Premarital testing for HIV infection: Marriage bureaus should lead
Harshal T Pandve
Department of Community Medicine, Dr. D.Y. Patil Medical College, Pimpri, Pune, Maharashtra - 411 018
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Pandve HT. Premarital testing for HIV infection: Marriage bureaus should lead. Indian J Dermatol Venereol Leprol 2008;74:215-216
Over the years the HIV/AIDS epidemic has moved from urban to rural India and from the high-risk to the general population, affecting mostly the youth. About 2.5 million people in India aged between 15 and 49 are estimated to be living with HIV/AIDS, the second largest such population in the world. The prevalence rate of HIV/AIDS in the country is 0.36%. Most HIV infections in India occur through heterosexual transmission.  Important prevention strategies include raising awareness about the disease in the general population, condom promotion, blood safety, and prevention of parent-to-child transmission. Premarital HIV testing could be an additional strategy for controlling the spread of HIV. It may help prevent the transmission of infection from an HIV-positive person to an HIV-negative partner.
Since premarital testing is done on members of the general population and not on any particular high-risk group, acceptance by the general population is crucial. According to Misiri et al ., not all population groups have an equal likelihood of accepting a public health intervention such as voluntary counseling and testing for HIV/AIDS. It is imperative that HIV/AIDS prevention and control programs take this fact into account if they are to design interventions that can attract population groups unlikely to use the HIV counseling and testing services.  According to a study by Zachariah et al . in rural Malawi, approximately 77% of those presenting for voluntary HIV counseling and testing had done so because of the encouragement of others who had taken an HIV test.
An important point to be kept in mind is that people expect confidentiality regarding HIV test results. With premarital testing, if one of the proposed partners turns out to be HIV positive and the marriage is cancelled on that account, then it may no longer be possible to maintain confidentiality.  Mandatory premarital HIV screening could lead to social stigmatization of infected persons and would infringe on their fundamental human rights. Voluntary and confidential HIV testing, and especially pre-test and post-test counseling, should form the basis of premarital HIV testing. 
Concerning the issue of accuracy of HIV tests, the standard HIV antibody (ELISA) tests are at least 99.5% accurate when it comes to detecting the presence of antibodies to HIV.  Clinical studies have demonstrated that the sensitivity and the specificity of rapid HIV tests are comparable to those of the ELISA test that is often used for screening.  One of the important questions is, what happens if a person is in the ′window period′ at the time of premarital HIV testing? To address this issue more reliably it is necessary to undertake repeat HIV testing for both the proposed partners 3-4 months after the first test. However, this particular solution would be difficult to implement practically. To overcome this difficulty proper pre-test and post-test counseling is essential.
Another issue is whether an HIV negative status at premarital testing ensures HIV negativity for the rest of the married life. This depends on the couple′s married life, faith in each other, and many other factors.
One important issue is the integrity of the person doing HIV testing. Results of the test must be carried out honestly and should not be manipulated at any cost. Ensuring this is not easy; it depends on many closely linked social and ethical issues.
When the potential partners had a frank discussion between themselves about HIV infection they, irrespective of sex, were found to be more likely to participate in premarital HIV testing.  Habte et al . found that when such a discussion was followed by professional counseling it was extremely helpful.  Further qualitative studies would be valuable to obtain in-depth information about the reasons why certain population groups do not accept premarital HIV counseling and testing.  While premarital testing is one of the tools for prevention of HIV infection, it will only work in India if it is coupled with measures to generate awareness about HIV/AIDS among the general population. Correct and in-depth awareness regarding HIV/AIDS may eventually create a scenario where people will voluntarily opt for premarital HIV testing and match test results, just like they match caste, kundali /patrika, etc., before finalizing an arranged marriage.
Considering the Indian social scenario we feel that in our country marriage bureaus are well placed to encourage premarital HIV counseling and testing. We suggest a lead role for them in popularizing the practice of premarital HIV counseling and testing.
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