HIV/AIDS SITUATION IN SINGAPORE

HIV/AIDS SITUATION IN SINGAPORE:

(Update): 4.

Dr Lim Wee Kiak asked the Minister for Health (a) if he will provide an update on the HIV/AIDS situation in Singapore;

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and (b) what steps, if any, will the Ministry take in light of a recent report that revealed one in 350 non-HIV in-patients' blood samples was found to be HIV-positive.

The Minister for Health (Mr Khaw Boon Wan): Sir, the World Health Organisation (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) classify HIV epidemics into three categories: low-level, concentrated and generalised, in ascending order of severity. Singapore's HIV epidemic is classified as a low-level epidemic. But we are at risk of shifting into the concentrated category, where the prevalence in the general population is low (below 1%) but among a specific high-risk population, the prevalence is high (above 5%). Hence, we must not be complacent, particularly because our region has high HIV prevalence.

I am sure Members are aware of the disastrous HIV prevalence in Africa. And in parts of South East Asia, like Papua New Guinea and Irian Jaya, their HIV rates are almost at African rates.

Let me provide some local statistics. Up till the end of last year, 3,060 HIV-positive cases had been diagnosed, of which one-third or 1,048 had died. In the first eight months of this year, 278 Singaporeans were newly diagnosed, bringing the total number of known HIV-infected Singaporeans to 3,338. Our prevalence of known HIV cases among the resident population above 15 years of age is 0.07%. This is low, but 10 years ago, it was only 0.02%. So it has been rising.

What is, however, not known is the prevalence of undiagnosed HIV. There have been various estimates. UNAIDS, in 2005, estimated our total adult prevalence, diagnosed plus undiagnosed, at 0.3%. This is higher than their estimates

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for countries like Australia, New Zealand, Japan or Korea which were all below 0.1%.

Early this year, my Ministry did a survey to determine the HIV prevalence among the patients in our public hospitals. Discarded blood samples of all patients who were not known to be HIV-positive were tested anonymously for HIV. Based on this study, we estimated

that one in 350 hospital patients was HIV-positive, giving an undiagnosed prevalence of 0.28%.

As patients are not representative of the general population, we should not extrapolate the hospital prevalence nation-wide. Nevertheless, it would suggest that the number of undiagnosed HIV-positive patients is more than the number of known carriers of this virus. Our experience is not unique. This is a common problem all over the world. There are many HIV-positive patients out there who are not aware of their infection.

While some of these patients may choose to be ignorant of their infection, we have to be concerned about the significant number of undiagnosed HIV cases. From the public health point of view, all persons who are HIV-infected should know their status. First, they can then receive early treatment. Second, they then can be counselled on how they can avoid infecting their loved ones. For example, a HIV-infected pregnant woman can protect her child if the obstetrician is aware of her infection. Likewise, a HIV-infected man can reduce the risk of infecting his sexual partner if he takes proper precautions.

Furthermore, in a hospital or a clinic, being aware of one's HIV status can reduce accidental transmission of the virus, for example, through a needle prick or cut during a surgical operation. The

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transmission can go from an infected healthcare worker to a patient but much more likely, from an infected patient to a healthy healthcare worker. While all healthcare workers will routinely take proper infection control measures, being alerted to the HIV status of the patient will be extremely helpful to all.

Every day, we treat about 4,500 inpatients in public hospitals alone. If the hospital study is representative, then one dozen unknown HIV patients come into close contact with healthcare workers every day. The risk of accidental transmission is not trivial.

That is why the US CDC (Centers for Disease Control and Prevention) has issued recommendations that require (a) certain categories of healthcare workers, eg, surgeons, to know their HIV status, and (b) adult patients to be offered HIV screening. The first measure is to avoid infected healthcare workers from participating in procedures which are prone to accidental transmission, what we call "exposure prone procedures (EPP)". The second measure is to pick up the infected patients for early treatment and counselling.

Our public hospitals are progressively implementing the US CDC recommendations. HIV testing will be included in the regular health screening of healthcare workers, on a voluntary basis. Changi General Hospital has started doing so. As for screening of patients, we have begun doing so for all pregnant women and have saved 30 babies from unnecessary HIV transmission in the last two years. Later this year, we will also start offering HIV testing to adult male inpatients on a voluntary basis.

A simple HIV test is all that is needed to diagnose the infection. HIV testing is now widely available in GP clinics and hospitals and my Ministry has just allowed the use of rapid HIV test kits in medical

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clinics. In trained hands, the kit can give accurate and reliable results in 20 minutes. We should take advantage of this to promote regular HIV screening among the population. It is an important measure in HIV prevention. In particular, all individuals who engage in high-risk sexual behaviour must go for regular HIV testing. The Infectious Diseases Act makes it an offence for someone who is HIV-positive if he has sex without informing his sexual partner of his HIV status. I will soon come to this House to amend the Act to clarify that ignorance of one's HIV status will not be a defence for those who engage in such high-risk sexual behaviour.

