Int J STD AIDS 2008;19:868-869
doi:10.1258/ijsa.2008.008235
© 2008 Royal Society of Medicine Press
A peculiar case of HIV transmission within a family in north India
N Wal MSc *,
V Venkatesh MD * ,
P Jain PhD 
,
S Barua MA ,
A K Tripathi MD 
and
S K Agarwal MD *
* Department of Microbiology;
Integrated Counseling and Testing Centre;
Department of Medicine, Chhatrapati Shahuji Maharaj Medical University, Lucknow 226 003, Uttar Pradesh, India
Correspondence to: Dr V Venkatesh, Postgraduate Department of Microbiology, Chhatrapati Shahuji Maharaj Medical University, Lucknow 226 003, Uttar Pradesh, India Email: venkatesh_vimala{at}rediffmail.com
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Summary
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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.
Key Words: HIV • heterosexual • sexual behaviour
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INTRODUCTION
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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.
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CASE REPORT
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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.
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DISCUSSION
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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.
(Accepted June 11, 2008)
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REFERENCES
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- Simoes EA, Babu GP, John TJ, et al. Evidence for HTLV-III infection in prostitutes in Tamil Nadu (India). Ind J Med Res 1987;85:335–8[Medline]
- Ministry of Health and Family Welfare. National AIDS Control Organization. See http://www.nacoonline.org/Quick_Links/HIV_Data/ (accessed on 3 June 2008)
- Kumarasamy N, Solomon S, Flanigan TP, Hemalatha R, Thyagarajan SP, Mayer KH. Natural history of human immunodeficiency virus disease in southern India. Clin Infect Dis 2003;36:79–85[Medline]
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INTRODUCTION
