Peru and the Politics of HIV Testing

Photo by Jeff Cleary Tarayn Grizzard

I hope by the time anyone reads this, the paperwork will be duly completed and an official in a suit will have presided over a 10-minute ceremony that will imbue me and mine with a new legal status. In short, I’m getting married—not having a wedding, mind you, just a civil ceremony with a few family and friends. It will be a simple affair, a brief, meaningful legal ceremony in my fiancé’s hometown of Lima, Peru, the only place we can marry without running afoul of the U.S. Immigration and Naturalization Service.

We planned on marrying in Lima to simplify immigration concerns and still be near family—we’d file a few papers at his local courthouse, submit to the usual premarital blood tests for syphilis and whatever else, and be on our way. It turned out, though, to be much more difficult to arrange than we’d ever imagined, making both of us wonder how on Earth anyone in Peru manages to get married at all. The afternoon of blood tests and paperwork that we had planned on turned into a four-week odyssey of forms and expensive legal and translation services, which is now, blessedly, almost over. There is only one outstanding requirement for me to fulfill: taking a government-administered, compulsory HIV test.

Not-so-safe Keeping
I was floored when I first was told that I would have to take an HIV test in order to get married. The real shock set in when I found out that not only was there no appeals process, but the test was not confidential. The test is administered in a government clinic and laboratory, and the state records every person’s result once the process is completed. Subjects can elect not to know their status or not to tell their spouse-to-be the results; however, the state will always have the information, which it makes available to spouses upon request.

I found that neither my Peruvian friends nor my fiancé were fazed by the requirement of a compulsory, non-confidential HIV test. Apparently, universities—even private ones—in Peru also require non-anonymous, non-confidential HIV testing at the time of admission. Once again, students can opt out of receiving test results, but their universities, which often grant student health insurance, will have the information to use as needed.

To me, this seems more than a bit disturbing and ill-conceived, particularly given that Peru has a rather low prevalence of HIV and that only a fraction of the population can afford to marry or attend a university. The HIV-testing laws apparently protect only a small percentage of the population, one that is likely to have insurance and medical care—not exactly a high-risk group. Yet according to our friends in the local health sector, these compulsory HIV tests exist largely to protect young women—particularly those getting married—from unknowingly contracting HIV from men, since in Peru men have more high-risk behaviors.

The Wrong Battle
Other testing for HIV, including prenatal testing, is not mandatory. And while the Ministry of Health considers HIV testing of all pregnant women to be one of its goals, such tests are rarely completed on a broad scale, partially due to scarce resources at public hospitals. But it’s also due to other, more shadowy concerns, namely the fear that a mother will seek an illegal, risky abortion—relatively common in Peru—if she receives a positive test result.

The government is unlikely to confront the issue of abortion, even in the context of mother–child transmission of HIV, especially in light of its recent rejection of several multimillion-dollar grants to address reproductive health and HIV solely because they included components on postabortion care. Currently, few government resources are put into preventing mother–child HIV transmission, apart from making tests available to providers. Such inaction contrasts sharply with the legions of government staff members who ensure that the government knows the HIV status of its married citizens and students. Given the possibility of preventing HIV transmission with universal prenatal testing, Peru might be better served by focusing its more invasive HIV control measures on the population most likely to benefit from early diagnosis—instead of adding yet another gauntlet to civil marriage.

—Tarayn Grizzard is a medical student at HMS.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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