Should HIV/AIDS testing be made mandatory before marriage?

Is it possible to implement mandatory testing for HIV before marriage? What are the advantages of such a move?

N. Kumarasamy: Regarding HIV, making anything mandatory is not acceptable. The HIV and AIDS (Prevention and Control) Act, 2017, clearly mandates counselling before testing, and testing only with the consent of a patient. As per the law of the land, once you do the testing, everything must be kept confidential. If they test positive, patients should be linked to the appropriate antiretroviral treatment centres. The next question will be whether they can get married — that has also been dealt with by the 2017 law.

Today, based on science, we know that if a HIV-positive person is put on antiretroviral treatment, the viral load goes to an undetectable level within 2-3 months. Studies have shown that a person who has an undetectable level of viral load will not transmit infections sexually to their partners. The person will also not develop any HIV-related complications such as opportunistic infections, tuberculosis (TB), and various other comorbid conditions, and maintain a normal immunity level. Mandatory HIV testing without the consent of such a person will be a human rights violation. And doing so will also increase stigma. For all these reasons, mandatory testing cannot take place.

HIV testing should be offered to as many people as possible — mainly to those who are at risk and also people who believe that they may be at risk. It should be offered. Consent is important. And testing, if done, should be done while maintaining appropriate confidentiality.

Jahnabi Goswami: Yes, the viral load can be managed with drugs. But I still think HIV testing should be made mandatory before marriage. There are a number of cases we know where people who have been infected, but are not taking antiretrovirals regularly, get married because of family and societal pressure. The spouse finds out only later, or perhaps when she or he tests positive for HIV. The children are likely to be affected too. In India we believe in matching horoscopes before the wedding. Why not a HIV test, to see if the couple are compatible at all? Such a test will also ensure the health of the family.

Will this move actually empower women?

Jahnabi Goswami: My agenda is not women or male empowerment per se. In the north-east, specifically, there have been a number of cases where the (HIV positive) status was concealed. Injecting drug use is responsible for nearly 64% of HIV infections in the north-east. Men (injecting drug users) clean up for three months, get married and don’t inform their wives. A few months later, they bring their wives too to test. Even today, we had such a case. This happens regularly. In fact, I believe that to safeguard women and girls, it is essential to go in for mandatory testing, with counselling.

About confidentiality and consent, I want to point out that in practice, doctors are forcefully testing for HIV. Even if you go for a small dental procedure — sometimes they counsel, sometimes they don’t, and force you to do HIV test. Sometimes it is good counselling and sometimes it is of bad quality.

Will the HIV test, if it comes negative, provide a false sense of security?

N. Kumarasamy: While you are doing appropriate testing, you are also counselling a patient to find out the duration of exposure. That also helps you determine the window period when testing should be offered. That is the reason you counsel someone.

If you force someone to do a test, they may go to a lab and get it done. The test report can be negative but the person might really be positive (for HIV) leading to transmission of infection. If testing is done with appropriate consent, counselling, and confidentiality, I’m sure people are not going to refuse it.

Goa also proposed mandatory testing some years ago, but it is still not a reality…

N. Kumarasamy: Yes, it is not implemented in Goa. But there is wide testing happening in the State. There is no mandatory testing before a wedding. The thing is they cannot implement this because this will cause human rights violations. The same thing is happening in Meghalaya. If you look at the reports on rising infections, perhaps the State is ranked 5th or 6th where a significant number of infections is through injecting drug use and also through sexual contact.

But I think it is possible to learn from other States, especially from southern India — Tamil Nadu, Kerala, and Andhra Pradesh — as well as Maharashtra. The ideal way to contain this infection is to do appropriate HIV testing as much as possible in a variety of settings with proper consent and then link those tested people to the treatment. That will reduce infectiousness in the country and also lead to a reduction in new infections in Meghalaya.

Jahnabi Goswami: I think it will definitely happen because the situation is quite different in Meghalaya. To understand it, you should understand the circumstances and people of the State. In Meghalaya, certain groups in the Christian community still think it is taboo to use a condom even if it is recommended by law. (The HIV Act promotes safe sex practices.) In fact, implementing the HIV/AIDS Act in Meghalaya is really difficult.

Also, culturally and socially, they have provisions for extramarital affairs and living together. These are quite common among the youth. Simultaneously, HIV is a big discriminator in Meghalaya and no one has actually accepts HIV-positive men or women.

How do we address the stigma that is still associated with HIV?

N. Kumarasamy: Stigma started in India because it (HIV) was first detected in a commercial sex worker, so it was attributed to multi-partner sex. But this is not true, as we have seen.

HIV is still an incurable disease. The way to address stigma today is to make sure that common people are aware that we now have treatment available. Even if it is not curable, it is permanently controllable. In our research studies in Chennai, we showed that treating one partner will prevent transmission if the viral load goes down. The message U=U (undetectable is untransmittable) does work. Such scientific messages can remove stigma from the community, so that as many people as possible will test and be linked to treatment. Someone who is already on treatment will do well, and not transmit infection to the others.

Addressing stigma is not an easy thing. Over 30 years of taking care of people with HIV and their families at our centre here, we realise that each one is different. Much is based on their education, how they were raised, and whether they live in the village or city. All this will have to be wrapped up in several rounds of counselling.

Jahnabi Goswami: As Dr. Kumarasamy has said, stigma is associated not with the disease, but with where the infection arises from. The impression is that people who are in sex work will get HIV; people who do drugs will get HIV. That is where the stigma comes from. We should constantly try to reduce stigma. The government, people who are infected, like me, and those working in the field should work hard to erode the stigma.

If someone has cancer, they say without any hesitation that their family members died of cancer. If they are diabetic, they say they don’t use sugar. And if they have hypertension, they don’t mind asking you not to put salt in their food. But people who have HIV or people who have TB do not talk openly about it because these are seen as behavioral issues. We must remove the stigma and make it comfortable for HIV-positive people to talk about their status.

I do believe we have to involve counsellors to tell people that they will not transmit because they are on treatment, that U=U; and involve more people with HIV as role models to reduce stigma and discrimination. The quality of counselling should be improved for sure.

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