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23 Mar 2005
By Dr Balaji Sadasivan, Senior Minister Of State For Information, Communications And The Arts and Health
Venue: Cheng San Community Club
WOMEN AND AIDS
Good evening ladies and thank you for taking time to join me for a dialogue on a difficult subject - AIDS prevention. The biology of AIDS is straight-forward but the social aspects of the disease is a difficult subject to discuss because it touches on the private behavior of individuals, sexuality, and religious and moral beliefs. My Ministry takes an objective public health view of the problem because our primary duty is to protect the health of all our citizens.
Tonight, I will present to you the problems we face in AIDS control as it relates to women and some of solutions that we are considering. Then, I would like your views and comments. If there is public support for the measures we are now considering, we will make the necessary changes in the Infectious Disease Act later in the year and implement the measures.
THE EPIDIMIOLOGY OF AIDS
Aids usually starts off as a disease that affects mainly gay males and drug users. So in 1985, women made up only 7% of HIV positive patients in the US. Later as the disease entered the heterosexual population, the proportion of women infected increased and in the US it is now 26%. Today, world wide, there are an estimated 35 million people living with HIV and 50% are women. In the later stages of the epidemic more women are infected than men. This is the case in some African countries where one in four adult females is HIV positive. AIDS is a catastrophe for Africa and is worse than any Tsunami. Because so many adult women are infected, men target younger and younger girls for sex and the phenomena of young virgin girls being raped is prevalent. The life expectancy in some of the countries has dropped from about 60 to less than 40. The large number of young adults dying has created millions of AIDS orphans. The population in some countries will decrease in the coming decade. How could such a catastrophe occur? Unlike a Tsunami or SARS, AIDS creeps into a society with little fanfare. Human rights and gay activists have confused the public health issues with general societal issues and hindered a rational approach to the control of AIDS. The long time interval between infection and disease - about 5 to 10 years, allows the disease to spread before the consequences are felt. Now, everyone can see the impact of the disease. But for the people of Africa, it is a tragedy and they cannot set the clock back. A generation of young adults in Africa will be decimated.
The prevalence of AIDS in Singapore adults is 0.2%. For comparison, the rate in Malaysia is 0.4% and the rate in the US is 0.6%. In some African countries it can be more than 30%. On the other hand, in New Zealand the rate is 0.1% - which is much better than Singapore. The epidemic in Singapore is in its early stage as indicated by the fact that only 7% of those positive are female, similar to the US figure in 1985. But there has been a sharp recent increase in the number of AIDS patients in Singapore. The year on year increase in 2004 was 28% and we are concerned. Let me now discuss some specific AIDS issues that relate to women.
AIDS AND PREGNANT WOMEN
One percent of HIV patients are children. In Singapore, eighteen children have been born HIV positive. This is now preventable. If a HIV positive woman is pregnant, there is a 25% chance of the baby being born positive - that is a one in four risk. If the mother breast-feeds the child, there is further risk of infection. However, if the mother is screened and found to be positive, and treatment started, the chance of the baby being born positive is only 2% - that is one in 50. In the US today, more than 90% of mothers are screened and the number of HIV positive babies born has dropped from a high of about 1000 HIV babies a year to less than 100 HIV babies a year. In Singapore, less than 30% of mothers were being screened. After we introduced the opt-out system recently, more than 70% of mothers are now screened. This is not good enough. There can no justification to allow a baby to contract HIV when it can be prevented. We want all mothers to be screened. This will help HIV mothers. Isn't life going to be easier for the HIV positive mother if her baby is not HIV positive? If her baby is HIV positive, than the mother will not only have to be on treatment but she will have also have to take care of her baby's treatment.
The Ministry is considering making screening of pregnant mothers mandatory.
AIDS AND INFORMING THE SPOUSE/WIFE
Currently the law does not create a duty on the healthcare system to protect the spouse. The doctor may tell the wife, but he must have reason to believe that the wife has not been told by the patient and that there is sexual activity between the patient and his wife. Because of the onerous conditions placed on the doctor, the wife is not told. Let me give you a snap short of the problem. Between Jan and Sept 2004, there were 53 married men diagnosed with HIV. In 24 cases, the HIV positive man told his wife and she was screened at CDC. Three of the wives were positive and were started on treatment. The remaining 21 were counseled on how to protect themselves.
Nine men said they told their wives but did not bring their wives to CDC for screening. Can we be sure these wives were told? Twenty men did not tell their wives. These wives are at risk of contracting the disease. This snap shot of nine months reveals that about 29 women are still at risk and they will continue to be at risk until we change the law so that it is clear to healthcare professionals that they are legally protected when they inform wives who are at risk. Some may have already caught HIV from their husbands but are unaware because they will only fall ill from HIV in 5 to 10 years time. I have given the figures for a nine month period. If we take the last five years, there are probably over a hundred wives at risk. Even if we change the law, the changes will be too late for some of the wives who may have already caught the infection, but we can at least protect those who are still HIV negative.
