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Frerichs, R.R. Early HIV detection, marriage and India.

SEA-AIDS Network, August 21, 1997

R.R. Frerichs Posting

The importance of early HIV detection will be discussed at the 4th International Conference on AIDS in Asia and the Pacific (ICAAP) in an official satellite meeting on Sunday, October 26 from 5:30 to 8:30 pm, focusing on HIV/AIDS in India. The location of the satellite meeting has been tentatively set at the Manila Holiday Inn, but recognizing the intense interest in this theme, the organizing committee is busy looking for a larger room. In Chiang Mai at the Third ICAAP more than 700 appeared to hear about a related topic, "issues of testing," while the number was closer to a 1,000 for a debate "Home HIV Screening" at the Vancouver Ninth International AIDS meeting in Vancouver. Thus it is likely that a larger space will be needed in Manila to accommodate the crowd that is likely to appear.

I will be one of the speakers presenting an affirmative view on the importance of detecting HIV (title of my talk: "Confronting HIV in India -- the Importance of Early Detection"). Other speakers are being approached to address the potential problems with early detection, adding to the richness of the discussion.

We intend this to be a practical three hours, dealing with problems in India, but also by those working in other "high to medium" prevalence HIV regions -- namely, denial, testing and case-finding, counseling characteristics and effectiveness, discrimination, public health and the rights of both susceptible and infected persons.

For those wanting background reading on this interesting topic, please download the following two files from SEA-AIDStest5.txt and test6.txt. To do so, send two email notes to with the message in the first email:

open get /pub/sea-aids/test/test5.txt

and the message in the second email:

open get /pub/sea-aids/test/test6.txt

The system cannot accommodate two requests in one message.

Your reward will be a thoughtful review and commentary by Maria de Bruyn of the AIDS Coordination Bureau in Amsterdam, The Netherlands: HIV Testing and Counselling as a Prevention Method (Discussion Paper, Part I and II, November 1996).

While I enjoying reading much of the material, I was quiet disturbed by the section on premarital testing. Specifically Ms. Bruyn wrote in Part I "In some countries, churches and other institutions are encouraging (or sometimes demanding) that prospective marriage partners undergo pre-marital testing. In Thailand, the Ministry of Public Health has launched a campaign for voluntary HIV testing before marriage, while the Thai Population and Community Development Association received funding from the EC for a project that invites couples who are registering their marriages to consider HIV infection risks [32]. Data from interviews with 120 couples reached by the pilot project in two provinces showed that 48% of husbands and 60% of wives chose HIV testing (with 30% of wives convincing their husbands to be tested as well)."

So far so good. To me this showed that there was considerable interest in Thailand in HIV testing, with both husbands and wives expressing concern that the virus may have infected either them or their partners. But then Ms. Bruyn continues...

"The rationale for such policy measures is that if one or both partners test HIV-positive, they will take this into account when considering whether to have children or not. As pointed out above, the wish to have children may be very strong; knowledge of a positive HIV-status will often not lead to a decision to refrain from childbearing. Moreover, given current gender roles and norms, it will frequently be women who suffer the consequences. If a man learns that his potential bride is HIV-positive, it is not unlikely that he will simply call off the wedding and marry someone else. On the other hand, if the man tests positive and his wife negative, the wedding may still take place, either due to pressure from relatives or because the man does not inform the woman of his serostatus." 

So the issue seems to come down to knowledge and power. Yet what Bruyn's commentary overlooks is that in Asia, HIV infection is much more common among men, estimated at 80 percent versus 20 percent in women based on a recent UNAIDS report (Weekly Epid Rec 72(27), 1997). Thus to avoid further transmission of the virus, knowing that the partner is infected holds disproportionate importance for women who tend to be susceptible. Getting women to act on this information to avoid infection may not be easy, but certainly should be the goal of public health professionals.

In the interest of preserving the public's health, we should not attempt to justifying the all-too-human emotion of denial by implying that knowledge of HIV status is harmful. Such denial has not served us well with other diseases, and certainly HIV as a communicable virus is no exception. The virus thrives on such deception.

Finally Ms. Bruyn writes what is perhaps the most curious element in this otherwise comprehensive review "Two other points must also be considered. First, sexual intercourse prior to marriage is quite common in many countries; when potential spouses are tested before marriage they might therefore be in the window period. Second, a common reaction to positive HIV-test results in one or both partners will be cancellation of the wedding. This means that the right to marriage of persons living with HIV/AIDS (PHAs) will be negated. Also, an increasing number of couples who might have wished to marry may simply live together without benefit of legal guarantees. In Phayao Province, Thailand, it is reported that premarital testing has almost become a "new tradition"; in most cases, the marriages are canceled if test results come back positive [33]."

The concept that an HIV infected person has the right to marry a susceptible person, and implication that the susceptible person does not have the right to avoid such infection by declining marriage, seems suggested in both the words and tone of Bruyn's passage. Perhaps this was not her intention. So the review article comes to a divide in the road, not unlike what we face in may Asian societies. 

Should we discourage premarital testing so that marriage is preserved but the virus is inadvertently transmitted? Of course by doing so we ensure the right of the HIV infected male (the usual person) to infect his susceptible female spouse, adding short-term comfort to his life but bringing early death to hers. Or should we encourage testing, and support susceptible partners in their choice not to consume the marriage and thereby remove their immediate risk of infection. Who's right do we hold more dear -- the infected person or the susceptible person?

These issue and more will be discussed in Manila at the official satellite meeting on Sunday, October 26, addressing HIV in India and the importance of early detection.