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Frerichs, R.R. Widespread testing in high prevalence countries

SEA-AIDS Network, January 27, 1999.

Posted in response to:

SEA-AIDS, January 25, 1999

From Bob Watt, United Kingdom 

In response to messages and in particular to Ralph Frerichs. Sorry that the URL to the journal article did not seem to work, it is correct, it does NOT work and it is particularly galling because it is a law review article in a web based journal which is supposed to be readily accessible!

However Ralph Frerichs made a good point in an email to me chasing the article and suggested that I digest the relevant point. Here goes (The testing/ SE Asia point is not well made in the article anyhow because we were addressing different circumstances.)

The central contention is that people who engage in behaviour which may result in the transmission of the virus bear equal responsibility for the action. It is wrong in principle to affix special responsibility to the person living with HIV/AIDS. The article focuses upon establishing this point. Can we take it as read?

What has this got to do with testing? Testing has two rationales:

(1) to prevent transmission and

(2) to identify those who need treatment. 

In South East Asia (and a number of other places in the developing world) rationale 2) does not hold. People in general are NOT going to get combination therapy - presently the only effective treatment. 

Does rationale 1) hold? It is suggested that it does not. The only prudent action is to assume prima facie that everybody is HIV+. There are two arguments in favour of this position - reading the horrific figures from parts of Africa and from parts of SEA it is clear that the disease is widespread in the community. Secondly, and more optimistically, the results from parts of Thailand (and Uganda) (and the gay community in the UK) show the fruits of acting as if the assumption is true. "Safe sex" (in its broadest sense) cuts transmission. Assuming that everyone is +ve is helpful.

The problem with this as a final argument is that conception is impossible. Conception being the only rational reason for 'unsafe sex'. Yes there are plenty of emotional ones - but fortunately emotions are not rational!

Now the tough part of the argument: it is taken from an analysis of a (Dine & I argue) wrongly decided case in the US military. We suggest that people who knowingly pass the virus between themselves in a relationship should never be said to be doing wrong (in the case - by grave- criminalised) There are strong arguments which say that since people live in relationships that there are positive reasons for allowing them knowingly to pass the virus between themselves. Simply and bluntly - life is short, generally nastyish, and the only source of relief from isolation is being with another. (Unlike Dine, I think that it is the only way of really being human).

Perhaps catching the virus can be seen, in a relationship, as the least bad thing or even as valuable- given the circumstances. (We present special arguments dealing with eg prostitution - but these are strictly aimed at the developed world).

All testing is going to do (where there is no treatment) is to further destabilise relationships. HIV is bad enough - don't let it dehumanise us.

Ralph Frerichs' case seems to be based upon individualism and ascribing blame. Where does that get us? Alright, there may be special cases in which blame ought to be ascribed and Dine and I canvass those.

Briefly they are those in which the behaviour may rightly be described as vicious - the person who sets out to kill another by desiring to pass the virus.

Bob Watt

SEA-AIDS, January 26, 1999

From Kenrad Nelson, Johns Hopkins University

David Wilson (#70) is certainly correct in pointing out the differences in the ability to promote condom use for commercial or casual sex and sex between steady partners or married couples. The use of condoms between married couples or steady partners is not impossible how ever, when they both are aware that one partner is HIV positive. In studies we have done in Northern Thailand in discordant couples, we have found a dramatic increase in "safe sex" in married couples when both were aware that one partner was HIV positive. In order for this prevention strategy to successfully prevent HIV transmission, HIV testing and counseling needs to be widely available, accepted and effective. Fortunately, in Northern Thailand this type of prevention is becoming a reality. But more efforts with this prevention effort are needed in Thailand and other countries facing major heterosexual HIV epidemics.

Kenrad Nelson, MD

Johns Hopkins University

Baltimore, Maryland USA

SEA-AIDS, January 27, 1999

From Pol Jansegers, Belgium

As Professor Frerichs rightly demonstrates with available research - and I think he is right in saying that that is the farthest you can go with this kind of research without becoming unethical - the answer to David Wilson's (#70) question is "Yes" (i.e. people knowing they are HIV seropositive are more likely to change their behaviour than others).

