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R.R.
Frerichs Posting
Should spouses of persons found to be HIV infected be notified? As routine
testing of pregnant women proceeds in many Asian countries, the question
of how best to inform partners takes on new urgency for the region.
In
a recent article from Thailand, the authors wrote, "most women are tested
for HIV, syphilis, and hepatitis B at first antenatal clinic visit and
at third trimester" (Siriwasin W et al. HIV prevalence, risk and partner
serodiscordance among pregnant women in Bangkok. JAMA 280 (1) 49-54, 1998).
They further reported that 307 HIV-positive women coming to two Bangkok
hospitals and their current partners were tested for HIV. Eighty-one (26.4%)
of the male partners of the 307 infected women were HIV negative, and thus
benefited from learning that they were are risk of becoming infected. The
HIV discordant couples (i.e., women positive and men negative) were together
shorter (1.9 years) then the HIV concordant couples (i.e., both positive;
2.2 years), pointing to the importance of extended sexual contact for viral
transmission.
Should public health officials in high prevalence areas of Asia promote
contact tracing of spouses as another important prevention tool? Some interesting
thoughts on both contact tracing and HIV reporting appeared in a recent
interview of the United States Surgeon General, Dr. David Satcher (Frankel
DH, Rovner J. Heading up the American dream of health. Lancet 1998; 352,
978-81,
September 19, 1998).
When asked, "Do you
favor reporting names and contact tracing for HIV
infection?," Dr. Satcher replied "I believe that we have to move to a system
of reporting HIV that would allow us to identify people as early as possible
after they are infected. You see, we have come to the point in our technology,
if you will, whereby it's as important to report HIV as it is to report
AIDS, because the sooner we identify people and treat them, the better
the prognosis. That's one thing. But also, the more likely it is that we
can reduce the spread of the virus."
So what happens if treatment as defined in the United States is not
available to HIV infected persons in Asia? Is the goals of "reducing the
spread of the virus" which Dr. Satcher talks about sufficient important
in high prevalence areas in Asia to warrant contact tracing even if expensive
treatment modalities are not available?
Surgeon General Satcher goes on in the
Lancet interview to opine: "So
for many reasons, I think it is time for us to move forward. I agree with
people who are concerned about confidentiality and about whether in fact
people who are identified as being HIV positive will suffer some consequences.
And therefore I think the government has to make the commitment to protect
those people. We haven't done that yet, but I think that's what we have
to do. We have to be willing to stand behind the programme, similar to
what we have done with vaccine safety. The government set up a trust fund
to protect people against vaccine injuries, and I think it's going to be
just as important to protect people who have HIV."
Should contact tracing be avoided in Asia until confidentiality and
anti-discrimination laws are in place that protect HIV infected persons
from disclosure or harm? If so, does this mean that spouses should not
be told of their partners' HIV infection until the legal system has fully
responded? Dr. Satcher partially addresses the urgency for HIV detection
in the concluding portion of the Lancet interview by stating, "But we [in
the United States] do need HIV reporting.
People can argue on name versus other forms of identifiers. Obviously,
name reporting gives us more opportunities to intervene. I think that's
where we are with this epidemic. We need to be able to intervene, to help
people, and to take whatever steps are necessary to minimize the risk of
spread, and to get people in treatment as early as possible."
Do health officials in high-prevalence Asian countries share his goals?
If so, what steps are being followed in various Asian countries to contact
spouses and how successful (or unsuccessful) have such efforts been in
limiting further viral spread?
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