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"Early AIDS intervention"
The
Star (www.thestar.com.my)
(06/12/06)
Byline: Marina Mahathir
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?
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