HIV/AIDS General Info
This page encompasses several general topics of HIV/AIDS that you may find useful below:
HIV and AIDS Facts
HIV is an EPIDEMIC
HIV rates in Singapore has risen from 0.8 cases per 1 million population in 1985 to 118.1 cases per million population in 2007.(Singapore MOH HIV Statistics)
There are 33 Million people in the world living with HIV. (WHO UNAIDS Statistics 2007)
HIV is NOT A HOMOSEXUAL DISEASE
68% of all HIV cases in Singapore were transmitted by HETEROSEXUAL SEX. (Singapore MOH HIV Statistics)
HIV is DEADLY
In the world 2 Million people died from AIDS in 2007. (WHO UNAIDS Statistics 2007)
HIV is SPREADING
In the world, there were over 7400 new HIV infections a day in 2007. (WHO UNAIDS Statistics 2007)
AIDS Phobia – The new HIV?
While running a clinic that is part of the MOH anonymous HIV screening program, it is inevitable that I end up conducting a fair bit of HIV screening. In the course of my work I have noticed what I feel is a worrying trend of an increasing number of young Singaporeans with what is described as AIDS Phobia. It is an excessive and irrational fear of HIV/AIDS that is affecting their lives and function. A short history of HIV in Singapore will help us better understand the emergence of this consequence.
1985 was the year HIV first reared its ugly head in Singapore. Back then the medical community was brimming with confidence some might even say complacency, over our seemingly unstoppable successes against infectious diseases. From the advent of Penicillin to the eradication of smallpox, we were basking in the glory of our victories. No one even heard of the concept of the superbug and MRSA was but a mild irritant. Then this contagious and deadly disease that we had nothing against came. All our antibiotics were utterly useless and vaccine development met with failure after failure. It chewed through the very thing that helps us fight infections, our immune system. This left HIV sufferers vulnerable to bacteria that the healthy would normally brush off without a second thought. We saw patients literally dissolving around us and there was nothing we could do.
We quickly fell back on age old proven strategies to combat an infectious disease, epidemiology and education, isolation and prevention. An initial trend that was established found that HIV was more prevalent amongst homosexual men. It was also found to be spread amongst drug users who shared needles. This quickly established a notion in the conservative majority that HIV was a disease of the sexually or socially deviant. Education was focused on a campaign of fear. HIV is incurable, HIV is contagious, HIV is invisible. These were the catchphrases of the times.
Perhaps our efforts were too effective. Even at this day and age, misconceptions, incorrect ideas and social stigmas are as rampant despite our efforts at re-educating the public. This has led to the emergence of this new phenomenon. It has many names: AIDS phobia, AIDS anxiety, FRAIDS (fear of AIDS) etc. Psychologists argue over its technical definition. Is it a phobia? Delusion? OCD? Paranoia? Hypochondriasis?
Whatever you wish to call it, it is a problem that is growing in size. The internet is awash with examples of people not daring to go home for months because they are convinced they have HIV and will spread it to their family. And of people who bathe in the dark afraid of spotting lesions of their skin that are caused by HIV. And of people who wash themselves with bleach everyday to prevent HIV. All of them have had multiple tests for HIV and were found to be negative. In medical parlance they are known as the ‘worried well.’
I read with interest a report from China earlier this year were many people claimed to be suffering from a mysterious AIDS like illness. They were convinced the medical authorities were lying to them about their negative HIV tests. A few eminent experts stepped up and termed this crisis ‘prostitute guilt.’ I personally find it amazing how a new term can be conjured up to explain away the problem simultaneously placing the blame squarely on the heads of the patients. These poor souls are blamed for taking up precious medical resources unnecessarily and their underlying psychological illnesses are left to gnaw away at them.
I can however completely empathize with the Chinese medical authorities. In the course of my work I have encountered many patients suffering from this so-called AIDS phobia. It is challenging and extremely time consuming to help them and treat them. Each consultation becomes wearying task of addressing repeated fears and doubts, of reassurance, support and encouragement and of answering the same oft repeated questions.
I had a patient who, when he came to me, had been regular testing himself for HIV for the past 1 year. After each test he would feel relieved but within a few days, he would inevitably find another reason to believe he has HIV. Any and all symptoms he interprets as caused by HIV from the mundane (my tongue looks white) to the ridiculous (my semen smells like the prostitute). Despite numerous efforts to get him to seek and start psychological help, he was adamant in his pursuit for a diagnosis of HIV. He is of a group of patients who I describe as ‘wanting to test till they are positive’. Fortunately most of my patients who suffer from AIDS phobia are hardly as recalcitrant. They have insight to the fact that their fears are irrational and respond very well to treatment.
