Abstract
We describe an unusual case of heterosexual HIV transmission between two brothers within a family, due to a locally prevalent social custom of remarriage of the elder brother's widow, to the younger brother. This case of HIV secondary transmission, which could possibly have been stopped at certain points by better understanding and awareness about HIV transmission emphasizes the need for extensive post-test counselling of affected individuals and their family members.
Keywords
Introduction
Since the first report of HIV infection among sex workers in Chennai in 1986, 1 the numbers of HIV-positive individuals and AIDS cases in India have been increasing explosively. Currently, it is estimated that about 2.5 million people are living with HIV in India. 2 A majority of these infections are due to heterosexual transmission. 3 Here, we describe an unusual case of a female who becomes the reason of HIV transmission between two brothers in a family by getting married to them one after another.
Case Report
A 35-year-old lady from Gorakhpur, Uttar Pradesh, accompanied by her second husband, attended Chhatrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India, in January 2007 with complaints of continuous, prolonged fever, cough, sudden weight loss, persistent diarrhoea, weakness and oral ulceration. The patient was tested for HIV at the ICTC (Integrated Counseling and Testing Centre) of our centre, as per National AIDS Control Organization guidelines, and was found to be positive. The patient consented to enrolment in an ongoing HIV-related project in the department. A detailed history of the patient's exposure to various risk factors was taken by the interviewer of the project. During interview, the patient revealed that she had unprotected sex with her first spouse, who had died of complications of HIV infection. After the death of her first husband, she was re-married to her husband's younger brother under pressure from her in-laws. Both the patient and her second husband were counselled by the ICTC counsellors and also by the interviewer of the project, but at that time the patient's second husband was unwilling to undergo an HIV test.
In February 2007, the patient's second husband became symptomatic and visited our centre. He tested HIV-positive and was started on antiretroviral therapy (ART). He met the interviewer for enrolment in the project. When asked about his wife, he said that the condition of his wife had deteriorated soon after their previous visit to the hospital and she had died. In January 2008, the patient chose to be transferred to the ART Centre in another district of Uttar Pradesh, nearer to his home town.
Discussion
This peculiar chain of events, where the locally prevalent social custom of re-marriage of the elder brother's widow to the younger brother led to heterosexual transmission of HIV in the family is reported here, to highlight the fact that even among HIV-affected families, the extent of understanding and awareness about HIV transmission, including heterosexual transmission, is insufficient. As can be seen in this case, family members of the HIV-infected elder son had, in spite of their likely knowledge of his HIV status, pressurized their widowed daughter-in-law to remarry their younger son, without any HIV testing being done.
This particular case was documented because of inclusion of the index patient in the follow-up project, where a detailed history of exposure to various risk factors for HIV was obtained and the subjects enrolled were requested to attend regular follow-up. Although other such instances come to light from time to time at our ICTC, they go unreported because of lack of documented linkage between clients in the voluntary centre. The need for extensive post-test counselling of affected individuals and their family members and the need for responsible sexual behaviour even within marriage are emphasized.