The Ministry is considering amendments to strengthen the law so that it will create a duty on the healthcare system to inform the spouse and so protect her.
AIDS AND PRE-MARITAL TESTING
I want to present some slides showing two real case histories. In the first case, Mr. A was HIV positive when he married. He infected his wife and two other unmarried women whom he seduced. In the second case, Mr. I, who knew he was HIV positive, went to a foreign country to bring back a bride. He infected the poor girl. Stories like this are troubling. Men are allowed to spread HIV with impunity. People today marry in their late twenties and thirties. There is the potential risk that one or both of the spouses may have had a risky sexual episode. By introducing pre-marital testing, both spouses-to-be can be certain that regardless of what they may done in the past, they are HIV negative and can begin a blissful married life without the worry of AIDS, provided they continue henceforth to be faithful to each other.
We want to consider the introduction of pre-marital testing for couples who want to get married.
SOURCES OF INFECTION
While Men having Sex with Men is a major source of HIV spread, Women do not spread HIV to other women. So the source of infection, when a woman gets infected, is almost always a man. The infection spreads more easily from a man to a woman than from a woman to a man. So how do the men who infect women get infected?
Many have pointed their fingers at Geylang where there is a health regulated sex industry. The incidence of HIV among sex workers in the regulated sex trade in the years 2003 and 2004 has been zero. Geylang is not a public health threat as far as HIV is concerned. For several decades, our public health officers have provided education to the sex workers and controlled the spread of sexually transmitted disease. The zero HIV rate is a testimony to the good work done by our public health officers and a testimony to the responsible behavior exhibited by these sex workers. The zero rate was achieved because public health officers were given the tools and power to perform their function - which is to control the spread of sexually transmitted diseases.
BISEXUALS
Ten percent of gays are thought to be bisexual. Bisexual men pose a threat to women. Often the woman may not know that the man is bisexual. I have previously said that about one-third of HIV positive men are gay. The Lancet has noted that there is often under-reporting by gays. So the actual proportion may be much higher. Since HIV infection spreads from the gay community to the heterosexual community through bisexual men who straddle the gay and straight community, the sharp increase of HIV in the gay community should concern women. The increase in the incidence of HIV in MSM poses a risk to MSM and, because of bisexual men, it also poses a risk to women.
UNDERSTANDING THE SPREAD OF HIV
We need to know more about how HIV spreads in both the gay community and in casual sex workers outside the health regulated sex industry. To understand the spread, MOH needs to have the power to collect information and do surveillance screening. For example, when there is a suspicion of a public health threat we need to collect data to check if the suspicion is correct. Over the last two weeks, many have commented that we should not be content with just a hypothesis without evidence. We should move on to the stage where we collect evidence and present hard facts to the public. I totally agree. To do this, our public health officers need the power and tools to collect evidence.
We are considering changes in the I.D. Act to give public health officers the powers needed to perform their role. They should be able to collect information on possible threats to public health and all members of the public should have a duty under the law to assist them. They should have the power to screen "at risk" populations to study the spread of HIV and so formulate policies based on hard data.
INDIVIDUAL RESPONSIBILTY
We cannot stop the spread of HIV unless each individual takes responsibility for his or her own actions. The two case histories I presented earlier clearly illustrate the irresponsible behavior of some individuals. If a person drives, he has a duty to ensure that he is not drunk. If a person wants to have sex, it should be the individual's responsibility to ensure that he or she is not HIV positive. It is not possible for MOH to enter the bedroom and sauna to monitor, influence or regulate the sexual activity of individuals and we do not wish to do so. It is time to stop blaming society for the spread of AIDS. AIDS is not spread by society. It is spread by individuals. Many aspects of society are being blamed for the spread of AIDS. Some individuals have made a big deal about an incident at the Nation party where the police did not allow obscene material to be distributed. The obscene material had a crude slogan which could be considered as an AIDS prevention message. The increase in HIV infection will not be stopped even if obscene material could be distributed. Handing out pornography is not the solution. The solution to the problem of AIDS must be based on individual responsibility.
We are considering changes in the law that will make people individually responsible for their own actions. If a person is HIV positive, he has a responsibility to ensure he does not spread the disease. Spreading HIV should be considered a serious offence. We will make HIV testing easily available. So no one will have an excuse for not testing themselves. Not knowing that he is positive should not be a defense when a HIV positive person has or intends to have unsafe sex with another person. Unless we change the law, we cannot change attitudes. And attitudes need to change if AIDS is to be controlled. We must return to that basic principle that underpins a successful society - an individual is responsible and accountable for his actions.
Thank you.