HIV / AIDS IN SINGAPORE

The Latest HIV Numbers and Trends in Singapore

In 2015, there were 455 reported new cases of HIV in Singapore among its citizens and permanent residents, bringing the total to 7,140 registered cases since initial documentation in 1985. This total was one case shy of 2014’s 456 recorded new cases. Ninety-three percent of new infections were seen among males, of which almost three-fourths occurred in those between 20 to 49 years of age, echoing last year’s trend.

Sexual intercourse is the main mode of HIV transmission, with almost all (440, 97%) of the 455 cases acquired through this mode. An increase in new cases was seen among homosexuals (51%, from 40%) and injection drug users (4 cases, from 1) compared to that in 2014. 1-2

Provider-initiated Testing versus Voluntary Opt-Out HIV Testing: What’s the Difference?

HIV testing done as part of medical care provision reflects a healthcare provider-initiated process. Cases detected via this route typically were at the late stage of their HIV infection.

In 2015, 29% of new infections were detected from routine programmatic endeavors, such as screening for individuals with sexually transmitted infections, persons identified through contact tracing, and hospital inpatients.

The target audience, uptake rate and case detection rate of the different types of services vary as reflected in the table below. (Table 1)

	POPULATION GROUP	TOTAL SCREENED	NUMBER POSITIVE	PREVALENCE (PER 1000 TESTED)
Action for AIDS (Voluntary)	High-risk, 33.3-40.4% MSM	18,190	368	20.2
NUH Voluntary Opt-out Screening	Low-risk; inpatients	4,850	3	0.62
Singapore Voluntary Opt-out Screening Program	Low-risk; inpatients	101,131	114	1.13
Singapore Antenatal Screening (Programatic endeavour)	Low-risk	43,304	27	0.62
Table 1. Characteristics of the different types of HIV testing (2010- 2012)4

The voluntary opt-out HIV screening program for all adult public hospital inpatients was instituted by Singapore’s Ministry of Health in 2008. The goal of this program is to diagnose HIV infection opportunistically, to increase access to care and optimize health outcomes for people living with HIV, and to reduce HIV-related health disparities.

Assessment of uptake of this program at a tertiary hospital (ie, Tan Tock Seng Hospital or TTSH), however, proved to be low, as the overall opt-in rate for HIV testing during their admission was 21% from 2009 to 2010.3

Another survey done in a different hospital (NUH) on inpatient admissions from 2010 to 2013, showed that only 4.9% opted-in to an HIV test during their admission.4

From the second study, significant factors associated with agreeing to take an HIV test were a younger patient age, a higher level of education, and having more regular sexual partners.

Patients who opted-out of the hospital’s HIV testing service believed that they had a low risk for the infection, felt that they were too old, found it costly, were averse to having blood drawn, and did not understand the rationale for the cost. Those who opted-in cited a desire to know HIV status as their foremost reason for engaging the service. (Table 2)

	NUS	TTSH
Period os survey	Jan 2010 – Dec 2013	Jan 209 – Dec 2010
Fulfilled VOS criteria	107,523	41,543
Agreed to testing – Had HIV test	5,215 (4.9%) – 4,850 (93.1%)	8,918 (21.5%) – 8,868 (99.4%)
Tested positive	3(0.06%)	16 (0.002%)
Reasons for Opting Out – Financial issues (too costly) – Low HIV risk perceived – Fear of blood/venipuncture	– 15 (6.9%) – 109 (50.0%) – 14 (16.5%)	– 24 (9.3%) – 144 (55.8%) – 58 (22.4%)
Table 2. Comparison of the VOS program of Two Tertiary Singapore Hospitals 3-4

A late HIV diagnosis may come as a result of symptomatic illnesses, and unfortunately, having an AIDS-defining condition can sometimes be the first occasion for a medical encounter in patients. Of the new HIV cases discovered in healthcare, more than half were found to be in the late stage of HIV, compared to only 20% among those who underwent voluntary testing.

Worrisome Decreased Testing Rates

14% in the previous year. Despite the increasing trend in voluntary screening, the uptake is still deemed to be low in Singapore. Action for AIDS reports that the number of clients seen at its anonymous test site in 2015 decreased by 12% from the previous year, which they reported as a worrying trend.

