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Frerichs, R.R. Acceptance of personal HIV screening.

SEA-AIDS Network, August 13, 1998.

Posted in response to:

SEA-AIDS, August 10, 1998

From Chris Green, Jakarta, Indonesia

Thanks once more to Prof. Frerichs' for returning to his theme of testing benefits. But you know, it worries me a lot to see a Professor (assumed to be someone who is entrusted with educating future generations) distorting what he reads so blatantly.

Discussing the journal article, he says "The two main points that the authors make are 1) the enormous benefits of treatment and care, and 2) the perils of lack of awareness."

In God's name, how did he draw these conclusions? Unless the abstract is missing some essentials, there is no discussion about 'care' either for the mother or the baby. The 'enormous benefits' are a reduction in transmission of 6 percentage points -- significant, yes, but enormous? Especially given that the child will in any case expect to lose its mother early in its life and be consigned to orphan status -- better than dying early of AIDS? Who knows! The 'perils of lack of awareness'? Where does this appear?

How on earth can he extrapolate regular c-section and avoidance of breastfeeding to a developing country environment? And how does he have the nerve to assume what the authors felt about the benefits of prevention?

"Those who are able to accept the importance of testing, early detection, early prevention and early care will have a greater chances to do good by protecting the society and helping infected persons. Those who want to remain general in their focus, obscure in their understanding of biologic principles, and unaware of the devastating trends of the epidemic may remain blissful, but will not be servants of public health."

Good Lord! How can he be so patronising! So if I don't accept all the purported benefits, I am 'blissful,' an enemy of public health, and losing chances to do good? 

Anyway, I cannot recall one posting of the many in this thread, which challenged the importance of these items; the concern is with implementation. Few can accept the 'blissful' assumption that all it needs is test kits. (BTW, in the current atmosphere of openness, would it be inappropriate to ask Prof. Frerichs to confirm that there is no conflict of interest which might attach to his promotion of this form of testing?).

The most extreme example of distortion appears at the end of the posting, "What efforts have they made to save their unborn infants from near certain death when the mother is infected?"

Worst case MCT rates that I have read are less than 50%. Or is the point that we are all certain to die? Perhaps American college students are more gullible than I realise.

No cause to assume we're the same...

Chris W. Green 

Jakarta, Indonesia

SEA-AIDS, August 10, 1998

From Ray Stricker, United States

I'm not sure that a drop in transmission rate from 15% to 9% represents a "major impact" or an "enormous benefit" from a highly toxic and expensive drug regimen. This is a bad example to support your reasoning, Dr. Frerichs.

Ray Stricker, MD

International DNCB Foundation

San Francisco, CA

R.R. Frerichs Posting

I am replying to Mr. Chris Green and his postings of August 10. Perhaps the most difficult aspect of stimulating policy discussion is having to absorb negative emotional or personal responses, in addition to the more positive points of clarification or dissent. I prefer that the SEA-AIDS public forum remain focused on HIV and what can be done to control the epidemic rather than serve as a site for personal attacks that invariably reflect more on the mind of the writer rather than the character of the recipient. We all benefit by holding such emotional outbursts in check, thereby encouraging others to write who might otherwise be reluctant due to the possibility of a personal attack. 

To ease Mr. Green's mind on my motives, I should clarify that I have no financial link to any company that provides tests or test kits, but instead have had a long-standing interested in stimulating the use of testing, both in the United States and in the developing world. I also have no financial interest in companies that produce male or female condoms, drugs to combat HIV infection, or the development of HIV vaccines.

Dr. Ray Stricker (posting of August 10) and Mr. Green both focused on the reported reduction of mother-to-child transmission in a British report from 15% before to 9% after. This change represents a 40% drop [i.e., (15-9)/15)] which some might consider enormous (I certainly do), given the lack of success of other programmatic efforts. In an earlier investigation in Thailand by CDC, MOPH and UNAIDS, a short course of AZT was found to produce about a 50% reduction in transmission, also sizable. The key point remains that such considerable benefits can only be achieved with effective testing, so that women know that they harbor the virus. How to bring about widespread testing of pregnant women in high prevalence countries such as India, Myanmar and Cambodia (joining Thailand were many pregnant women are now routinely tested) is what needs to be addressed.

I look forward to the contributions of others from Asia on how such testing might be brought about, and presentation of programs that have been effective at reducing mother-to-child transmission.