From 3rd World to 1st in Aids treatment

04 Dec 2008, The Straits Times

Question

Name of the Person: Benjamin Tung

From 3rd World to 1st in Aids treatment

AS A final-year medical student, I am often taught about HIV and Aids, as not only is it a devastating disease but also its prevalence in Singapore is rising. At the end of tutorials by learned doctors and professors in our best institutions and hospitals, the conclusion is often sombre and frustrating - patients diagnosed with HIV here often cannot receive the World Health Organisation-recommended anti-retroviral therapy (ART), not because we do not have it, but because they cannot afford it.

As mentioned in the Saturday Special Report, 'Waiting for aid', Dr Balaji Sadasivan said in a 2006 interview that 'the issue is prevention of HIV transmission', and that ART has nothing to do with it. The Ministry of Health has announced that by year end all patients aged 21 and above will be offered HIV testing. If this increased testing is not coupled with increased availability of ART, what is the clinical significance of this early diagnosis? If you were a patient diagnosed with a chronic disease like diabetes and the doctor told you there was effective treatment but you could not afford it, would the diagnosis be relevant to you? I know it seems almost blasphemous to compare HIV and diabetes, but in a true clinical sense, both are incurable chronic diseases with proven therapy which can control disease progression and allow the patient to live a functional life.

In a purely economic sense, subsidising ART can save on health-care expenditure in the long run as an HIV patient under ART with good CD4+ counts is less likely to develop serious infections which may require prolonged hospitalisation. This argument has been used with other chronic diseases, and I do not see why the same cannot be said of HIV.

Is the true reason for this apparent lack of enthusiasm to subsidise ART the fact that HIV is linked to infidelity, immorality and homosexual acts - so these patients do not deserve our sympathy, or taxpayers' money? In my course of study and contact with HIV patients, they are often grateful to health-care professionals and medical social workers who deal with them as dignified human beings, and most regret contracting the disease. To say we should not subsidise ART because these patients will get better and infect others, is like saying we should not let convicts out of prison. Just as we give ex-offenders a second chance, why does our compassion fall short with HIV patients?

If we truly want to tackle the problem of HIV in Singapore, there must be an increased effort to de-stigmatise HIV and improve the availability of ART, which will make people more willing to go for HIV testing. I hope the Government will take the lead to take us from our current 'Third World' mentality, to the First World management of HIV our nation deserves if we claim to provide First World health care.

Reply

Reply from MOH 

Singapore's approach to HIV is certainly not Third World

Mr Benjamin Tung felt that our approach to HIV reflected a third world mentality. This is an unfounded criticism.  Singapore's healthcare system and HIV prevalence show that it has more in common with the first world than the third world.  Our HIV rate of below 0.2% is similar to that in the US, rather than say Africa which exceeds 10%.  Strategies advocated for Africa are not appropriate here.

Instead, our approach follows the guidelines recommended by experts in the Communicable Disease Centre in Atlanta, USA.  Our hospitals are implementing their guideline on HIV testing, with a view to pick up patients early so that treatment and counselling can start promptly.   This is an important prevention strategy.  

In certain aspects, HIV is similar to other chronic ailments.  But there are also significant differences.  Getting infected with HIV is not to be taken lightly.  We should not send the wrong message to young people that getting infected with HIV does not have serious consequences.  It is a serious life changing event for any individual who catches the infection. 

In many infectious diseases, like TB or cholera, treatment of the infected patient not only cures the patient but also makes him non-infective. So focusing on the treatment of all the infected persons is an effective strategy in the prevention of transmission of the disease. HIV infection is however different. Even if the HIV-infected person is on treatment, he can still remain infectious, although his infectiousness would be reduced. It is therefore not sufficient to focus on treatment alone as a public health measure. 

Our HIV patients do have access to affordable medications.  There are many ways to ensure such an outcome.  We have noted some feedback that there were some gaps in implementation; we will fix them.  Meanwhile, we have injected additional resources to our hospitals to improve the clinical care of their HIV patients.