June 30, 1998
Martin Foreman, London
have just read Prof Frerichs' latest posting on the question of personal HIV screening, and I am glad to see issues
being brought out in a manner which
recognises both the value and the implications of advising individuals on their HIV status (positive or negative). I
would, however, like to clarify
some of these points further.
seems to be general agreement that testing is valuable for those who seek it and who are offered pre- and post-test
support. Certainly, comments from
colleagues in developing countries support broader testing and counselling.
But I would like to follow the implications a little further.
Prof Frerichs' postings seems to be the implication that testing couples
will lead to an overall reduction in the rate at which HIV spreads. However, I doubt that it will have a major
impact. As I commented in an earlier
posting, I see a difference between those (mostly women) who are at risk of contracting HIV and those (mostly men)
who are at risk of both contracting
and disseminating the virus.
statement is based on studies of sexual behaviour undertaken by WHO [Carael
et al, AIDS 1995, 9, 1171-75] and others indicating that in every society
surveyed a higher percentage of men than women report more than one sexual partner - and men with more than one
sexual partner usually indicate
more partners than women with more than one sexual partner. Even if men over-estimate their sexual partnerships
and women under-estimate them,
anecdotal evidence suggests the pattern is true. (It should be noted that in no surveyed society do more than 47%
of men report more than one sexual
partner in the last twelve months - which suggests that most men are
at low risk of contracting and transmitting
HIV.) This means, as most of us know, that women, who tend to be
monogamous, are at greater risk of contracting HIV, but men who have casual sex partners - women who are not
monogamous, sex workers, other men
- are more liable to both contract and transmit the virus.
discordant couples (or partners in polygamous unions) to know their serostatus and assisting them to reduce the
likelihood of transmission obviously
helps that particular family; however, since the family is usually a "dead-end", epidemiologically
speaking, such screening may have little impact
on the epidemic as a whole.
men (and women) in relationships who have other sexual partners may change their behaviour as a result of
counselling with their long-term partner(s).
This would be a bonus and might affect the course of the epidemic.
However, there is little sign of that happening. Colleagues in India
and Guatemala who work with couples, report that despite their best efforts only 20% to 50% of men come to
couples' counselling. These may be the
men who have extramarital affairs, but I suspect that many of the men who have sex with others are not interested in
discussing the issue.
if the emphasis is on couples, it will omit unpartnered men and women,
who are also responsible for HIV transmission. As
I indicated in an earlier posting, I suspect that the overall epidemic occurs as a result of transmission in sexual
and drug-injecting circumstances
where "loss of control" is a key element and attraction. There is much evidence that some people who know
they are HIV-positive rationalise their
risky behaviour and allow themselves to transmit the virus to others.
other words, knowledge of one's serostatus does not always lead to safer sexual and drug injecting behaviour. Changing
the attitudes and behaviour of
those who continue to place themselves and others at risk will remain our greatest challenge for many years to come.
summarise if we can put adequate counselling and support systems in place, then by all means let us encourage
couples and polygamous unions to consider
testing. Such testing may have also have an impact on the broader spread
of the epidemic, but we cannot at this stage confirm that this will be the case.
Programme, Panos Institute
Lawrence Hammar, United States
would like to respond to several of the good, provocative points made and positions taken by Dr. Frerichs in a recent
posting that responded to a couple
of other postings. For the sake of argument, I'm going to assume that HIV causes AIDS, just like that (though that
thesis appears to be demonstrably
false on a number of grounds), that "home test" kits detect HIV (they don't), and that specificity and
sensitivity of such home test kits is a
simple matter (it isn't).
stipulating that, I'd like to raise another issue
having to do with "couples" and "discordancy," and suggest
that most conventional arguments
about such have a fatal flaw of assuming that "couples"
(presumed heterosexual) necessarily act as one; they don't, and I believe
there is a missing gender(ed) element from most of our discussions on this list.
of my points are grounded in a desire for all of us to use language far more precisely so that we can think more
clearly and openly. I am not writing,
therefore, merely about semantics, but about real life, real reality.
