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     FrontPage Edition: Sat 13 November 2004

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Singapore facing an alarming AIDS epidemic

 

Excerpt of speech by Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and the Arts and Health

We are facing an alarming AIDS epidemic in Singapore. This should not surprise us since much of the world faces the same crisis.

In 2003, an estimated 4.8 million people became newly infected with HIV. This is more than in any one year before. Today some 38 million people are living with HIV which killed 2.9 million in 2003. Over 20 million have died since the first case of AIDS was identified in 1981, which is less than 25 years ago.

The epidemic remains extremely dynamic. We are a global city and Singaporeans travel around the world. When global efforts to control AIDS have failed dismally, we should not be surprised that we now face the same problem that the world has been grappling with.

In Asia, the HIV infection remains largely concentrated in MSM, and sex workers and their clients. This is the case in Singapore too.

MSM

For those hearing the term MSM for the first time, let me explain what it means. It does not mean Minister's Staff Meeting although that is also called MSM.

MSM is now the politically correct term in AIDS circles to mean gays or homosexuals. It stands for Men having Sex with Men. Even the UN Secretary General, Mr. Kofi Anan uses this term. Personally, I find the term a bit graphic and prefer gay which at least has a happy connotation associated with it.

The AIDS problem in Singapore

Most Singaporeans often read about AIDS in other countries. They may come across reports that in Sub-Saharan counties like Swaziland and Botswana, more than one-third of pregnant women delivering are HIV positive, or that there are about 5 million HIV cases in India, or that there will be 10 million infected cases in China by 2010.

The Aids problem in Singapore is not as dramatic as these reports but nevertheless just as dangerous because it has quietly crept into our society over the last two decades without much fanfare.

Most doctors are only peripherally involved in the management of AIDS and follow its development as spectators.