In parallel, we will strengthen other prevention efforts. Last July, Senior Minister of State Dr Balaji Sadasivan, who chairs the National HIV/AIDS Policy Committee, led a delegation from my Ministry and three NGOs involved in HIV prevention to Sydney to study their prevention efforts. A key learning point was the strong collaboration among the stakeholders, ie, Government, NGOs and academia to create an enabling environment that allows people at risk to take personal responsibility to reduce risky behaviours and go for regular testing. My Ministry has formed a working group involving the NGOs to apply what they have learnt in Sydney to further enhance our HIV prevention strategy.

Dr Lim Wee Kiak (Sembawang): I would like to thank the Minister for the comprehensive answer. The best way to stop an epidemic is to stop the transmission of the disease by early identification and intervention and also through public education. Will the Minister consider a more proactive step, in terms of screening the entire cohort of Singapore males, similar to what the NS has done for mandatory medical examination at the age of 35 for all NSmen prior to IPPT? Perhaps, the Ministry could consider to add HIV testing

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as part of the testing so that the entire male cohort of Singaporeans can be screened regularly when they are doing their reservist or when they go back to NS at the age of 25, 30 and 35.

Mr Khaw Boon Wan: For population-wide screening or test, there is a trade-off that we have to make because there is a cost to screening and also we do not want to cause unnecessary inconvenience to the vast majority. That is why if you study the US CDC recommendations, they were careful to say that even in a hospital setting, they recommend a voluntary routine screening only if the prevalence is above a certain level. In our case, our adult male prevalence would have exceeded that threshold, but not the female. That is why the first step that we will be doing before the end of this year is to start offering this HIV testing to adult males. With the benefit of better data, we can then revise our strategy going forward.

If we do it well and keep the prevalence low, hopefully we do not have to cross the threshold to have to do population-wide screening. Let us continue to review this because, as I said, it has to do with cost-benefit. Fortunately, the cost of HIV testing is coming down. As it becomes cheaper to do so, we may then decide to make it more accessible, much like routine blood pressure or simple blood test. At some stage, HIV may become one of the routine checklist of tests to be done.

Dr Lam Pin Min (Ang Mo Kio): I would like to ask the Minister, with the introduction of voluntary HIV screening for healthcare workers, what would the possible implications be if the healthcare worker is found to be infected with the virus in terms of his work, and whether we consider it a work-related infection and he be compensated accordingly.

Mr Khaw Boon Wan: This is not a new issue because another disease that has a

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longer history is Hepatitis B. In fact, empirical data globally has shown that the transmission of Hepatitis B is even more common than HIV transmission. We can apply the same model or approach. And that is why in the US CDC recommendations when they suggest routine screening for healthcare workers who are engaged in EPP (exposure prone procedures), such as surgery, it is to re-deploy those infected, to put them in other work areas which are less or non-exposure prone. Those are standard ways that institutions will adopt.

As for compensation, you have to take into account and establish if indeed there is infection from a patient to a healthcare worker. You also have to establish that the healthcare worker was not himself careless because as healthcare workers, we know there are occupational hazards in this chosen profession. That is why we are taught and we learn how to protect ourselves. If you are careless, then you have yourself to blame. But, like all things, better get to the basic approach, which is to pick up as many HIV-infected patients as possible so that we can treat them and counsel them, and in that way we can protect the rest of the society.

Mdm Halimah Yacob: I would like to ask the Minister what other measures can be taken in order to deal with undiagnosed HIV cases. My second question is: is it possible or feasible to make HIV testing compulsory for male patients?

Mr Khaw Boon Wan: This is an evolving field and so everyone is learning from one another. I propose that we take a step-by-step approach. In US, because their numbers are higher, they have been studying this for a longer period. That is why we look to the US CDC recommendations and also other regimes to see whether we can learn from

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them. That is part of the reason why Dr Balaji led a delegation to Australia recently.

To take the measures that I mentioned just now with hospitals offering screening to our own healthcare workers as well as beginning to offer the screening for adult males will be a big step forward. Let us go through this step first and learn from that experience. With better data, we can then decide whether we need to be more aggressive or just hold it at that level. Compulsory HIV screening - no country has done it yet. I think that is something for us to think about, whether we want to be ahead of the curve, especially when our prevalence is not as high as in the rest of the world.