Comment on DOS-2026-0694-0008

I am submitting a response as a Civil Surgeon based on the applicant population I see. In considering each of the items in the proposal, my mind went to highly variable "pros and cons" of each item listed based on the relevance per the mandate of the immigration medical exam and prevalence of items being tested. I generally and mostly agree with the other comments already submitted arguing against significant change to the requirements. Because of the length of a narrative that could be typed here, I ran this question through ChatGPT and critically reviewed it before posting it. I think it is summed up well in the ChatGPT inquiry, which is too long to post, if others would like to do the same. I will leave my individual thoughts based on my experience: 1) Controlled substance testing: In-office testing could be performed for minimal additional financial cost, but would add significant logistical time. If this is added, I would allow +THC results to be "explained away" and not disqualifying as long as the person seemed honest with regard to historical use. Sometimes we just have to make our best judgement call and go with our clinical instinct informed by experience. Otherwise, a quantitative confirmatory test could sent for screens positive for substances such as cocaine, and would be for any other positives as well if the person did not have a documented prescription to justify the results. 2) I have found Chronic Hep B several times over the years in foreign nationals in the general medical side of my practice. Because it is usually asymptomatic, and can be spread inadvertently through sexual contact, this one may be worth checking. I have no doubt I have seen people who had chronic hep B, didn't know it / didn't divulge it, based on the law of averages/prevalence. It still does not have to be disqualifying. If someone does not have private health insurance or significant resources, I can send them to the teaching hospital in my city, and if they qualify through the hospital, they can receive subsidized care without violating the public charge rule. 3) Chronic Hep C - same as chronic hep B 4) HSV antibody testing - No, as has adequately been explained in other comments already. I never order this in my general medical practice. 5) Chlamydia - This is easy enough to screen for and treat, along with gonorrhea, and can be asymptomatic 30-40% of the time. Should not be disqualifying. 6) Trichomonas - same as chlamydia, although much lower prevalence 7) HIV - I know of 2 cases, in 14 years, of applicants coming back to see me for a repeat immigration medical exam, and on the second visit, divulged they have HIV that was being treated. They did not tell me during the first exam out of fear of being denied a green card. Otherwise, I find HIV after a positive syphilis screen, almost exclusively in MSM. I suspect the prevalence is low, but real, that there are people with HIV immigrating into the US and not revealing it. If they are treated, compliant, undetectable, then their IGRA testing should be reliable, but if they are not adequately treated, then TB could also be a concern. I do support NOT making every HIV positive patient go through the TB protocol requiring smears and cultures if their medical records can be obtained, or labs checked, showing they have undetectable viral loads, CD4 > 200 with neg IGRA and neg CXR. 8) Tattoos - No. If this is to identify gang affiliation, wouldn't their background check do that more reliably? I really do not believe I see a large number of people whom are trafficked in my practice. I have suspected it only a few times over 14 years. We are not law enforcement or the emergency room. I would never want to miss someone, but the logistics of this would be overwhelming for what I believe would be low yield at least in my practice. 9) Cholesterol - No. Even if it is very high, it doesn't necessarily mean they have CAD as noted with CAC scores. And it shouldn't be disqualifying anyway. It is not contagious. I don't see the role of lipid profiles in immigration medical exams.