So here we are stuck in this conundrum. We want everyone ‘at risk’ to test regularly for HIV yet we do not want people to worry excessively about it. This places serious challenges in public education campaigns as we struggle with the balance of instilling concern, awareness and just the right dose of fear. We want patient to trusts our tests yet understand the window period. All this is made even more exigent by the deluge of information on the internet which is generic at best and outright lies at its most awful.
Of course the focus of our efforts should remain on creating awareness, pushing education and eventually, we hope, to eliminate HIV from our shores. But in our pursuit of this admirable quest, we should not forget this group of people who also suffer from HIV albeit from a completely different angle. Moreover, the majority of such sufferers are prime active economic contributors and the loss of their economic efficiency would mean a blow to our economic capability.
I hope we can strive to increase the awareness of this condition among Singaporeans and our primary care doctors. We can all guard against it by educating ourselves on the facts of HIV, trusting our Doctors and our tests and being more aware.
HIV Notification Requirements
(INFECTIOUS DISEASE ACT OF SINGAPORE) If a person is tested positive for HIV, these are the notification requirements:
- HIV positive people are required by law to disclose their HIV status to their sexual partners before engaging in sexual intercourse.
- HIV positive people are recommended to disclose their HIV status to medical and dental personnel performing invasive procedures on them.
- The HIV positive person is encouraged to get his/her sexual partners and others who might be exposed (such as children of HIV positive mothers) to test.
- The person will also be referred to the Communicable Disease Centre (CDC) of Tan Tock Seng, which is the national referral center for HIV/AIDS for further management.
- Apart from the above situations, no one (including employers and other family members) will be notified, as the Infectious Disease Act protects the identity of HIV infected people and prohibits the unwarranted disclosure of information, which can identify someone as being HIV positive.
HIV in Singapore – Overview
Human immunodeficiency virus (HIV) is a worldwide pandemic. It reached our shores in 1985 with the diagnosis of the first HIV patient in Singapore. It has since developed into what UNAIDS terms a ‘low-prevalence epidemic’ with 4000 people living with HIV/AIDS out of a population of 4 million i.e. a HIV prevalence rate of 0.1%. This same agency also estimates Singapore’s HIV prevalence rate to be closer to 0.3% with a ‘high-estimate’ of 0.5%. This frightening statistic was supported by a study that conducted HIV tests on unused blood specimens in Singapore hospitals. The rate found in the study was 0.28%.
The majority of people diagnosed and living with HIV/AIDS are between 19 and 49 years old. They come from our most economically productive segment of the population.
This terrifying trend is likely to continue if not worsen. Many of our political leaders and experts in the field of HIV have warned that, if not checked, Asia, and Singapore, might very well go down the road that Africa has gone. There is no need to reiterate the horrific economic and social consequences that many African countries currently have to struggle with that is a direct result of the HIV/AIDS pandemic.
HIV/AIDS is indeed a unique disease. In the past half century, modern medicine has won victory after victory over bacteria and viruses. For a long while there was no such thing as an incurable infectious disease; until HIV. To be able to catch an incurable disease we can neither see nor smell nor hear nor taste nor touch from a fellow human being is repulsive and absolutely frightening to our psyche. Furthermore, HIV is caught through having sex which is a taboo subject with the conservative majority and a sin amongst some within the religious community.
Singapore is unique in the sense that through good governance and policy, we have managed to virtually eliminate HIV transmission via tainted blood products, sharing of needles amongst drug users and HIV transmission from mother to child. This means we are only left with tackling that HIV transmission through sexual contact.
This also means having to engage a segment of the population that most people will find distasteful at best and outright disgusted at worst. These are people who visit prostitutes, people with multiple casual sex partners and men who have sex with men (MSM).
It is time to put aside all the bigotry and prejudice, to stop blaming people for catching HIV, to stop grumbling about how government agencies do not communicate with each other, to stop whining about violation of human rights, to stop bellowing about repealing 377A. We need to stop ignoring and ostracizing and start engaging and educating. We need to find creative means to reach out to communities at risk within the confines of existing laws and policy and at the same time not affront the senses of the conservative majority.
HIV/AIDS affects us all Singaporeans, directly and indirectly.
Stop blaming, start helping.
The cost of HIV in Singapore
A recent report by WHO, UNICEF and UNAIDS stated that only 1 out of 3 people in the world living with HIV has access to life saving anti-HIV drugs.
Our neighbor Cambodia has achieved universal access for it citizens to fully subsidized HIV treatment which is truly remarkable.
Singapore is in a unique situation where everyone has access to anti-HIV drugs. We are not plagued by supply chain problems and lack of trained medical personnel like some of the other less developed countries. However, the issue still remains that many Singaporean living with HIV are unable to afford these life saving medicines.
