A Look at the World Bank Debate

Julia Nagel
Web and Social Media Assistant, Global Health Policy Center

At a recent World Bank debate on “Discordant Couples and HIV Transmission,” discussion focused on HIV-discordant couples – that is couples where one partner is HIV-infected and the other is not yet infected. Arguably, all (100%) of new HIV infections are due to contact – exchange of bodily fluids – between an HIV-infected person and an HIV uninfected person. At this debate, the subject was long-term sexual partnerships, and the question before the panelists was whether such couples drive the majority of HIV transmission and should therefore receive greater focus in HIV prevention funding. Arguing for the affirmative were Dr. Susan Allen, of the Rollins School of Public Health at Emory University, and Dr. Elizabeth Marum, Regional HIV Prevention Advisor for the Centers for Disease Control and Prevention. Arguing the negative were Dr. Ronald Gray, of John Hopkins School of Public Health and Dr. Daniel Halperin, from the Harvard School of Public Health.

Dr. Allen first presented a wide range of data indicating that most new HIV infections arise within discordant long-term partnerships. She argued that, for effective control of HIV transmission, long term sexual partners must be HIV-tested as couples, so that they know each other’s HIV status. When this happens, Dr. Allen argued, HIV-discordant partners are more likely to practice safer and less likely to transmit HIV. Dr. Marum agreed, emphasizing that these data are the reason that more attention and resources must be focused on these individuals. Identifying HIV-discordant couples and successfully educating them about preventing HIV transmission is vital to the control of HIV/AIDS in most countries

On the other side of the argument, Drs. Gray and Halperin agreed that there is still no conclusive evidence that long-term discordant couples drive-in transmission versus more casual, or intermittent contact, including involving drugs and transactional sex. Dr. Gray specifically argued that the research he has conducted in Uganda did not lead to that conclusion; Dr. Halperin emphasized that very few studies exist on this topic. Adding to this, Dr. Halperin questioned the accuracy of Dr. Allen’s research, implying that her facts were based on modeling data and not on thorough empirical studies.

A few brief observations on the debate.

First, the debate was conducted with impressive levels of argumentation, nuance, and civility. The passion of this debate did not get in the way of intelligent, insightful and informed discourse.

Second, of the panelists, Dr. Marum brought the most human face to the debate. She compared HIV-discordant couples facing HIV to her husband’s recent diagnosis of pancreatic cancer and how, as her partner, his disease affects the decisions she makes every day. While she acknowledged that her situation is far from that of HIV-discordant couples – because she doesn’t have to worry about being infected – her approach was refreshing. The audience appeared to appreciate that a highly academic debate could connect directly at the human level.

Third, the front-end of the debate could have been streamlined to permit earlier and more dynamic interaction with the audience. After forty minutes of arguments – ten minutes from each panelist – only eight minutes were allotted for rebuttal. Forty minutes is simply too long to be stating the fundamental tenets of the debate without any conversation. That portion could be shortened, and the rebuttals and critiques lengthened somewhat. After Dr. Halperin critiqued the essence of Dr. Allen’s research, Dr. Allen needed more than two minutes to defend what she presented. Because Dr. Allen did not have the proper time to do this, it was difficult to judge whether her research can properly answer the question of discordant couples transmitting HIV.

Tensions emerged momentarily in the debate over whether stereotypes of African sexual behavior shape HIV prevention efforts cultural sensitivities. Specific questions were also raised, from audience members via satellite about testing and counseling for discordant couples in different circumstances.

I’m extremely interested to hear readers’ opinions about this sort of issues Do you feel long-term discordant couples drive the majority of HIV transmission and should receive the majority of HIV prevention funding? Feel free to leave your comments below.

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