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Premarital Aids testing - think through implications first

Consumers Association of Penang president SM Idris', suggestion that the government extends premarital HIV-testing to couples of all communities ( The Star , Nov 1), if adopted, will only serve to compound the practical problems raised by Malaysian Aids Council's president Marina Mahathir ('Aids body against plan to force pre-marriage HIV tests', Oct 31).

According to Idris "although all points (opposing the move) are valid, they do not address the key problem - protecting and preventing the spread of HIV to unsuspecting spouses and future offspring".

I would say that although Idris' point in supporting the move sounds equally valid, it is futile if the object of the move is defeated by problems of practical implementation and other considerations that create new problems.

Firstly, do our hospitals and clinics have the necessary infrastructure and manpower in terms of lab technicians, counsellors, administrators, nurses and doctors to conduct such tests with the degree of accuracy as is necessary?

Secondly, if resources for such testing are inadequate, wouldn't a nationwide testing compound the problems of wrongly identifying, due to human errors, many persons as HIV-positive when they are actually not, or in the converse situation of the 'window period for HIV manifestation' raised by Marina not being adequately factored in, clear as negative those who are truly HIV-positive?

Either errors will, in due course, lead to severe stress and possibly endanger jobs, health insurance, and family relationships, so the question arises, are government hospitals and private practitioners adequately covered in terms of medical insurance indemnity to buffer the legal suits instituted by those affected adversely by wrong identification?

What about a contractual suit for the breach of medical ethics of confidentiality as bureaucrats seek findings of testing from doctors? Or are we going to legislate an exemption from doctor-patient confidentiality for divulging the results of Aids/HIV testing?

Another issue is if HIV is a scourge on unborn children, so is hepatitis, venereal diseases and a host of other communicable or hereditary diseases. Why don't we also test against those diseases before allowing couples with raging libidos to marry?

Thirdly, on the issue of money, who shall bear the costs of such testing which presumably is not cheap? To pass such a cost to marriage applicants compounds their financial burden already incurred in the intended marriage or is it suggested here that the state defrays and underwrites all such costs? If so, this is not economical because so much money will be spent on testing and clearing the majority of couples not infected in order to ferret out the very few who are.

Why should such an uneconomic venture (i.e. more false-positive than true-positive results with high costs per detected case) be passed on to tax payers, the majority of whom do not belong to the category of those intending to marry?

Fourthly, whilst still on the issue of so much money spent on ferreting out the infected few, the waste of resources is not only money but also to be factored in the disproportionate diversion of monetary, human and lab resources to HIV/Aids from other diseases, that though not as fatal, are however more endemic.

On the question of allocation of scarce resources, wouldn't it be more effective to counteract the Aids/HIV problem by spending the money on health services and support, education and research related to that disease?

Fifthly, consideration must be given to cultural mores of the respective communities. Non-Muslims are not confronted with the religious ban against close proximity and cohabitation outside wedlock. I can imagine that at least some non-Muslim couples will opt for either deferring marriage or cohabitation for the time being rather than go through the hassles of compulsory premarital testings, that are in any case, not sure proof of accuracy but sure raises a host of problems of visits from health officials if diagnosed as HIV-positive.

Then the problem faced by Muslims: there is a fear that if identified as HIV-positive, there will be a lot of follow up by public, regulatory agencies or even religious authorities on how the HIV was contracted in the first place, that is to say, whether through sharing of needles for drugs or other risky behaviour of unprotected promiscuous sex, whether heterosexual or bi-sexual, that not only Islamic values condemn but the laws proscribe. There is also a question of jurisdiction and circumvention as in the case of the couple contracting a Muslim marriage in southern Thailand, (say) Pattaya, that does not implicate premarital testing. Will such Muslim marriages not be recognised?

Sixthly, let us examine the objectives and premises of such premarital testing once again.

If the avowed objective is to prevent transmission of HIV by identifying infected persons and warning their prospective spouses not to have sexual intercourse with them, it assumes, many a time wrongly, that the couples do not engage in sexual intercourse before marriage when they actually do - by which time, the virus is already passed!

And what happens if one of the couple is identified to be HIV-positive by such premarital testing?

The assumption that couples, when one is diagnosed HIV-positive, cannot be prevented from marrying is debatable. Under what law, they cannot be prevented - the constitution? If so what about the constitutional right of an unborn baby not to be infected by its parents? In any event, if it were the legal position and human rights position that couples cannot be prevented from marrying, why then initiate premarital testing and make it mandatory, as opposed to advisory or directory, at such cost that will be borne by the public?

If Johor authorities who first came up with the suggestion opine that preventing a couple to marry is by law unconstitutional and an infringement of human rights, what about the constitutional right not to be tested - doesn't forced testing involving an involuntary withdrawal of blood constitute an unreasonable search and seizure or violation of bodily integrity that citizens can sue the government for?

If it were limited to creation of awareness of the Aids/HIV problem, then such periodical testing should be prescribed for all segments of society at different times - though the exorbitant costs of test still needs to be contended with) and should not be confined to marital hopefuls!

A more practical move is to identify, address and mitigate by education or programmes, the root of the socio-cultural conditions in which milieu the risks of HIV transmission are enhanced.

If the objective of premarital testing is that it will prevent conception of offspring infected with HIV, then compulsory testing should be at the time of early pregnancy rather than the time preceding marriage (though I agree will trigger a host of other ethical, moral or religious issues regarding abortion if the tests prove HIV-positive).

One should not forget that a man who had not contracted HIV at the time of marriage in relation to his first child can do otherwise in relation to his second and third children after he had gone to and return from Thailand after a tryst of unprotected commercial sex. What then? Are we to extend testing from premarital to post-marital scenarios as well?

An aspect to be considered is whether there is sufficient data in local context to demonstrate that most HIV-infected children are from wedded or unwedded parents. Is there data to support the contention that such testing actually uncovers the disease for the target market of marital hopefuls, unaware of such condition, and they would have precipitated the plunge and produced children had it not been for such a test?

If most HIV-infected persons, suspecting their own condition or likelihood, thereof refrain from marriage (those unknowing cases being far and in between) or if the data supports that most infected men were homosexuals and gays, that our laws do not allow marriage between the same sex or if the data establishes that the preponderance of HIV-infected children are conceived from unwedded mothers, what good will premarital testing (at such great economic costs against limited benefits) achieve?

In conclusion, although there is much humanitarian appeal - and political points to be scored - in initiating compulsory HIV premarital testing, I ask whether the authorities have thought through the whole range of implications and considerations (technical, legal, ethical, economic) implicated by such a move for implementation on World Aids Day (Nov 13)? I am sure Marina and the Malaysian Aids Council (and even the Medical Council) will not oppose the move unless they have sound reasons.

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