07 December 2006

The articles are captured from the original writer, MsMarina (with her permission). SambalBelacan is just compiling articles to make easier to find. Any comments received will remain un-respond because it's not mine.
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Wednesday December 6, 2006

Early AIDS intervention


SOME people have opined that I should stop writing about ‘mushy’ things like AIDS and write more hardhitting stuff in this column. Given that I only write about AIDS twice a year out of 26 columns, I really wonder where I got this ‘mushy’ reputation from.

In any case, since this is December, I will dedicate this column to AIDS again. Why? Because it hasn’t gone away. And because we still insist on doing empirically unproven interventions rather than things that have been shown to work.

In conjunction with World AIDS Day, Negri Sembilan announced that it will begin mandatory premarital HIV testing for all Muslim couples. Joining states like Johor, Pahang, Selangor, Kelantan, Terengganu, Kedah, Perak and Perlis, this means that no Muslim can get married without being tested for HIV.

It is not clear why this is being done. If the intention is prevention of sexual transmission, there has yet to be empirical evidence that it works.

I detect a certain naivete that only married couples have sex and therefore liable to pass on the virus, unless, of course, people who have premarital or extra-marital sex deserve to get infected.

As with much in Malaysia, we do things not because it is the right thing to do but because we want to show that we are doing something, regardless of effectiveness.

In contrast, in the United States, the Centres for Disease Control and Prevention has recommended near-universal HIV testing, which means that everyone who goes to a university student clinic, hospital emergency wards and walk-in clinics as well as free clinics across the country are given an HIV test routinely.

On the face of it, the CDC recommendation seems to support what we are doing here in Malaysia. But a closer examination reveals very great differences.

For one thing, the goal of universal testing in the US is to get people into treatment early.

As most people in the early stages of HIV infection display no symptoms, they are unlikely to obtain treatment until their immune systems are severely compromised. This would make treatment not only more difficult but also more expensive.

The goal of mandatory testing in Malaysia is merely to identify who is HIV-positive and who is not. If it were aimed at referring people for treatment early, then it would be run by the health departments of each state, not the Islamic religious departments.

Secondly, testing in the US is now being promoted to everybody, regardless of whether they are getting married or not, whatever religion they may be.

Unlike many here, US doctors recognize that you don’t have to be married to be infected, nor is sexual transmission the only way to become infected.

Thirdly, while those found HIV-positive in Malaysia are not prohibited from getting married, it is unclear what counseling is given to not only help them deal with their HIV status but also to prevent transmission to others.

Specifically, they need to be told about condoms and not to share needles. Without this, the stated aim of prevention is unlikely to work.

It is not only newly married couples who are at risk of infecting each other; there are certainly a large number of long-married couples who have become infected. Common sense will tell you that premarital testing would have no effect here.

Fourthly, universal testing is not the same as mandatory testing. Nobody is forcing you to get tested. However, if you are a person at risk and you don’t get tested, you would be depriving yourself of early treatment.

Mandatory premarital testing is punitive; take the test or else forget about getting married. Not getting married, however, is not the same as not having sex.

It is worth knowing that the World Health Organisation does not support mandatory premarital testing.

As a member of the WHO, we are contravening this.

As much as we like going our own way, this would only be supportable if we had a sound scientific basis for doing this.

In the case of mandatory premarital testing, we don’t. It does not prevent people from getting infected, least of all women, as long as nothing is done to change the power dynamics in a marriage that allows men to do what they want without giving women any say. That is the crux of women’s vulnerability to HIV.

As the Minister of Health has reported, the numbers of women becoming infected in this country is rising rapidly, including since 2001 when the first mandatory premarital testing programme began in Johor.

The question we are not asking is this: why are the state religious departments running HIV testing programmes? Is this a way out of our obligation to conduct sound public health practices, replacing them with moral-laden unscientific and expensive ones instead?