The social and gender context of HIV disclosure in sub-Saharan Africa: a review of policies and practices.

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.

Premarital screening programmes for haemoglobinopathies, HIV and hepatitis viruses: review and factors affecting their success.

This literature review is a comprehensive summary of premarital (prenuptial) screening programmes for the most prevalent hereditary haemoglobinopathies, namely thalassaemia and sickle cell disease, and the important infections HIV (human immunodeficiency virus) and hepatitis viruses B and C (HBV and HCV). It describes the background to premarital screening programmes and their value in countries where these diseases are endemic. The use of premarital screening worldwide is critically evaluated, including recent experiences in Saudi Arabia, followed by discussion of the outcomes of such programmes. Despite its many benefits, premarital testing is not acceptable in some communities for various legal and religious reasons, and other educational and cultural factors may prevent some married couples following the advice given by counsellors. The success of these programmes therefore depends on adequate religious support, government policy, education and counselling. In contrast to premarital screening for haemoglobinopathies, premarital screening for HIV and the hepatitis viruses is still highly controversial, both in terms of ethics and cost-effectiveness. In wealthy countries, premarital hepatitis and HIV testing could become mandatory if at-risk, high-prevalence populations are clearly identified and all ethical issues are adequately addressed.

An economic analysis of premarriage prevention of hepatitis B transmission in Iran.

BACKGROUND: To assess the economic aspects of HBV (hepatitis B virus) transmission prevention for premarriage individuals in a country with cultural backgrounds like Iran and intermediate endemicity of HBV infection. METHODS: A cost-effectiveness analysis model was used from the health care system and society perspectives. The effectiveness was defined as the number of chronic HBV infections averted owing to one of the following strategies:1) HBsAg screening to find those would-be couples one of whom is HBsAg positive and putting seronegative subjects on a protection protocol comprising HBV vaccination, single dose HBIG and condom protection.2) HBsAg screening as above, in addition to performing HBcAb screening in the HBsAg negative spouses of the HBsAg positive persons and giving the protocol only to HBcAb negative ones.Sensitivity and threshold analyses were conducted. RESULTS: The cost of each chronic infection averted was 202$ and 197$ for the strategies 1 and 2, respectively. Sensitivity analysis showed that strategy 2 was always slightly cheaper than strategy 1. The discounted threshold value for the lifetime costs of chronic liver disease, above which the model was cost saving was 2818$ in strategy 1 and 2747$ in strategy 2. CONCLUSIONS: Though premarriage prevention of HBV transmission in the countries with cultural backgrounds similar to Iran seems cost saving, further studies determining precise costs of HBV infection in Iran can lead to a better analysis.

[The serological exam for the human immunodeficiency virus (HIV) as part of the premarital exams]. / El examen serológico para el virus de la inmunodeficiencia humana (VIH) como parte de los exámenes prenupciales.

Due to the presence of the acquired immune deficiency syndrome (AIDS), it has been frequently stated, by several segments of the society, that mandatory human immunodeficiency virus (HIV) testing as premarital requirement is useful for AIDS prevention. The usefulness of these tests among general population are discussed, as well as some problems for its eventual implementation, concluding that this screening procedure is impractical, inefficient and expensive as a public health measure. The overall HIV prevalence in Mexico is very low (4 per 10,000), therefore, a person from this population with a positive screening test, has a slight chance of being truly infected (16%), in other words, screening tests have a low positive predictive value in general population. Conversely, having a negative screening test, predicts this state accurately (negative predictive value greater than 99%). Several problems arise when HIV screening tests are applied: logistics, for example avoidance of the tests, economic, ethic, and human rights problems, among others. It is concluded that mandatory HIV screening tests are not cost-efficient and that there are other options, for instance education, which would imply better changes for HIV prevention.

An economic evaluation of mandatory premarital testing for HIV.

This study provides a comprehensive assessment of mandatory premarital testing for HIV. We incorporate new evidence about the assumptions underlying an economic evaluation of premarital testing, use standard methods of program evaluation (cost-effectiveness analysis and cost-benefit analysis), and carefully evaluate how changes in the various assumptions affect the results. The cost-effectiveness results show that, under the most likely conditions, the cost per case of HIV infection prevented by mandatory premarital testing would be between $70,000 and $127,000. In the cost-benefit analysis, the benefit-cost ratio in the most likely scenarios ranges between 3.1 and 28.2.

[The analysis of motivation and attitude of premarital medical examinees].

The study aims to analyse the motivation and attitude of premarital medical examinees. Ninety-two premarital medical examines, which include 46 self-paid persons and 46 government paid (subsidized by the Department of Health) visited the Family Clinic. They were studied from Oct. 27, 1988 to Nov. 8, 1989. Among 48 male and 44 female examinees, the sex ratio (male:female) was 1.09:1. The predominant age distribution was 26-30 y/o (58.2%); and the predominant level of education was college (54.4%). Questionnaires were sent to these premarital medical examinees. We received 70 questionnaires-47.1% from self-paid, and 52.9% from government paid. The recovery rate was 76.1%. The results of analysis were: 1) Concerning the motivation of examination, 35.1% of self-paid were introduced by relatives or friends; while 50% of government paid were introduced by newspapers; 41.2% of the total response were afraid of genetic disease. 2) Concerning the opinion of the examination fee, there were no significant differences between those of self-paid and government paid.

