Introduction to the problem

Article by: Bibek Raj Giri MPH, B.Sc(Microbiology)

 

HIV is Human Immunodeficiency Virus and AIDS (Acquired Immunodeficiency Syndrome) is a syndrome caused by the virus which is the most advanced stage of HIV infection. HIV/AIDS spreads through certain body fluids attacking the body’s immune system, destroying or impairing their function. HIV generally infects CD4 cells i.e. T cells.

Problem

UNAIDS (2015) reported that a total of 36.7 million people of all ages are living with HIV and 2.1 million new cases were seen in 2015. Similarly, in Asia and the Pacific region, there are 5.1 million people of all ages living with HIV and 300,000 new HIV cases and 1.1 million AIDS-related deaths were registered in 2015. This is a big threat and challenge from public health perspectives. Advocating for this data, in India alone, there are 2.1 million HIV infected persons and 68000 deaths due to AIDS. The HIV epidemic in India is concentrated among high-risk groups and is heterogeneous in its distribution. The exposures that determine the epidemic are different in different parts of the country.

It is well-known fact that HIV/AIDS has been among the major communicable diseases form decades but 95 percent of those infected worldwide do not know that they are harboring the most fatal virus, and are therefore spreading it unintentionally. The primary reason for this is that routine AIDS testing is virtually absent in most countries and is developing in many countries.

In India, husband related risk factors increase the chance of women for HIV infection. The prevalence of HIV among ever-married women is higher than the national average. The concepts on premarital checkups are growing to minimize the risk factor. Premarital checkups are preferred before any sexual contact but these days most of the couples practice pre-marital sex which is making premarital checkups ineffective. Some studies also show that people who knew that they did not have HIV had a much greater motivation to practice safe sex in order to stay uninfected.

What is Premarital HIV testing?

Premarital HIV testing is a test mainly designed for those who are planning to get married. It can contribute to the prevention of HIV infection by diminishing heterosexual transmission between partners and indirectly protects any potential child from contracting the virus. Therefore, premarital checkups are preferred to prevent such a communicable disease.

Premarital HIV testing also prevents further transmission by encouraging couples to take precaution steps. Determining the behavior of acceptance or rejection of premarital HIV testing, one can get an idea about what the general adult population (18-35 years) think about mandatory premarital testing which may be helpful for any intervention accordingly and if necessary.

Concept of Premarital HIV testing in the world and India

Even though there are many controversies about mandatory premarital testing worldwide; it is gaining many religious and political supports. Countries like Guinea, Bahrain, UAE, and Saudi Arabia have passed national laws and policies about mandating premarital testing. Local governments and legislatures in five Indian states, districts in Yunnan province of China, Ethiopia and the Democratic Republic of Congo have introduced or enact similar laws or regulations. Screening HIV before marriage has led to marriage rate decreased by 9 % and 16 % than in the previous 2 years in Louisiana and Illinois respectively. It was also found that mandatory premarital screening would be expensive and would probably have a minor impact on the HIV epidemic when compared to other HIV preventive methods. Most researchers have indicated that only testing alone can’t change the behavior, a crucial step is counseling and promotion of behavioral change; HIV testing should be accompanied by counseling about what a positive result will mean for an individual’s sexual lifestyle and stigma they might suffer. If an individual test positive, antiretroviral drugs should be available.

A significant difference between the age group about the willingness of HIV test before marriage and also positive comments about HIV testing in asymptomatic individuals. There is also a significant difference between the two gender groups about willingness to marry after HIV positive tests of their wives. Several demographic factors, awareness, knowledge, and attitudes towards premarital screening had a significant influence on participation in the premarital screening program. Promotion activities and health education to improve knowledge and attitudes to premarital screening will help increase the rate of voluntary premarital screening.

What should be done?

At a minimum, testing should be required at three specific moments in a person’s life: at marriage, before childbirth and upon any visit to a hospital. There are lots of benefits to individuals, women, children, and society as early detection and treatment of HIV has been proven to be a successful way to improve not only the survival but also the quality of life of HIV patients. Socio-demographic factors and past sexual history were predictive of pre-marital HIV testing. Knowledge factors about STD/HIV/VCT were not found to be significantly associated with pre-marital HIV testing.  Voluntary and strictly confidential premarital HIV testing is more desirable than a mandatory form. Arab countries, being predominantly governed by Islamic laws any individual found to be positive after premarital HIV testing may become socially isolated, the challenge in such countries is to put more effort into shifting social norms toward a de-stigmatization of the disease and acceptance and support of People living with HIV(PLH). HIV prevalence in Kuwait is less due to strict regulations, preventive policies and guidelines which also includes premarital HIV testing by law. In developed and committed countries, mandatory premarital screening does have the potential to succeed as long as the target population is clearly identified and all ethical issues (including confidentiality of the results), religious, cultural and human rights and concerns about proper post-diagnostic management are fully addressed.

Voluntary counseling and confidential HIV testing, especially pre-and post-test counseling, as the basis of pre-marital HIV testing would be particularly desirable. Guidelines for the management of test-positive individuals, the management of non-concordant couples and the safeguarding of confidentiality should be developed.

In India husband related risk factors increase the vulnerability of Indian women for HIV infection. The prevalence of HIV among ever-married women is higher than the national average. Indian states like Goa, Himachal Pradesh, Karnataka, and Maharashtra have been proposing mandatory premarital HIV testing but again changing it to voluntary testing with times.  As the proposed mandatory premarital testing some of the states were unclear about the marital consequences of a positive result, in some state marriage was allowed and while some states with forbidden marriage.

There are many potential barriers to adopt the policy in context to India. Some difficulties are; issues with the implementation and marriage registration, limited beneficiaries of a policy of mandatory premarital HIV testing, high and low-risk groups, the problem of the test itself (a person can be in window period but not detected at the time of premarital test).

 

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