More Mandatory Premarital Testing: Burundi

Leaders of the Roman Catholic Church, the dominant religion in Burundi, have instructed priests only to conduct weddings for couples who possess a recent HIV test. Church leaders emphasize that those who are unwilling to be tested may still be married through a civil ceremony, and that they are not asking to know the results: they only demand that the couples are tested and that they 'tell the truth' (presumably to each other). The booklet issued to Burundian priests also forbids marriage for pregnant women.

What is peculiar about the Church’s position is that, relatively speaking for sub-Saharan Africa, Burundi does not have a high HIV prevalence rate (6%). Are Church authorities in Burundi making (possibly stigmatizing) marriage rules that in order to promote public health, or are they simply using HIV/AIDS as a tool to stamp their moral authority on Burundi society?

Erratum: in an earlier version of this post, I mistakenly used information from a press release that stated that the Church in Burundi instructed priests to find out the test results of couples and not to marry those who are HIV positive. I apologize for having passed on this erroneous information, which has been making its rounds on the Web.

Premarital HIV testing in India

The government of the western Indian state of Goa seems to be planning to make HIV testing a mandatory requirement for couples planning to get married. Couples would be tested to find out their HIV status, and then – depending on the results – decide whether or not to go through with the ceremony. This proposal raises obviously a number of concerns such as the social fate of Indian women who are found to be HIV positive and rejected by their fiancés. Will the mandatory testing policy create a new stigmatized underclass? How would the policy protect women in India, when many of them end up being infected after marriage by unfaithful spouses? Will HIV positive persons start gravitating towards other HIV positive persons as their only likely marriage partners (a form of what is known as ‘serosorting’)? Is HIV testing compatible with the Indian tradition of arranged marriages, where the main criterion is not the sexual behavior of the bride or groom-to-be, but whether he or she ‘comes from a good family’? A nice short radio item about the changes to Indian marriage culture brought by the HIV/AIDS epidemic is available here.

Before writing off the policy as unethically draconian, one should realize that India has the second highest number of persons living with HIV/AIDS after South Africa, and that America also had a flirt with mandatory premarital testing. Back in 1988, Illinois passed a law requiring premarital HIV testing as condition of obtaining a marriage license. This had an interesting effect: the number of marriages in Illinois dropped 14% while the marriage rates rose in the neighboring states. When the law was repealed, the number of marriages in Illinois returned to its pre-1988 level. Perhaps the governors of Goa should take note.

Harper's gets hornswaggled

Poor Africans mercilessly exploited by pharmaceutical companies: this byline is a dream for some health journalists. Breaking that kind of story appeals to self-interest and altruism: it can promote your own career, and it places you are on the side of the angels, protecting the vulnerable by speaking truth to power. As long as the story, of course, holds water.

In this month’s Harper’s Magazine, Celia Farber has published a damning indictment of AIDS drug testing practices by pharmaceutical companies in the United States and Africa. (An edited version of the article is available here.) Farber’s main accusations are (a) that one of the study drugs (nevirapine) of an DAIDS/NIH clinical trial on the prevention of mother-to-child transmission of HIV caused the death of Joyce Ann Hafford by liver toxicity, although the true cause of death was obscured and never told to her family and (b) the dangers of liver toxicity with the use of nevirapine were already long known. The policy of using nevirapine with HIV positive pregnant women is based on HIVNET 012, a deeply flawed (according to Farber) DAIDS/NIH study conducted in Uganda back in 1997. Farber basically argues that the regulatory, scientific and ethical problems of the HIVNET 012 trial were overlooked in order to profile nevirapine as a safe, effective and cheap way to reduce mother-to-child transmission in Africa. Voices in the NIH who questioned the methods and results of HIVNET 012 were silenced or sidelined. By the time the use of the drug was implemented (particularly in the developing world) too much was at stake: the reputation of the NIH for one thing, and the profits being made by the drug’s manufacturer (Boehringer) for another.

Farber, in fact, aligns herself with those who believe that nevirapine is not an effective HIV prevention drug, and that the risks outweigh the benefits. This line of thinking takes her on a whole other tack: that AIDS research in general is not about helping patients, but merely a way of serving the interests of the powerful. She tries to rehabilitate the reputation of Dr. Peter Duesberg, well-known for his view that HIV does not cause AIDS, that AIDS drugs themselves are behind (what are called) cases of AIDS, and that if toxic AIDS therapies were discontinued, thousands of lives would be saved overnight. For Farber, the bottom line is that the ‘AIDS industry’ – represented by pharmaceutical companies, health agencies and activist groups – promote the production and consumption of dangerous drugs to fight a syndrome that may well not exist. She’s been doing this sort of thing for awhile.

Reaction to Farber’s article has been swift. The Treatment Action Campaign in South Africa has issued a statement citing 56 errors (of various types) in Farber’s piece. In Slate, Jon Cohen uses the article as an example of ‘pharmanoia’, the pathological mistrust of all things pharmaceutical. (Is there a brand name drug for that? Never mind.) Perhaps the best comment is that of Pulitzer Prize-winner Laurie Garrett: “Harper's got hornswaggled. They thought they had a scoop, but it was tired old BS dredged up from the bad old days.”