Premarital screening for antibodies to human immunodeficiency virus type 1 in the United States. The Premarital Screening Study Group.

To evaluate premarital human immunodeficiency virus (HIV) screening as an approach to AIDS prevention in the United States, we determined the HIV antibody seroprevalence in marriage license applicants in eight areas by blinded testing of blood specimens routinely collected for syphilis serology. The seroprevalences were 0.0-0.4 percent in women and 0.0-1.1 percent in men. We also examined the impact of mandatory premarital HIV screening on marriage rates in Louisiana and Illinois. In 1988, after screening began, 9 percent and 16 percent fewer marriage licenses than in the previous two years were issued in Louisiana and Illinois, respectively. We estimated that mandatory premarital screening, if adopted nationally, would cost $167,230,000. We conclude that compared with other HIV prevention programs mandatory premarital screening would be expensive and would probably have a minor impact on the HIV epidemic.

Mandatory premarital testing for human immunodeficiency virus. The Illinois experience.

During the first 6 months of legislatively mandated premarital testing for human immunodeficiency virus in Illinois, 8 of 70,846 applicants for marriage licenses were found to be seropositive, yielding a seroprevalence of 0.011%. The total cost of the testing program for 6 months is estimated at $2.5 million or $312,000 per seropositive individual identified. Half of the reported seropositive individuals reported a history of risk behavior. During the same period, the number of marriage licenses issued in Illinois decreased by 22.5%, while the number of licenses issued to Illinois residents in surrounding states increased significantly. We conclude that mandatory premarital testing is not a cost-effective method for the control of human immunodeficiency virus infection.

KIE: Data obtained from the Illinois Department of Public Health were analyzed to assess the economic, social, and public health impact of legislatively mandated premarital HIV antibody testing that took effect in Illinois in January 1988. In the first six months of the program, eight seropositive individuals were identified out of 70,846 applicants for marriage licenses, at an estimated cost of $2.5 million. During the same period, the number of marriage licenses issued in Illinois decreased by 22.5% while increasing significantly in surrounding states. The authors conclude that mandatory or publicly supported HIV antibody screening in premarital and other low-prevalence populations is not cost effective.

Compulsory premarital screening for the human immunodeficiency virus. Technical and public health considerations.

The effectiveness of a mandatory premarital screening program was examined as a means of curtailing the spread of the human immunodeficiency virus (HIV) infection in the United States. The epidemiology of the HIV, the technical characteristics of tests for antibodies to HIV, and the logistic, economic, and legal implications of such a program were considered. In one year, universal premarital screening in the United States currently would detect fewer than one tenth of 1% of HIV-infected individuals at a cost of substantially more than +100 million. More than 100 infected individuals would be told that they were probably not infected, and there would likely be more than 350 false-positive results. Public education, counseling of individuals, and discretionary testing can be important tools in reducing the spread of HIV infection, but mandatory premarital screening in a population with a low prevalence of infection is a relatively ineffective and inefficient use of resources.

KIE: The effectiveness of a mandatory premarital screening program to curtail the spread of human immunodeficiency virus (HIV) infection in the U.S. was examined by a subgroup of the Study Group on Acquired Immunodeficiency Syndrome and Public Policy in the Division of Health Policy Research and Education at Harvard University. In one year such screening would detect fewer than one-tenth of one percent of HIV-infected individuals at a cost of more than $100 million with more than 100 false-negative and more that 350 false-positive tests. The authors maintain that screening statutes that significantly restrict marriage would be constitutional only if they were the least restrictive policy to achieve a compelling public health purpose. They conclude that public health education, individual counseling, and discretionary testing of populations with a moderately high prevalence of infection would be a more effective and efficient use of resources to reduce transmission of HIV.

A cost-benefit analysis of California's mandatory premarital screening program for syphilis.

As do most states, California requires premarital serologic tests for syphilis. The Venereal Disease Research Laboratory (VDRL) test and a fluorescent treponemal antibody-absorbed (FTA-ABS) are often used in series for this purpose. In 1979 in California, there were approximately 300,000 persons tested premaritally, but only 35 were found to have asymptomatic infectious syphilis (incidence=0.012%). Including all the direct costs of this screening program, the yearly costs of premarital screening is $8.5 million or almost $240,000 per case found. If one takes into account the sensitivities and specificities of the tests, one still has 6 false-negative and 90 false-positive tests using the 1979 figures. The benefits of the program are the number of cases of congenital syphilis that are prevented. Using a worse-case method, no more than 1.5% of the cases of syphilis detected would result in a case of congenital syphilis. The estimated benefits would result in a savings of approximately $161,000. The economic costs of the premarital screening program far outweigh the benefits.

Repeal of mandated premarital tests for syphilis: a survey of state health officers.

Statistics on the mandated premarital tests for syphilis (PMSTs) in the United States for the year 1978 were analyzed to determine whether this program is epidemiologically and economically effective. Overall close to four million PMSTs contributed 1.27 per cent of the tests found positive for infectious syphilis in the 44 states where PMSTs are mandated. Of all mandated PMSTs, only one in 8,461 was positive for infectious syphilis. In a companion study, venereal disease control officers were canvassed for their opinions regarding the retention or abolition of the mandatory tests. Out of 44 states which mandated tests, only 13 respondents favored retention while 31 found the program unsatisfactory, preferred abolition or changes, or were undecided.