A report published in 2006 in the International Journal of STD AIDS stated that the cost of Life Years Gained for people living with HIV in Singapore between 1996 and 2001 ranged from S$10,000 to more than S$20,000 per year depending on the stage of infection they were at. This situation has not changed much as cost of anti-HIV drugs is currently about S$1000 per month. This does not even take into account costs of tests and treatment for other HIV related illnesses like TB.
It is heartening to see our Ministry opening up Medisave and Medifund for use in HIV treatments but having to pay more than S$1000 per month for medication is still a struggle for the average Singaporean. This is assuming that they even get to keep their jobs which is often not the case.
Minister Khaw has made the call for life saving anti-HIV drugs to be included in the list of subsidized medications. This will truly be a significant milestone in our fight to eradicate HIV from our shores.
I can understand why the conservative majority of Singaporeans will be against using our tax dollars to help people living with HIV. After all they ‘brought it upon themselves’ and have to ‘pay for their mistakes’. However, it is my humble opinion that we need to look beyond this and see the bigger social picture. Having access to affordable medicines will help keep people living with HIV on treatment and therefore lower the chance of them spreading HIV to others. Also, knowing that there is affordable treatment available will encourage more people to come forward for HIV screening and lower the rate of unknowing transmission.
I look forward to the day Singapore joins the ranks of countries that provide universal access to subsidized HIV treatment.
Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector by WHO, UNICEF, UNAIDS. 28th September 2010.
HIV/AIDS in Singapore – Virtually no HIV?
“If we do not act, by 2010, we may have more than 15,000 HIV persons in Singapore. Then, sometime in the next decade, Tan Tock Seng may very well become the AIDS hospital.” Dr. Balaji Sadasivan during a speech delivered in 2004 at the Tan Tock Seng Hospital Doctor’s Night.
I read with great sadness about the passing of Dr. Balaji. Reports of his efforts and visionary leadership with regards to controlling HIV/AIDS in Singapore brought to mind a beautiful book by Dr. Elizabeth Pisani I once read titled ‘The Wisdom of Whores.’ It was a great read, simultaneously engaging and thought provoking. I was however rather tickled when she described Singapore as a ‘hyper-organized Asian city state….well stocked with indigenous talent, and there was virtually no HIV.’
It got me thinking about how the rest of the world perceives Singapore through the HIV looking glass. Does everyone hold the impression that Singapore has ‘virtually no HIV’? It would genuinely come as a complete non-surprise if they do. Singapore exudes an image of cleanliness, efficiency, wealth and, dare I say, purity. There is no corruption, no drugs, no development problems so why should there be HIV? In fact, I’d be willing to wager that most Singaporeans feel the way most of my friends and acquaintances do, that although HIV/AIDS in Singapore should be dealt with but it’s really not such a big problem.
As a typical Singaporean obsessed with ranking, I trawled the internet for any information on our HIV ranking in the world. According to Wikipedia, Singapore ranks 113th in terms of total number of people living with HIV/AIDS but due to our small population size, we rank 94th in terms of prevalence. Not too bad out of 168 countries. We are a little better than Malaysia (81st) and a lot better than Thailand (49th). We however lag behind Indonesia, Philippines, China and India just to name a few. Of course Wikipedia may not be the preeminent authority in epidemiological accuracy.
With the leadership of the late Dr. Balaji, Singapore has won many victories against the spread of HIV. An efficient blood transfusion service, potent anti-drug laws and universal and routine HIV screening of pregnant women have all contributed to controlling the epidemic. Yet we can ill afford complacency. In 2008 Singapore’s MOH reported 3941 people living with AIDS but we now suspect the actual number is closer to 3 times that. This has been estimated by UNAIDS and supported by a study on unused blood samples in Singapore hospitals. This implies that there could be up to 8000 people living with and spreading HIV unknowingly in Singapore. This is a frightening prospect indeed.
Our own clinics have conducted more than 2600 HIV tests since we attained the mandate for anonymous HIV testing in November 2008. And the statistics are staggering. We reported a HIV positive rate of 0.75% which is more than twice UNAIDS’ estimate and more than 7 times the current reported infection rate in Singapore. It can be argued that the people who choose to undergo anonymous HIV tests are the ‘at risk population’. But this is still higher than any of the estimates for the so called ‘high risk groups’. 85% of the HIV positive individuals in our study were between the ages of 20 and 49 years old, presumably our most economically productive. 42% were heterosexual.
So why are these 8000 or so people not coming forward for testing? There are without doubt numerous barriers to HIV testing. A team of researchers from the University of Washington has cleverly compartmentalized them into barriers associated with individual concern, with programs, policies and laws and with counseling and testing strategies. The introduction of an anonymous HIV screening program in Singapore has removed one of the largest barriers to testing. This leaves essentially the barriers related to the fear of segregation, discrimination, lack of availability and affordability of treatment, and the lack of perception of HIV risk, the ‘individual concerns’.
