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Rapid Responses: Rapid Responses published:
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Is this a logical approach
- Jeffrey C McILwain (20 June 2003)
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Preventing HIV:Time to get serious about changing behavior .
- Syed Abdul Mujeeb, Ambareen Khan, Sharaf Ali Shah (22 June 2003)
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Preventing HIV ?
- James E Parker (25 June 2003)
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Preventing HIV and breast feeding: a cautionary note
- Hugo Pilkington (12 September 2003)
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Jeffrey C McILwain, Consultant, Clinical Risk Management Whiston Hospital, Prescot, Merseyside L35 5DR
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Arthur J Ammann is either being deliberately provocative, or has got it entirely wrong. Paragraph 3 'All individuals should be tested for HIV regardless of perceived risk factors, to break down the barrier that HIV only affects "us" and not "me"' will likely do exactly the opposite. Labelling people as "having" and "have not" foments discrimination, it does not dispel it. Further, given the sero-conversion window of 3 months does Ammann expect everyone to be tested on a permanent three monthly cycle to close the loop? Such impractical suggestions that promote discrimination demonstrate blindness to what is going on in society in general. In Cuba, HIV infected people have been imprisoned "for the public good" and in Africa the denialists rule countries and opinion. Further, within his own country patients with HIV can be denied entry to visit the USA, by law. Without the offer of political education and further funding, to provide a virocidal agent, as opposed to an enzyme inhibitor virostatic agent, the suggestion of mass testing is as illogical as it is impractical. Why test masses of people, label them but offer no chance of a cure, let alone clinical management? Such an approach whilst being morally bankrupt in the face of confidentiality leads to more despair. Ammann's strategy should be to pursue political education and funding for virocidal solutions before offering mass screening to an incurable condition. His motives for suggesting such a strategy may have logic but lack a practical outcome in the absence of a cure or appropriately funded management programmes. However, if Ammann believes that regular and persistent testing is the way forward he may wish to publicly declare his own HIV status, today, in 3 months, in six months, in nine months etc. Competing interests: None declared |
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Syed Abdul Mujeeb, Incharge, AIDS surveillace center Jinnah Postgraduate Medical Center, Karachi,75510, Pakistan, Ambareen Khan, Sharaf Ali Shah
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It was very enlightening to read Ammann AJ’s editorial” Preventing HIV: time to get serious about changing behavior(1).” People living with HIV/AIDS(PLWHA) are the primary source of spread of the disease in the community, either because of their ignorance, negligence or false assurance of care and cure by the informal health care sector including traditional healers, faith healers and practitioners of complimentary medicine(2,3). In Pakistan, like elsewhere in the developing world, most of the people go to informal health sector for their ailments . A good number of informal health care practitioners believe HIV/AIDS is a curable disease and they advertise their expertise openly in media and by people to people contacts (4). PLWHA usually remain in doubt about their clinical diagnosis, as they do not find traditional signs and symptoms of the disease among themselves . Each passing day with good health further add their uncertainty about their HIV status of illness. Soon after the diagnosis PLWHA go from pillar to post to find some help and soon come across with these practitioners of informal health care, claiming their cure . One meeting of PLWHA with these informal health care practitioners take away the several weeks effort of HIV/AIDS program management to counsel them and change their high risk behaviors. These infected people remain in their false sense of assurance or recovery till they develop full blown disease AIDS or find their wife, or partners got infected with the virus. There is a time that public health authorities in the developing world must focus informal health care sector in their HIV/AIDS control programs to educate and sensitize them about HIV/AIDS and their moral responsibility to avoid undermining the national efforts to control the disease in the community. There is also a need to have a legal frame work asking all health care practitioners to refrain from misleading PLWHA with regards their false claims of care and cure . Media should also be asked to show more responsibility in publicizing the false claims of development of HIV/AIDS care and cure. There is also a need to develop a program focusing specifically PLWHA to address about their uncertainties about their HIV status and developing a resistance to the tempting un ethical advertisements of informal health care sector Competing interests: None declared |
