"ABC & CAT"

04 Dec 2010

By Mr Khaw Boon Wan

Venue: Orchard Hotel Singapore

1. When AIDS was first diagnosed in the US 30 years ago, it was met with fear and prejudice. Around that period, I was in the US with Prof Oon Chong Jin on a working visit pertaining to Hepatitis B Vaccine. Prof Oon was a professor in Medicine then working in the Singapore General Hospital. On the plane and during the trip, he gave me a tutorial on the disease. I recall that he visited some AIDS patients in a New York hospital as there were then no cases in Singapore. He explained to me how HIV was transmitted. I remember him telling me that it was not that easy to get HIV unless you led a high-risk lifestyle. For those with normal lifestyle, without promiscuity and drug addiction, and living in a city with a safe blood supply, the risk of infection was practically zero.

2. I kept up the reading on HIV and AIDS, after we had our first case here 25 years ago. I watched with grave concern the rapid expansion of the disease in the US, and its subsequent spread to other parts of the world. As HIV jumped from the gay to the heterosexual population, through drug addicts and sex workers, I knew that it would be a matter of time when HIV would also

kill innocent babies.

Staging of Epidemic

3. I formed a way of staging the progression of the disease through a community by looking at the percentage of new cases who were women and infants. In the first stage of the epidemic, patients are largely male homosexuals. But as HIV spreads to the heterosexual population, female patients will begin to grow and eventually outnumber men. As the epidemic reaches its extreme, as in some African countries, large numbers of babies will be born with HIV.

4. In the US, women now form 1 in 4 of new HIV cases. In South America, the figure is higher at around 1 in 3. In Sub-Saharan Africa, women have outnumbered men, forming 6 in 10 of new HIV cases. Correspondingly, children now make up 1 in 5 of new HIV cases there. In Asia, the countries are at different stages of the HIV epidemic.

5. In Singapore, women form 10% of new HIV cases. WHO classified us as having a low-level HIV epidemic, way below the situation in the US, South America and Africa. However, we cannot be complacent. In our region, several countries are experiencing a significant HIV burden in some high-risk populations. Indeed the HIV prevalence in some of these populations is higher than the national HIV prevalence in sub-Saharan African countries.

Tribute to Dr Balaji

6. The late Dr Balaji made himself quite an expert on the public health problem of HIV. He read up on the subject, consulted experts in this field, made trips to the key countries to understand the subject deeply. When he was my SMS in MOH, I found his advice on HIV policy to be sound and practical. He made a number of significant contributions in this area.

7. First, he helped me introduce HIV testing among pregnant women, by including it as part of the standard antenatal screening package. Though not compulsory, practically all pregnant women are now routinely screened. As a result, we have largely eliminated mother-to-child transmission of HIV. In the last 3 years, we picked up a dozen pregnant women with HIV each year, but through timely medical intervention, none of their children were born HIV positive.

8. Second, he helped me work with the secondary schools to introduce the “Breaking Down Barriers” education programme. This programme imparts knowledge and skills to enable students to protect themselves from HIV and other sexually transmitted infections. The number of sexually transmitted infections among our youths has dropped from 820 new cases in 2007 to 681 last year.

9. Third, he helped me work with employers to de-stigmatise HIV among their employees. He helped to raise awareness of HIV/AIDS among workers. He set up the AIDS Business Alliance to promote a supportive and nondiscriminatory working environment for HIV-infected workers.

10. Fourth, he helped me introduce HIV screening in hospitals, both among staff and patients, in accordance with the best practices as recommended by the US CDC. We now have an opt-out HIV screening programme for adult inpatients in public hospitals, as a normal part of medical practice, similar to screening for other treatable conditions.

11. When Dr Balaji was posted out of MOH, I got his agreement and Minister George Yeo’s blessing to continue to help me on HIV. His passing was a great loss to my Ministry. We are pressing on with his good work.

Early Testing

12. Our current challenge remains in early identification of those who are infected. More than half of our new cases are diagnosed when their infection has reached an advanced stage. It is important for us to reach out to them earlier than now. There are two significant benefits for doing so. First, starting them on treatment earlier will improve their health outcomes. Second, when they know they have HIV, they can be counselled on how to protect their partners, with condoms.

13. To do this, we must step up our efforts on HIV testing.

a. First, we have expanded the anonymous HIV testing programme to 7 clinics. This has increased the number of anonymous HIV tests by more than 50%. If further expansion of clinics can get many more to be tested, I am prepared to do so.

b. Second, we have implemented opt-out HIV screening in public hospitals. Last year, the programme picked up 50 HIV-positive individuals who otherwise may not have known that they have HIV. But how many have we missed out? More than 80% of inpatients who were eligible for screening opted out of HIV screening. It will be safer for all, if we can raise the take-up rate. And we must try.

14. In parallel, we are helping patients to gain access to HIV treatment. Our CDC has helped to negotiate down the prices of HIV drugs substantially. The cost of first-line drugs has come down from $1,000 per month to about $200. We have also recently amended the Medifund rules to remove any financial barriers. This has saved HIV patients more than $800,000 so far.

15. But the key to controlling the HIV epidemic remains prevention. While HIV treatment can now prolong life and restore some quality of life, it is still not a cure. While HIV has now been classified as a chronic disease like diabetes, living with HIV is not the same as living with diabetes.

16. That is why we must press on with public education, to the masses, to the high-risk groups, to the young and to the old. Our messages and our approaches have to be customised to fit the target groups. For the masses and the young, the key message remains ABC: Abstinence, Be Faithful & Condom use. For the high-risk groups, the key message is CAT: Condom use and Testing.

Down With Prejudice

17. One reason why many people refuse testing is their fear of being stigmatised and discriminated against by the family, friends and colleagues if they are found to be positive. A lot of stigma and discrimination stems from misconceptions.

18. We do not condone and we should not encourage irresponsible behaviours, such as not using condoms or cheating on their sexual partners. However, it should not stop us from caring for those living with HIV. Acceptance by family and friends will encourage those who may be infected to come forward for testing and treatment.

19. In the workplace, there is little to fear about accidental transmission of HIV. Prof Oon Chong Jin’s advice remains valid. You cannot get HIV like you get flu from your office colleagues through casual contact. The Health Promotion Board has programmes to educate employees about HIV and correct their misconceptions. We strongly urge all companies to take up such programmes.

Conclusion

20. We alone cannot change people’s mindset. We need the support and active engagement of the community, grassroots organizations, religious leaders and community groups. With less prejudice and stigmatisation, it will be easier to encourage testing and treatment. The more people know and understand about HIV, the more they will be able to take personal responsibility to protect themselves and their partners from infection. We can then keep Singapore’s HIV epidemic at the current low-level.

21 On this note, I wish all a good Conference.