I remember that as a young Medical Officer at Tan Tock Seng Hospital in 1981, I first read about the new disease that was affecting young healthy homosexuals in California. The following year, the term "AIDS" was coined.
In 1985, just before I left for the United States, the first case was reported in Singapore. The rate of new cases diagnosed that year was 0.8 new cases per million population.
When I returned in 1990, there were about 17 cases reported that year, giving a rate of 6 new cases per million population. Doctors were afraid of treating AIDS patients.
I remember a young gay singer with AIDS who had a brain lesion which did not respond to treatment. He was referred for a brain Biopsy. We could not do the operation at Tan Tock Seng Hospital and so we did the case at CDC. I believe it was the first neurosurgery case done at CDC.
I remember another AIDS patient, who developed paraplegia. Investigations were normal and we could not explain his paralysis. When he died, we got a consent to do a limited autopsy to discover the cause of his paralysis.
However, the pathologists were reluctant to do the autopsy. After speaking to the late Prof Chao Tzee Cheng and getting his permission, I did the autopsy at CDC. The spinal cord showed inflammation from vacuolating myelitis. I think it was the first AIDS autopsy at CDC.
I left Tan Tock Seng Hospital at the end of 1993. The number of new cases that year was 64 giving a rate of 22 new cases per million population.
When I returned to public service as Minister of State in the Ministry of Health in 2001, the number of new cases that year was 237 giving a rate of 71 new cases per million population.
This year CDC expects the number of new cases to exceed 300 which will give a rate of about 100 new cases per million population. The number of new cases diagnosed appears to double every 3 to 4 years. At this rate of increase, we can expect more than a thousand new cases to be diagnosed in the year 2010. What is more, this is only the tip of the iceberg.
WHO Statistics
According to WHO, there are about four thousand people in Singapore with HIV. We have only diagnosed less than half of them. 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.
There is a difference between AIDS and SARS. SARS hit you without warning. With AIDS, you can foresee the crisis. CDC is part of TTSH. If all of you put your minds together, you can come up with the solutions needed to stop this epidemic, in the same way that you conquered and stopped the spread of SARS.
We are fortunate that at the present time, the explosion in HIV infection is occurring in two distinct groups of men. HIV has not entered the mainstream population in a big way. The two groups are MSM i.e. the gays, and heterosexual men having casual sex in other countries.
Gays are the bigger concern
Of the two, the gays are the bigger concern. CDC briefed me on the AIDS situation in Singapore.
CDC believes that there is a real explosion of the disease among gays. CDC doctors told me that the gays are themselves concerned by the increase in AIDS among gays.
Last year, there were 54 gays who were diagnosed with AIDS. By October, this year, 77 cases have been diagnosed. There has been a high incidence of sero-conversion among gays diagnosed this year. This indicates that the infections are recent.
This recent explosion of cases is due to the promiscuous and unsafe lifestyle advocated and practiced by some gays. Men who have sex with men are at extremely high risk because of the variety of their sexual practices, the large number of sexual partners with whom they engage with in these sexual practices, and the high percentage of homosexual men who are already HIV- positive.
Recently "Her World" had a feature story with a title that went "I slept with a hundred men and one of them could be your husband." It was a story of a gay who had sex with a hundred men, some of whom were married men.
I asked doctors who are involved in contact tracing if this type of reckless promiscuous behavior occurs and they said "Yes". This means our AIDS prevention message is not getting through to the gay population.
On Action For Aids
Action for Aids is a Non Governmental Organization or NGO that does AIDS prevention education in Singapore. CDC has left much of the gay community education effort to this NGO.
I went into their web site to see how educational it was. In Capital letters, there was the statement "NOT EVERYONE WHO HAS SEX CONTACT WITH AN INFECTED PERSON WILL GET INFECTED." The statement is true but the statement misleads and promotes the spread of the infection by giving assurance when alarm would be more appropriate.
The proper statement should be "YOU HAVE A HIGH CHANCE OF GETTING AIDS IF YOU HAVE UNPROTECTED SEX WITH AN INFECTED PERSON". Without clear messaging, we may actually make things worse by promoting unsafe sex.
On Fridae.com
I next went into www.fridae.com. It was started by a Singaporean and there was some hype about this site in the media. I was shocked by what I read.
A "sexpert" called Alvin Tan, I presume "sexpert" means a sex expert, was advocating a promiscuous and reckless lifestyle. In an interview with the Far Eastern Economic Review, the CEO of the web-site said "Change at the grass roots is outpacing change at the policy level. But things are moving in the right direction."
However from a public health perspective, the lifestyle advocated in the website which is a life-style of reckless regard to sexual health and safety is dangerous. Those who follow such a lifestyle will run the risk of getting AIDS. There were also many advertisements for saunas. Why so many saunas? We are not Russians or Finns.
San Francisco bath-houses
Randy Shilts, a gay journalist wrote a book called "And the band played on". He eventually died of AIDS. As a journalist, he covered San Francisco during the early days of AIDS and he describes the events in San Francisco in his book.
San Francisco had many bath-houses where rampant reckless sexual activity occurred despite the danger of AIDS. This was one reason why so many in San Francisco died of AIDS. He was attacked by many in the gay community in the US for his honest and accurate description of the promiscuous behavior of some gays which was a contributing factor to the AIDS epidemic in the US.
In response to the AIDS epidemic, the San Francisco Health Department eventually banned bathhouses in the city, a health measure that helped stem the epidemic in San Francisco. CDC must ensure that saunas in Singapore do not become San Francisco style bath-houses.
Taipei Police Raid
Recently, Taipei police raided an all male party and tested 27 people arrested at the party. Fifteen or 55% of them tested positive. We do not know how high the incidence of HIV is in our gay population. If we do not have champions to spread the anti-AIDS message among the gay, a high percentage of them will get infected and many will eventually die. Action for Aids needs to review its messaging so that it is simple, it is effective and it promotes safety. CDC should look for more community partners in its fight against AIDS.
Males Having Casual Sex Outside Singapore
The second group who are HIV positive are males who have casual sex outside Singapore. Fortunately, 70% do not have a Singaporean spouse. Many are poorly educated. Spreading the prevention message to them is difficult.
Perhaps a different approach will be needed. If CDC can screen high risk Singaporeans at our borders when they return, we may be able to protect Singapore women from catching AIDS from these men.
When I visited CDC, I wanted to give them a hypothetical case to ponder on. You may have read about the German who knew he had HIV but nevertheless went to Thailand and infected hundreds of women. He refused to give consent to the Thais to test him. The Thais deported him. We do not know who this German is. I wanted to ask CDC, what they would do if this German came to Singapore.
Before I gave them the question, they gave me a hypothetical case which they wanted me to ponder over. I want to share this hypothetical case with you, so that you may all sleep over the problem too.
A 30 year old Singapore man develops HIV. He decides to go to another country and gets himself a bride who he brings back to Singapore and marries. He does not tell her he has HIV. She now becomes positive. What should we do?
The fight against AIDS is not going to be easy. Many will oppose public health measures like contact tracing and compulsory testing arguing that the right of the individual over-rides the safety of society.
In the end, we must convince these people that public health measures protect everyone and it is better to have living people complaining about their rights than dead people buried with their last rights. Everyone has a role to play in this battle...

Full Text of Speech

Source: Ministry of Health Press Release 10 Nov 2004

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Public Holidays HARI RAYA PUASA is the next public holiday. It falls on 14 November 2004.