As a social scientist, it amuses me (when it doesn't anger me) that we presume ourselves to have the information
to give to informants, clients, policy-makers,
etc.) and much/most/sometimes all of that information is logically
and otherwise false.
such article I recently read ("HIV-Related
Knowledge and Risk Behaviors of Street Youth in Belo Horizonte,
Brazil" AIDS Education and Prevention 7(4) 287-97, 1995) was based on a purported study of client
"knowledge." The test respondents were deemed
to have scored "poorly," even though several of the 12 questions contained false statements (asserting, for
instance, that a pregnant woman can
"pass AIDS" to a child, though such is physically and logically impossible).
let me tangle with a couple of issues raised by Dr. Frerichs. First, do the
benefits of HIV detection exceed both the financial and social cost associated
with the information? Home
test kits do not detect for the presence of HIV. From now on, I propose that, bare minimum, we unceasingly distinguish
between "HIV" and "HIV antibody,"
unless we are talking about HIV antigen tests and testing policies,
which we aren't currently. Antigen tests aren't so easy to do, either,
and obviously they are way too expensive to do on a broad scale.
bad enough that we confuse "HIV" with "AIDS" or with
"HIV disease." I'm not
even going to raise the terrible specter of how much more complicated testing is than it would appear from this
list's discussion (see among other good
references, Eleni Papadopulos-Eleopulos,et al, "Is a Positive Western
Blot Proof of HIV Infection?" in Biotechnology 11, 1993).
point raised by Frerichs, namely "the clearest evidence of the merits of
HIV testing comes from the many discordant couple studies that have been
published in the literature. In general they show that couples act different
when they know that one is infected
and the other is not, and that this knowledge leads to behavior change
that reduces HIV transmission, at least within the couples."
point here is that "couples" do not act in the ways they are asserted
to. List members may refer to
Nicolosi, Correa Leite, Musicco, Arici, Gavazzeni, and
Lazzarin's paper in Epidemiology 5, 1994 570-75 (and my apologies
for some missing diacritics) for just one of many examples of why it
isn't necessarily sound theorizing to take a "couple" as a unit of analysis. I picked this article to discuss for
a reason, though perhaps a flawed
reason. I'm assuming that far more people on this list are better read
in quantitative than qualitative thinking and analysis, though I know that there is substantial overlap. I could
make the same argument more easily
from more ethnographic sources, but maybe this'll work.
going to summarize their
argument as follows: There were 730 "discordant" (one person
apparently infected, the other person apparently not) couples in this Italian study, of which 524 couples contained
an apparently uninfected woman.
Of those 524 apparently uninfected women, 71% of their sexual "partners"
(husbands, boyfriends, etc.; I put "partners" in quotation marks given the level of sexual violence to which
some of the women were subject) NEVER
used condoms, even though ALL of them were apparently infected. Two hundred and six of the remaining couples
contained an apparently infected woman,
and 35% of those women's sexual partners NEVER used condoms.
conclusion is that of this study's 730 discordant couples, infected male sexual partners were slightly more than TWICE
as likely to engage in unprotected
penetrative intercourse with uninfected women than were apparently
uninfected men with infected women. In other words, condoms are twice
as likely to be used if they protect an uninfected male than if they protect and uninfected woman.
believe that we're ignoring significant social structural forces here that proposals for HIV antibody testing (whether in
a home setting or a clinic) just
never get around to addressing. My point would be, therefore, that the following chain of inference
people decide that providing couples with HIV test results is important and desirable, then the second question comes
up -- how can this best be done when resources are low?" -- is missing a
step or two.
relations are the key, not technology. I believe that it would be largely
(not wholly, but largely) a waste of time, labor, and resources to promote technological approaches to what are
more fundamentally social relational
and social structural problems, sexual political in the case I cited
very much for your ear this morning, and I welcome all comments. Thanks,
too, for the previous posters whose perspectives I could bounce off of.
S.E. 43rd Portland