The prevention of measles: a victory for Africa

Corrupt governments, deadly locust plagues, armed ethnic conflicts, famines: that is generally the kind of lurid stuff that one expects to slink off the African news desk. So it is at refreshing, at least for a change, to hear some good news concerning health coming out of Africa last week. Cases and deaths of measles dropped 60% in sub-Saharan Africa last year, largely due to a massive vaccination campaign spearheaded by the WHO and UNICEF between 1999-2005. This is a tremendous public health victory.

Of course, if one still insists on harping on about Africa's privations, there is ample opportunity. There is no good reason why 440,000 children should die from measle-related illness in 2005, when there has been a cheap and simple vaccination has been around (at least in the countries of the North) for more than 40 years. And measles is only one of the smaller of the killer diseases roaming the continent. And so on. But this sort of fixation with 'Africa-the-disaster' is unhealthy. The small successes should be honored and emulated, not relativized and minimalized in favor of the next horror story.

Treatment Action Committee wins case against the notorious Dr. Rath

South Africa's Treatment Action Campaign (TAC) is one of the world's best known and most successful AIDS activist groups. TAC was instrumental in leading the fight against the ridiculous lawsuit that 39 pharmaceutical companies brought against the South African government in 1998 to stop the government from making cheaper, generic AIDS medicines available in their country. That time, the pharmaceutical companies backed down, and the issue never made it to the court.

It is no small irony then that TAC has been recently accused of being lackeys for the pharmaceutic world. The delightfully named Dr. Rath, of the Rath Foundation, put out full page ads in the New York Times last summer that stated (besides the usual stuff about the toxicity of anti-retroviral drugs and the wonderful healing powers of vitamins produced by the Rath Foundation) that the TAC was actually being funded by pharmaceutical companies, and that was the dark reason why TAC was pushing for universal access to AIDS treatment. It seems that for Dr. Rath, either you are with him, or you are with the pharmaceutical mafia.

The South African court has told Dr. Rath to cease his ad campaign. TAC is gearing up to hit the Rath Foundation with a full defamation lawsuit.

Fly to fight AIDS, tuberculosis and malaria

A French initative to finance health and development in low-income countries and help meet the Millenium Development Goals seems to have some legs: imposing taxes on airline tickets. Jacques Chirac had already introduced the idea at the 2005 World Economic Forum, but an international meeting in Paris last week saw 12 countries (including Britain) agree to the tax. The French parlement decided in January that what they call the 'solidarity tax' should come to 47 Euros (around $60) for every flight leaving French soil. The Congolese president Denis Sassou Nguesso takes the idea to a whole new level, calling for a health and development tax imposed on weapons of war and on international financial transactions. Now that's a thought.

Given that this is a French initative praised by the UN, that it involves raising taxes and solidarity for the poor, it should not come as a shock that the United States flatly rejects the proposal. And the basic argument against the proposal is predictable enough: imposing the taxes would not be in the interest of resource-poor countries. The editorial from the International Herald Tribune encapsulates this line of thought: the airline ticket tax would hurt developing countries dependent on income from tourism and air freight. It would be better, the editorial claims, to concentrate on 'proven strategies' to alleviate poverty and its impact on health, like lifting trade barriers and opening markets. But the airline ticket tax comes precisely out of frustration with decades of 'proven strategies' that coincide with a widening gap between the (health of the) rich and the (health of the) poor.

Avian flu in Africa: media update

The BBC news service has posted a nice review of how the issue of bird flu is being handled by the press in different African countries: some present a picture of doom and gloom (with fingers pointed at the government) while others are more sanguine about the threat posed to their country and the state of the preparations by local health authorities.

Male Circumcision: all the rage in Swaziland

Mbabane Clinic in Swaziland has recently seen a sharp rise in the number of men seeking to be circumcised. Or perhaps that is putting it too lightly: the administrator of the clinic, Dr. Mark Mills, described it as a ‘stampede’ that nearly culminated in a ‘circumcision riot.’ Mbabane clinic has, in fact, hired two new doctors full-time just to meet the rising demand, and all this despite circumcision being traditionally foreign to Swaziland.

The new-found desire for male circumcision clearly stems from a recent, randomized controlled study in South Africa indicating that male circumcision may reduce risk of HIV acquisition. Those results have been supplemented by new data presented in Denver last month that suggests circumcision may also protect transmission of HIV from men to women. In an increasingly interconnected world, word soon trickles down from international conferences to African towns and villages.

In a country where roughly 40 percent of the adult population is believed to be HIV positive, the idea that a relatively cheap surgical procedure could provide some protection against HIV is a very attractive prospect. For its part, the Swaziland Ministry of Health is not really heeding WHO/UNAIDS recommendations to exercise caution and wait until the results of other circumcision studies in Uganda and Kenya are made available. The Ministry is already promoting the practice as an HIV prevention tool, and has funded a circumcision refresher course for local doctors.

In the background of all this is a raging debate on research that has tried to establish an association between HIV transmission and male circumcision for the last twenty years. Critics of the research point out that HIV has taken the greatest toll on the African continent, where roughly two-thirds of the men are already circumcised, and argue further that behavioral, cultural and economic (rather than anatomical and biological) factors are the main forces driving the transmission of HIV in Africa and elsewhere.

The stakes are very high. If the recent research findings are correct, male circumcision is -- given the failure to discover an effective vaccine -- a much needed tool in the struggle against HIV/AIDS. If critics of the research are correct, then the well-publicized promotion of male circumcision is a dangerous distraction, and men (and women) in Swaziland are being given false hope.