From there to conclude that HIV testing, and more specifically massive HIV testing - because that is I thought the debate with Dr Frerichs - should be used as a prevention tool, is a quite different matter. Besides the impact of HIV testing on behaviour change, there are indeed a number of other questions that need to be considered. Two of them are fundamental:

1) What is the opportunity cost of widespread testing? In other words, isn't there a more efficient use of the resources that massive testing would require? A very explicit answer to that question was given in this forum, and I think that Rachel Sacks (#67), as far as the content of her message is concerned, is right.

2) What about the side effects of massive HIV testing, especially if it is coupled with routine partner notification? Limited experiences in the USA may have shown that people react rather positively to that scenario, the fact is that this is not - hopefully just not YET - the case in Africa, and even less in Asia. Numerous stories about all kinds of discrimination are there to remind us the reality.

Taken together, these two considerations should be sufficient to argue against widespread HIV testing.

Pol Jansegers

Public Health consultant

Lasne (Belgium)

R.R. Frerichs Posting

The debate on the merits of widespread HIV testing is moving into an interesting phase, with thoughtful postings from Drs. Watt, Nelson and Jansegers. Before continuing, however, I would like to limit the discussion if possible to high prevalence countries or regions in Asia in which HIV is infecting five percent or more of the sexually-active population. It is in such settings that I feel routine testing is in order, and should be considered as a prevention strategy.

Some might also notice that I have switched terms from "mandatory" which stimulates so much emotion (see "Confronting HIV in India" for an example) to "routine" which better reflects the reality of medical care in much of Asia. The distinction of course is that routine testing means that a person could decline the test if so desired, while "mandatory" testing means there is no choice. I am very comfortable with the thought of routine testing, and am even more comfortable with another component of widespread testing, namely home screening (i.e., rapid test at home by fingerstick or saliva with confirmation by a physician using a laboratory based assay), which places all of the control for initial screening in the hands of the individual and his or her sexual partner, rather than the government or medical care provider. To me, home screening is an especially important option for countries experiencing a shortfall in government funding, giving personal freedom with access in the marketplace to those who can afford such tests (for a more complete discussion, see Frerichs RR. Lancet 343: 960-962, 1994).

"Routine" testing means that the HIV assay is done in a clinic or hospital setting as part of routine medical care, the same as measuring blood pressure, checking for anemia, assessing height, weight and the like. Thailand has such high HIV prevalence regions and thus, if the five percent criteria is followed, would be an excellent candidate for routine testing in medical care settings and the sale of home HIV screening in the private sector.

As far as I know, areas in Northern Thailand have now included routine testing for many couples planning to be married and for all women attending antenatal clinics. An interesting article appeared in today's Bangkok Post (Bhatiasevi, Aphaluck. Results of ZDV use revealed. The Bangkok Post, January 26, 1999) that described such testing in Thailand. The article was reporting on a seminar entitled, "Experiences on Reduction of Mother-to-Child HIV Transmission in Upper Northern Thailand" attended by over 450 health representatives from several northern provinces. 

According to the Bangkok Post, a public health official reported that zidovudine (i.e., AZT) has been provided free to all HIV-positive pregnant women at district and provincial hospitals in the upper North regions of the country. From the time the project was started in July 1997 until September 1998, the Bangkok Post article states that 436 HIV-infected pregnant women were identified and willing to participate in the AZT treatment program. Among these, 417 had given birth and they had 95 babies whose HIV status is known. Only six of the 95 were reported infected with HIV (i.e., 6.3 percent). 

At the same seminar, the director of the Communicable Diseases Control Centre for the upper North stated that the usual mother-to-child HIV transmission rate without AZT treatment is 25 percent, or if breast-fed, as high as 35 percent. Thus they reported that 6.3 percent is very low, ascribing this to the preventive effects of treatment with AZT.  What was not clear from the article is what percentage of pregnant women in Northern Thailand are being tested (i.e., is HIV testing now routine?) or why 417 - 95 or 322 who gave birth did not know the HIV status of their children. 

Perhaps some researchers or officials from Thailand could provide SEA-AIDS readers with further insight as to their experiences with widespread testing in the Northern Region, adding reality to our often theoretical debate. Please also comment on spousal notification procedures, including how this is done and if there have been problems with administering the program. Once such case-studies appear, we might find common ground in considering policies that rely on widespread HIV testing.