Reported barriers for voluntary HIV testing include fear of disclosure to family and friends, employment outcomes (disclosure to employer, termination, opportunities for future employment), the financial burden of healthcare, being subject to stigma & discrimination within their social spaces and social networks, and lack of awareness of the benefits of testing early for HIV.5

This is quite unfortunate as the benefits of testing are invaluable, such as earlier access to treatment, translating to a longer life span and a better quality of life.

Amongst newly diagnosed cases in 2015 picked up by voluntary screening, a larger proportion were homosexual or bisexual (28%), compared to heterosexuals (3%). This may reflect a disparity of HIV awareness among heterosexuals and men who have sex with men (MSM), which translated into better testing and prevention behavior among MSM.

Ways to Beat the Virus: Singapore’s Public Health Approach

Since 1985, the Ministry of Health has had in-place a multi-pronged HIV control strategy, which included education, legislative measures, immigration and labour policies, management of people living with HIV, counseling , and surveillance.

In addition, the creation of the National HIV/AIDS Policy Committee in 2006 as a guidance committee for all policy matters related to HIV, hoped to achieve adequate control over the spread of HIV in the country.

Present efforts continue to improve awareness, such as continuous encouragement of condom use among those engaging in high-risk sexual behaviour (having multiple partners, engaging with commercial sex workers), increased efforts to provide early and regular testing, the use of anonymous screening processes, and availability of the rapid HIV test.

The Ministry of Health also provides information on additional preventive measures such as remaining faithful to one’s spouse or partner, counseling to protect partners from infection, and early treatment to delay onset of AIDS and to achieve active and productive lives.

Bridging the Gaps in Healthcare: How Action for AIDS Supports People Living with HIV

Action for AIDS’s anonymous HIV testing service (ATS) is the largest and longest-running program in the country, and its assurance of patient identity confidentiality, overcomes one of the main barriers to the uptake of HIV testing.

The ATS provides affordable, safe, quick, simple, and private testing services to anyone regardless of race, nationality, gender, and sexual orientation.

Action for AIDS also provides a mobile testing service, the only one in Singapore, where a van is made available as an extension of the ATS service, and an HIV/AIDS hotline to answer queries of interested parties.

More importantly, to ensure that the HIV continuum of care is preserved, the Coordinated Care program, an integrated holistic care model for patients and their families, connects clients to a wide range of assistive services, including healthcare funding and patient support groups that provide coping strategies to both patients and their caregivers.

With a seamless assistance program that begins with education, through testing, linkage to care, and personal and familial support, Action for AIDS aims to fulfil its goal of addressing the gaps in service for people living with HIV, while providing a safe space for them, and ultimately to enhance the health and well-being of people living with HIV.

References

Report On Registration Of Births And Deaths 2014. Immigration & Checkpoints Authority. Government of Singapore. Available at https://www.ica.gov.sg/data/resources/docs/Media%20Releases/SDB/Annual%20RBD%20Report%202014.pdf. Accessed 12 October 2016.
Update On The HIV/AIDS Situation In Singapore 2015 (Jun 2016). Ministry of Health. Government of Singapore. Available at https://www.moh.gov.sg/content/moh_web/home/statistics/infectiousDiseasesStatistics/HIV_Stats/updateonthehivaidssituationinsingapore20141.html. Accessed 12 October 2016.
Chua AC, Leo YS, Cavailler P, Chu C, Ng A, et al. Opt-out of Voluntary HIV Testing: A Singapore Hospital’s Experience. PLoS ONE 2014;7: e34663.
Tan XQ, Goh W-P, Venkatachalam I, Goh D, Sridhar R, Chan HC, et al. Evaluation of a HIV Voluntary Opt-Out Screening Program in a Singapore Hospital. PLoS ONE 2015;10:e0116987.
Qi LJ. Voluntary HIV screening rate in Singapore ‘extremely worrying’: Action for Aids. Available at http://www.channelnewsasia.com/news/singapore/voluntary-hiv-screening/2857834.html#.V1nDEXoFIiA.facebook. Accessed 12 October 2016.