Letter to editor 19
AIDS- Are we reallyserious? 5ir,
What do readersthink?
Michael King's letter raisessome interestingpoints. Voluntary counsellingand testingfor HI\- doescontribuieto preventionof infection:knowingthat )'ou are seronesatireis a stronsmotivator to remain uninfected. and knou'ing vou are positive may encourage behaviour change in order not to infect others. However, if testing becomesmandaton. careful consideration must be given to what happensto thosefound to be infected. Is Dr King suggestingthat HIV positive people should not be eligible for education,employmentor marriage? Ercludin-upositive people from employment would considerabll' reduce the potential workforce, as well as making life even more diffrcult for those living with HIV. Someonewho testspositive ma1'have up to l0 years of reasonablehealth before AIDS develops. and this is of course greatly increased by Anti-Retroviral Therapy (ART). The rising maternal morlality in Malawi does indeed warrant research. Women need accurate information about contraception and the risks of HIV and pregnancy,and also the opportunity to know their status,in order to make decisions about their lives. However, I believe we must be careful about "advising women to avoid pregnancy." Women will make up their own minds about whether or not to have a baby, if their situation allows them a choice at all. The many HIV positive women who do get pregnant, through choice or otherwise, need increased accessto health care for themselvesand their babies,rather than feeling alienatedbecausethey have gone againstmedical advice. Termination of pregnancy is widely available in UK but many HIV positive women do not want it. They are usually on ART so that the risk of transmissionto the baby and progressionof their diseaseis minimized. Even in Malawi, where ART is not widely available, I suspectfew women would choose to terminate their pregnancy. Working in palliative care for sick and dying children, I seeevery day the suffering and sadnessbrought by AIDS. However, I also seemuch joy, fulfillment and love in the relationships between mothers and their sick children, and other family members who share the work of caring. I do not believe that encouraging termination and going the way of the UK, where more than 5 million babies have been aborted since the liberalisation of the law, is the answer to the problems of women and children in Malawi. A more constructiveresponse is to work on increasing availability of ART and supportivecare, in the context of improving education of women.
MichaelKing FRCS Visiting surgeonto the Northern Region Surgeonat QECH 1976-94 PO Box 4 Nkhata Bay
Dr Vicky Lavy Paediatric Palliative Care QECH, Blantyre
Among the strategiesfor combating AIDS, the following have no! been given adequateconsideration: TESTING - The idea that a medical examination before a course of training for ajob, or entranceto a school or university (or marriage?), should not include a test for a major diseaseis beyond reason. In many countries an AIDS test is obligatory. Malawi, with its scarcity of money, has to make sure its public funding is used to the best advantagefor the people of the nation. One reasonput forward for the apparentslowing of the epidemic in Uganda is that some churchesinsist on a couple being HIV testedbefore marying. Youngstersare therefore being encouraged to say "no" to early sex in order to remain marriageable. The prospect of being HIV tested would be a positive help to thousandsof young people to say "no" to a promiscuous lifestyle. Can we afford not to help them? PREGNANCY - The rising maternal mortality rate is a reflection of the AIDS epidemic. The real figure is probably much higher than the quoted figure of 12.1 per 1,000. This figure refers to a mother dying within six weeks of childbirth, but the AIDS maternal mortality continues for several months. Pregnancy,by decreasingthe HlV-positive mother's immunity, may often precipitate her hnal AIDS illness. I have been told of this delayedmortality in severalsmall district hospitals.In these hospitals it is often the same nurse who delivers the mother and looks after the general female ward - nursing these mothers in theirfinal illness. This is anecdotalevidenceworthy ofresearch. Not enough advice (or contraception)is given to HlV-positive women to avoid pregnancy,and thus, if they are already mothers,enablingthem to survivelonger to look after their own children. Many ladies, becauseof the death of a previous child, may suspectthey are HlV-positive, or perhapseven have been tested and not told the result. If an HlV-positive woman becomes pregnant in UK, she is advised and offered termination in order that she may stay free of ARC symptoms for longer. Why cannot Malawian women have this facility available if they wish? The law would have to be amended.
