corps’ three goals is to bring the experiences of the developing world back to the US, HIV-infected Peace Corps volunteers can help bridge the gap in the application of AIDS prevention practices and technologies.