January 25, 1999
Bob Watt, United Kingdom
response to messages and in particular to Ralph Frerichs. Sorry that the URL to
the journal article did not seem to work, it is correct, it does NOT work and it
is particularly galling because it is a law review article in a web based
journal which is supposed to be readily accessible!
Ralph Frerichs made a good point in an email to me chasing the article and
suggested that I digest the relevant point. Here goes (The testing/ SE Asia
point is not well made in the article anyhow because we were addressing
central contention is that people who engage in behaviour which may result in
the transmission of the virus bear equal responsibility for the action. It is
wrong in principle to affix special responsibility to the person living with
HIV/AIDS. The article focuses upon establishing this point. Can we take it as
has this got to do with testing? Testing has two rationales:
to prevent transmission and
to identify those who need treatment.
South East Asia (and a number of other places in the developing world) rationale
2) does not hold. People in general are NOT going to get combination therapy -
presently the only effective treatment.
rationale 1) hold? It is suggested that it does not. The only prudent action is
to assume prima facie that everybody is HIV+. There are two arguments in favour
of this position - reading the horrific figures from parts of Africa and from
parts of SEA it is clear that the disease is widespread in the community.
Secondly, and more optimistically, the results from parts of Thailand (and
Uganda) (and the gay community in the UK) show the fruits of acting as if the
assumption is true. "Safe sex" (in its broadest sense) cuts
transmission. Assuming that everyone is +ve is helpful.
problem with this as a final argument is that conception is impossible.
Conception being the only rational reason for 'unsafe sex'. Yes there are plenty
of emotional ones - but fortunately emotions are not rational!
the tough part of the argument: it is taken from an analysis of a (Dine & I
argue) wrongly decided case in the US military. We suggest that people who
knowingly pass the virus between themselves in a relationship should never be
said to be doing wrong (in the case - by grave- criminalised) There are strong
arguments which say that since people live in relationships that there are
positive reasons for allowing them knowingly to pass the virus between
themselves. Simply and bluntly - life is short, generally nastyish, and the only
source of relief from isolation is being with another. (Unlike Dine, I think
that it is the only way of really being human).
catching the virus can be seen, in a relationship, as the least bad thing or
even as valuable- given the circumstances. (We present special arguments dealing
with eg prostitution - but these are strictly aimed at the developed world).
testing is going to do (where there is no treatment) is to further destabilise
relationships. HIV is bad enough - don't let it dehumanise us.
Frerichs' case seems to be based upon individualism and ascribing blame. Where
does that get us? Alright, there may be special cases in which blame ought to be
ascribed and Dine and I canvass those.
they are those in which the behaviour may rightly be described as vicious - the
person who sets out to kill another by desiring to pass the virus.
January 26, 1999
Kenrad Nelson, Johns Hopkins University
Wilson (#70) is certainly correct in
pointing out the differences in the ability to promote condom use for commercial
or casual sex and sex between steady partners or married couples. The use of
condoms between married couples or steady partners is not impossible how ever,
when they both are aware that one partner is HIV positive. In studies we have
done in Northern Thailand in discordant couples, we have found a dramatic
increase in "safe sex" in married couples when both were aware that
one partner was HIV positive. In order for this prevention strategy to
successfully prevent HIV transmission, HIV testing and counseling needs to be
widely available, accepted and effective. Fortunately, in Northern Thailand this
type of prevention is becoming a reality. But more efforts with this prevention
effort are needed in Thailand and other countries facing major heterosexual HIV
January 27, 1999
Pol Jansegers, Belgium
Professor Frerichs rightly demonstrates with available research - and I think he
is right in saying that that is the farthest you can go with this kind of
research without becoming unethical - the answer to David Wilson's (#70) question is "Yes" (i.e. people knowing they are HIV
seropositive are more likely to change their behaviour than others).
there to conclude that HIV testing, and more specifically massive HIV testing -
because that is I thought the debate with Dr Frerichs - should be used as a
prevention tool, is a quite different matter. Besides the impact of HIV testing
on behaviour change, there are indeed a number of other questions that need to
be considered. Two of them are fundamental:
What is the opportunity cost of widespread testing? In other words, isn't there
a more efficient use of the resources that massive testing would require? A very
explicit answer to that question was given in this forum, and I think that
Rachel Sacks (#67), as far as the content
of her message is concerned, is right.
What about the side effects of massive HIV testing, especially if it is coupled
with routine partner notification? Limited experiences in the USA may have shown
that people react rather positively to that scenario, the fact is that this is
not - hopefully just not YET - the case in Africa, and even less in Asia.
Numerous stories about all kinds of discrimination are there to remind us the
together, these two considerations should be sufficient to argue against
widespread HIV testing.