Frerichs, R.R. Response to Acceptance of HIV Personal Screening.

SEA-AIDS Network, July 11, 1998.

Posted in response to:

SEA-AIDS, June 30, 1998

From Martin Foreman, London

I 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.

There 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.

Underlying 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. 

That 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.

Enabling 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.

Some 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.

Furthermore, 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.

In 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.

To 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.

Martin Foreman

AIDS Programme, Panos Institute

London

From Lawrence Hammar, United States

I 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). 

Even 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.

Some 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. 

One 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).

So, 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.

It's 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).

Second 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." 

My 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[6], 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. 

I'm 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.

The 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.

I 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 -- 

"Once 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.

Social 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 above.

Thanks 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.

Lawrence Hammar 

5445 S.E. 43rd Portland

Oregon 97206

R.R. Frerichs Posting

The discussion on personal HIV screening is addressing many policy issues that extend well beyond the technical merits of HIV testing kits. In this posting, I am responding to the SEA-AIDS messages of Martin Forman (July 17) and Lawrence Hammar (July 20). I remain focused on people who are struggling to respond to HIV in higher prevalence communities of Asia.

When people are not able to identify those who are infected by using accurate HIV antibody tests, they rely on less accurate methods such as avoidance of those who they think might be infected. Dr. Chris Beyrer writes of this phenomena in his recent book, "War in the Blood" (Zed Books, Ltd, New York, 1998, p. 122). "The women of a similar district, also in the suburban ring of Chiang Mai [Thailand], San District, have used another approach. So many young men were dying in San Sai that the community opted for a moratorium on marriage until it was clear the young men would survive the disastrous HIV epidemic in the district. (Between one in five and one in four young men have died, or will die, if the spread stopped tomorrow.) This is probably not going to work, but it represents an incredible change in the social structure of San Sai's villages. Local women know what may happen when they marry -- HIV infection -- and are opting, at least for the short term, for not marrying rather than risk exposure."

Beyrer goes on to write... "Women's attitudes toward prospective partners are changing as well. In a study among female factory workers in northern Thailand, young men reported that they strongly favored men who did not visit sex workers, and that the sexual history of their potential partners was an important criteria for marriage. This is a sharp change from the attitudes of their mother's generation, for whom visits to sex workers were often preferred over husbands having mistresses.

There were women whose fathers and older brothers traditionally took their adolescent boys to brothels to begin their sexual lives."

Rather than developing understanding or caring attitudes towards high risk groups such as commercial sexworkers, intravenous drug users, or homo- or bi-sexuals, the general public in the absence of knowledge on HIV status will likely be more fearful of people in these groups, rejecting them outright. Statements such as "you're gay so you must have AIDS" or "you're a prostitute so you must be infected" will become more common, as the signs and symptoms of AIDS become apparent in communities.

In many Asian communities, the messages "AIDS kills" and "fear AIDS" have widely appeared on signs, billboards, and posters, and been written and voiced in newspapers and radio. The public sees and hears these messages, and with no more exact knowledge, rejects "high risk" people who all too often already exist at the margins of society.

The alternative to this traumatic social evolution is to promote more testing, thereby bringing the disease out in the open where the problem can be addressed. If public health and medical officials can assure communities that they are working with HIV infected persons to limit further transmission, then fear will subside and acceptance will come. At least this is the theory.

Will such shifts in community attitudes take place? It is hard to say, but certainly worth trying, given the many failures that have come before when word gets out that someone is infected, and people react badly with no trust in their health officials.

The main point of my discussion remains, if public health leaders are committed to widespread testing and normalization of the disease (i.e., decreasing stigmatization), they must think of ways to make tests easily available. I do not see reliance on current counseling and testing clinics as an economically viable strategy for delivering testing throughout South East Asia. Thus other strategies, such as home tests or testing by family planning or community health workers, must be tried and evaluated.

Mr. Forman perceives correctly that I have limited my focus to couples planning to be married and to have children. The former would be tested pre-marital, and the latter either before they plan to have children or early during the pregnancy. If testing works well in these two groups, people will feel more empowered in dealing with the virus, recognizing that the agent is biologic, not social. The same need for assurance and safety is evident in most blood testing programs, also limited in focus.

Mr. Hammar mentioned an interesting article on discordant couples that I would like to consider.

Specifically, the article and abstract are...

Nicolosi, A., Correa Leite, M.L., Musicco, M., Arici, C., Gavazzeni, G., and Lazzarin, A. The efficiency of male-to-female and female-to-male sexual transmission of the human immunodeficiency virusa study of 730 stable couples. Italian Study Group on HIV Heterosexual Transmission. Epidemiology 5(6)570-575, 1994.

To compare the efficiency of male-to-female and female-to- male sexual transmission of human immunodeficiency virus (HIV), we studied 524 female partners of HIV-infected men and 206 male partners of HIV-infected women in 16 Italian clinical centers. All of the partners had had a sexual relationship with the index case lasting for at least 6 months and presented no other risk factor than sexual exposure to the HIV-infected partner. Among the 730 couples, 24% of the female partners were HIV positive, in comparison with 10% of the male partners. Using logistic regression analysis, including gender and controlling for condom use, frequency of intercourse, anal sex, partner's CD4+ cell count and clinical stage, sexually transmitted diseases, genital infections, and contraceptive use, we found that the efficiency of male-to-female transmission was 2.3 (95% confidence interval = 1.1-4.8) times greater than that of female-to-male transmission. Between-gender differences in the contact surfaces and the intensity of exposure to HIV during sexual intercourse are possible reasons for the difference in efficiency of transmission.

The goal of the authors was "to estimate the relative efficiency of male-to-female and female-to-male transmission at the individual level and investigate the interactions between gender and factors known to influence the probability of sexual transmission of HIV. To this end, they conducted a case-control study of HIV infected index cases (i.e., cases) attending 16 Italian centers and their heterosexual partners (i.e., controls) to determine the odds associated with various characteristics of the partner being HIV negative. 

In a logistic regression analysis, the authors found that condom use (defined as greater than 50% of intercourse) was associated with an 80 percent reduction in HIV transmission from male to female and 70 percent reduction from male to female. The analysis also showed that those who avoided anal intercourse had a 57 percent reduction in transmission from males to females, and 62 percent reduction from females to males. 

Thus by knowing the HIV status of their partners and changing their sexual behavior (i.e., no anal intercourse and regular condom use), some of the couples in this study were able to avoid having the susceptible member become infected. In most marriage settings, condom use is extremely low. Thus learning that their partner is infected should help some married susceptibles (who most often are women) to survive.

Rather than continuing this dialog with people from Europe, Australia or the United States, I would like to get additional thoughts on the merits of widespread testing from health professionals in Southern or Southeast Asia. The losses due to infection are especially evident in India (now thought by UNAIDS to have 4,100,000 HIV infected persons), Myanmar (440,000 HIV cases), Thailand (780,000 HIV cases), and Cambodia (130,000 HIV cases). Without solutions to this ever expanding epidemic, citizens in these countries who rely on their public health leaders for leadership become the greatest losers.

Eventually as the AIDS cases become more evident they will look elsewhere for solutions. Thus while public hope and trust remains high, the guiding opinions and views of regional medical and public health professionals are desperately needed.

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