Reply
Malawi Medical Joumal
AIDS- Are we reallyserious? 5ir,
What do readersthink?
Michael King's letter raisessome interestingpoints. Voluntary counsellingand testingfor HI\- doescontribuieto preventionof infection:knowingthat )'ou are seronesatireis a stronsmotivator to remain uninfected. and knou'ing vou are positive may encourage behaviour change in order not to infect others. However, if testing becomesmandaton. careful consideration must be given to what happensto thosefound to be infected. Is Dr King suggestingthat HIV positive people should not be eligible for education,employmentor marriage? Ercludin-upositive people from employment would considerabll' reduce the potential workforce, as well as making life even more diffrcult for those living with HIV. Someonewho testspositive ma1'have up to l0 years of reasonablehealth before AIDS develops. and this is of course greatly increased by Anti-Retroviral Therapy (ART). The rising maternal morlality in Malawi does indeed warrant research. Women need accurate information about contraception and the risks of HIV and pregnancy,and also the opportunity to know their status,in order to make decisions about their lives. However, I believe we must be careful about "advising women to avoid pregnancy." Women will make up their own minds about whether or not to have a baby, if their situation allows them a choice at all. The many HIV positive women who do get pregnant, through choice or otherwise, need increased accessto health care for themselvesand their babies,rather than feeling alienatedbecausethey have gone againstmedical advice. Termination of pregnancy is widely available in UK but many HIV positive women do not want it. They are usually on ART so that the risk of transmissionto the baby and progressionof their diseaseis minimized. Even in Malawi, where ART is not widely available, I suspectfew women would choose to terminate their pregnancy. Working in palliative care for sick and dying children, I seeevery day the suffering and sadnessbrought by AIDS. However, I also seemuch joy, fulfillment and love in the relationships between mothers and their sick children, and other family members who share the work of caring. I do not believe that encouraging termination and going the way of the UK, where more than 5 million babies have been aborted since the liberalisation of the law, is the answer to the problems of women and children in Malawi. A more constructiveresponse is to work on increasing availability of ART and supportivecare, in the context of improving education of women.
MichaelKing FRCS Visiting surgeonto the Northern Region Surgeonat QECH 1976-94 PO Box 4 Nkhata Bay
Dr Vicky Lavy Paediatric Palliative Care QECH, Blantyre
Among the strategiesfor combating AIDS, the following have no! been given adequateconsideration: TESTING - The idea that a medical examination before a course of training for ajob, or entranceto a school or university (or marriage?), should not include a test for a major diseaseis beyond reason. In many countries an AIDS test is obligatory. Malawi, with its scarcity of money, has to make sure its public funding is used to the best advantagefor the people of the nation. One reasonput forward for the apparentslowing of the epidemic in Uganda is that some churchesinsist on a couple being HIV testedbefore marying. Youngstersare therefore being encouraged to say "no" to early sex in order to remain marriageable. The prospect of being HIV tested would be a positive help to thousandsof young people to say "no" to a promiscuous lifestyle. Can we afford not to help them? PREGNANCY - The rising maternal mortality rate is a reflection of the AIDS epidemic. The real figure is probably much higher than the quoted figure of 12.1 per 1,000. This figure refers to a mother dying within six weeks of childbirth, but the AIDS maternal mortality continues for several months. Pregnancy,by decreasingthe HlV-positive mother's immunity, may often precipitate her hnal AIDS illness. I have been told of this delayedmortality in severalsmall district hospitals.In these hospitals it is often the same nurse who delivers the mother and looks after the general female ward - nursing these mothers in theirfinal illness. This is anecdotalevidenceworthy ofresearch. Not enough advice (or contraception)is given to HlV-positive women to avoid pregnancy,and thus, if they are already mothers,enablingthem to survivelonger to look after their own children. Many ladies, becauseof the death of a previous child, may suspectthey are HlV-positive, or perhapseven have been tested and not told the result. If an HlV-positive woman becomes pregnant in UK, she is advised and offered termination in order that she may stay free of ARC symptoms for longer. Why cannot Malawian women have this facility available if they wish? The law would have to be amended.
Reply
Malawi Medical Joumal