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James E Parker, Retired Paediatrician 289 McCallum Rd ,Abbotsford BC CANADA V2S 8A1
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'For two decades we have known how to prevent evry single route of transmission......' Arthur Ammann (BMJ 2003; 326: 1342-1343 -21 June) tells us and 'yet the number of people infected with HIV worldwide is estimated at 42 million with 5 million new infections each year. How can this be ?.' One doesn't have to look very far for answers -indeed the philosophy expressed in the immediate rapid response 'Is this a logical approach ?' by Jeffrey C McIlwain (20 June 2003) provides them. While unconstrained HIV screening would appear to be a public health imperative in ascertaining the whereabouts of disease and thus prevent it's transmission to susceptibles, McIlwain takes issue with this on the basis of stigma. It is interesting that only one country worldwde has contained HIV/AIDS. That country, Cuba, invoked orthodox public health measures including temporary quarantine in vacant hotels. Imprisonment for 'the public good' ?. In his final paragraph McIlwain challenges Amman to declare his own HIV status at serial intervals !. This philosophy, I submit, has been a major stumbling block in HIV containment. One's HIV status as with any other personal medical condition is one's own business unless it comprimises another individual which then becomes a matter for public health (but not necessarily public knowledge !). Muddled ethics -test results rendered anonymous, 'endorsement of ignorance', 'right not to know', HIV exceptionalism, fear of discovery and failure to protect. These are the reason for the AIDS debacle. If a fraction of the degree of resolve applied to the containment of SARS had been applied to HIV the picture might be very different. James E Parker Competing interests: None declared |
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Hugo Pilkington, Geographer Department of Geography, University of Paris (Saint-Denis)
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Editor – In his editorial, Ammann states that breastfeeding substitutes (provided these are administered with clean water) could prevent thousands of HIV infections each year (1). He also states that the provision of safe drinking water would be less costly than providing lifelong treatment for HIV infection. These statements seem logical at first: indeed, United Nations Programme on HIV/AIDS (UNAIDS) estimates that approximately 800 000 children were newly infected with HIV in 2002 and that 90% of these new infections occurred in sub-Saharan Africa. Almost all HIV-infected children acquire HIV from their infected mother through a number of different routes, and a major source of mother to child transmission of HIV (MTCT) is after birth through breast feeding (2). Nonetheless, reality is more complex and the author fails to take into account two fundamentally important factors in preventing MTCT. First, while it is certainly doubtless that breast feeding is a major risk during early infancy and that the risk of HIV transmission through breast feeding persists as long as it continues (3), studies have shown that breast feeding is a major protective factor against diarrhoea, a leading cause of death in young children in many developing countries (4). Moreover, it has been strongly suspected that breast feeding may help protect infants against parasitic diseases (such a malaria) in such settings. Furthermore, if used incorrectly, a breast milk substitute can cause infections, malnutrition and even death (5). Second, implementing exclusive breastfeeding substitutes in some communities is a delicate matter. In communities where people living with HIV infection and AIDS are prone to suffer from social stigma and discrimination, it may be very difficult for an infected woman to adopt an alternative feeding habit for her young children. Such a change from the norm would, in effect, be a clear sign to the community of infection. Research has noted the difficult decisional dilemma women may face in such a situation. Far from helping HIV-positive women care for their children, stigma and discrimination may have quite the opposite effect if individuals are to be isolated and rejected (5). The delicate fabric of biological, epidemiological and social factors needs to be considered in the long and difficult struggle against HIV, especially when behavioural change is needed. References 1. Ammann AJ. Preventing HIV. BMJ 2003;326(7403):1342-1343. 2. UNAIDS, WHO. AIDS epidemic update, December 2002. Geneva: UNAIDS/World Health Organization, 2002. 3. De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. Jama 2000;283(9):1175-82. 4. Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet 2003;361(9367):1418-23. 5. UNAIDS. Mother-to-Child Transmission (MTCT) of HIV: Questions and Answers. Geneva: UNAIDS/World Health Organization, 1999. Competing interests: None declared |
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