On 1st December 2009, World AIDS Day turned 21. In most countries, this is a legal age for suffrage. It is then perhaps timely and appropriate that the sub-theme for the year’s World AIDS Day is ‘Universal Access and Human Rights’. The so-called ‘I am – theme’. I am accepted.I am safe. I am getting treatment. I am well. I am living my rights. Everyone deserves to live their rights. Right to Live. Right to Health. Access for all to HIV prevention treatment care and support is a critical part of human rights.
The empowerment of people living with HIV/AIDS might leave in bitter taste in your mouth if you fall into the virtually all-encompassing portion of the population known as the ‘conservative majority’. However, even the most bigoted amongst us must accept the scientific fact that only people with HIV can spread HIV. It is also fact that people who know their HIV status are more likely to take precautions to protect their partners from contracting HIV. And since a high viral load and concurrent STD infections makes a HIV infected person more contagious, treatment of the HIV to lower the viral load and treatment of any STDs will decrease the chance of the HIV infected person from spreading HIV. It is therefore rational to conclude that helping people living with AIDS and removing stigma and barriers to allow more people to come forward for testing and treatment will in turn lead to a decrease in prevalence of HIV in the country and thus protecting all of us. Blaming, segregating and ostracizing will only lead to more people deliberately choosing ignorance and ignorantly continuing to spread HIV. We can venture that if people at risk know that there is support, available and affordable treatment rather than damnation, they would be much more prepared to come forward for testing and treatment. Of course, crucial to its success is the imperative need for resources and talent to be committed to enhancing said support. The message of HIV prevention, testing and treatment then can be broadcasted through a campaign of education and not fear mongering.
This brings to focus the debate of which is better: a campaign targeted at the general population or a campaign targeted at high risk groups only? Admittedly from an economic efficiency perspective, a targeted campaign will most likely have a higher yield for a lower cost. However, it will potentially contribute to further exclusion and segregation. Furthermore, many people who are at risk do not consider themselves to be in these ‘high risk groups’ (which incidentally are commercial sex workers, their customers and men who have sex with men). These are not the fiends we picture with unshaven faces, lecherous glares and that unforgettable gloating laugh as he rubs his hands in glee while preparing for another session of debauchery. These people could very well be our friends, our colleagues, our spouses, our bosses. And they would more likely be incredibly offended if they were targeted by a HIV education campaign aimed at ‘high risk groups.’ Making HIV testing special is segregation in itself. It everyone is educated about HIV and we can all talk about it openly with out embarrassing giggles and we can all walk in to a clinic and ask for a HIV test without glancing furtively over our shoulders then another gigantic barrier to HIV testing and treatment will be shattered.
Support and provision for people living with HIV/AIDS is critical but in spite of that, the old adage ‘prevention is better than cure’ still holds true. Even the most obstinate proponents of condom use must admit that the 2 unquestionably foolproof ways of preventing oneself from catching HIV are total abstinence and staying in a mutually monogamous relationship. This is why in spite of all the rhetoric by epidemiologist that preaching abstinence to our youth does not work, preach abstinence to our youth we must. Even if the message only gets through to 10% of them, it translates to 4000 of our children per year (based on an approximate of 40,000 live births per year) that absolutely and positively will not get HIV or any other STD. That is 4000 of our children per year that we do not have to spend a cent on anti-retro viral treatments or STD treatments or social support or counseling or any of the other multiple support elements that people living with HIV/AIDS require. All this achieved by sending well trained educators to each and every one of our schools and teaching our children to ‘do the right thing’.
So what happens to the other 90% (or 99% for the more cynical amongst us)? We will just have to teach them to use condoms. I apologize to the conservatives and traditionalists but we just cannot argue against scientific fact. Condoms might not work a100% of the time but they sure are better than nothing. Significantly better in fact. Using condoms not only prevent a HIV negative person from contracting HIV, it also prevents a HIV positive person who is unaware of his/her status to unintentionally spread HIV.
So here we are in 2010 and it would seem Dr. Balaji was right when he predicted the scale of the epidemic 6 years ago. I believe he would have wanted his passing to be a call to arms to galvanize our efforts to rid Singapore of HIV. We now stand at the cross roads where we can decide if Tan Tock Seng Hospital truly becomes the next AIDS hospital or Singapore truly becomes an island state with virtually no HIV.
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About Dr. Tan
Dr. Tan graduated from the National University of Singapore in 2001. His residency was in the two largest public hospitals in Singapore; Tan Tock Seng Hospital and Singapore General Hospital.