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Dr. Wong Chen Seong, Deputy Director of the National HIV Programme and Director of the National Centre for Infectious Diseases (NCID) joins us in an interview session to talk about HIV awareness.
1. We know that the vast majority of HIV transmission is through sex. How would you rank the rate of transmission of these sexual activities, from highest rate of transmission to the lowest? Assuming that they are unprotected.
- A) oral sex
- B) Vaginal sex
- C) Anal sex
- D) kissing and Making out
The risk of HIV transmission for unprotected anal sex is the highest, followed by unprotected vaginal sex, then oral sex, and lastly, kissing – which generally is considered to carry a negligible risk of transmission unless there is obvious, severe bleeding in the mouth.
2. Can you share why unprotected Anal sex’s transmission is so much higher? Any data on how much using condom can reduce the rate of HIV transmission in anal sex?
The risk of unprotected anal sex, especially for the receptive partner, is higher as the rectal mucosa – or the lining of the rectum – is prone to injuries and bleeding, providing a site for the virus to enter the bloodstream.
It must be noted that the risk of transmission is present if one of the partners is HIV-positive, and not on treatment, and hence has a detectable HIV viral load. People with HIV infection who are on treatment and have an undetectable viral load have effectively no risk of transmitting the virus to their sexual partners. Condoms, when used correctly and consistently, can reduce the risk of HIV transmission by more than 90%.
3. Based on MOH’s website on the update of HIV, there were about 261 new HIV infections amongst Singapore residents in 2020. 92% male. 48% was homosexual transmissions and the rest heterosexual or bisexual transmission. So the stats are fairly even between homosexuals and non-homosexuals. However, there are a lot of stigma out there that homosexuals (particularly gay men) are more prone to HIV. Is there any truth in that? And why?
The risk of HIV transmission is best understood through sexual behaviour, rather than particular groups. The protection afforded through the use of prevention like condoms and pre-exposure prophylaxis or PrEP benefits all who use it correctly and consistently. Overall, stigma and discrimination should be addressed, particularly if it helps to reduce barriers to HIV testing and treatment.
4. In terms of testing for HIV, what is the gold standard for screening test at the moment? Who are the high risk groups that you would recommend to get a screening test done and how frequently?
HIV testing should be performed using a 4th generation HIV antigen-antibody assay, which may either be in the form of a rapid, point-of-care test, or a conventional blood sample sent to a lab. People who have high risk behaviour should be tested more frequently – 3-6 times monthly if very high-risk, and at least annually.
5. In the event someone is tested positive, could you quickly walk through what are the immediate steps that you would do for the patient in the next 2-3 consultations?
All people who test positive should be linked to care with a HIV specialist as soon as possible. At the National Centre for Infectious Diseases, where I am the Head of the Clinical HIV Programme and where I practise, we see all our patients within 7-10 days of referral.
At the first visit, we take a complete history, carry out a full examination and do some comprehensive blood tests to evaluate the patient’s overall state of health, particularly their immune function.
In accordance to local and international guidelines, we will start HIV treatment as soon as possible – usually within 7-14 days.
Over the next few consultations, we will monitor the patient for response to treatment, looking for an undetectable HIV viral load, as well as look out for any uncommon side effects that may occur.
We also counsel the patient on the importance of adherence to treatment, and take care of the patient holistically – including their mental health and coping.
6. We know that there are anonymous testings available in Singapore. Now, in the event any of these anonymous testings turn out to be positive, do the test centres really not need to submit their details up to MOH?
All anonymous test results will not be notified to the National HIV Registry. However, we do strongly encourage all people who test positive for HIV to be linked to care and start treatment. If they choose to do so in the country, they will need to register for care and in those cases, they will be notified.
However, the importance of notification is so that we are able to better monitor the overall HIV situation in the country, as well as advise partners of the patient to get tested as well.
7. This question is about prevention. Please rank for me the importance of these methods of prevention of HIV:
- Usage of condom
- Having sex with someone of the same HIV status
- Pre-exposure prophylaxis
It is not so important for us to rank these methods of prevention – both condom use and PrEP are highly efficacious, and should in fact be considered parts of an effective overall strategy for HIV prevention.
8. You and your team penned the latest guidance for prescription of HIV pre-exposure prophylaxis in Singapore in 2019. Do you feel that enough people know about PrEP at the moment? And how strong is it in the prevention of HIV transmission?
We can definitely do much better in increasing awareness and knowledge of PrEP – something I hope to do with this talk! HIV PrEP has been very well studied in research and in real life, and has been shown to have a very high level of effectiveness when used correctly. It can be up to 96% effective in preventing HIV when used correctly.
9. There are now many antiretroviral therapies in Singapore. How much is the average cost per month for a typical HIV patient in Singapore before subsidy?
There are more than 20 different drugs used in the treatment of HIV available in Singapore. Subsidies now mean that patients can have up to 75% subsidies on their HIV treatment.
10. We know that a list of 16 ART drugs are now subsidised for HIV treatment since September 2020. What impact does it have on your patients who are receiving treatment now? And have you since seen an increase in HIV patients coming to seek treatment?
It has definitely had a huge impact on treatment – effectively making HIV treatment universally available and accessible in Singapore. It also sends a huge message that HIV treatment is important – and in fact essential to ensuring the health and well-being of people living with HIV.
It’s still too early to tell whether this has had an impact on increasing the willingness of people to get tested and seek treatment, but this is something we hope to study and evaluate in the coming years.
11. I’ve spoken about u=u in my third video in HIV prevention. That is if your HIV viral load is undetectable, you will not transmit the virus to others. What would be your advice to someone who has undetectable viral load and now feels that he or she has the license to involve themselves in unprotected promiscuous activities?
This is definitely not the message, or the intent, of the U=U message.
The U=U message was meant to increase knowledge around the effectiveness of HIV treatment in ensuring the health of individuals and prevention of transmission; and also to reduce the stigma and discrimination that often arises when people mistakenly think that HIV cannot be treated, and that people living with HIV remain infectious throughout their lives.
It also gives hope to people living with HIV that they can continue to plan for families, and have meaningful physical relationships with their partners – something which is a part of human life.
I will always tell my patients and HIV-positive friends that U=U is a tool for engagement and enlightenment, not a free pass for unprotected sex. One must remember that such high-risk sexual behaviour may still carry the risk of transmission of other sexually transmitted infections, as well as unplanned pregnancies.
12. Thank you very much Dr Wong for your time! Any last parting words, messages or advice to our audience out there?
Thank you for taking the time to listen to us and hopefully learning more about HIV. Please know that HIV is treatable and controllable, and getting tested and treated early is the best way to keep yourself well and prevent your loved ones and partners from being infected.
Last of all, know that each and every one of us can play a role in reducing the stigma and discrimination faced by people living with HIV by educating ourselves, correcting our misconceptions, and talking openly, honestly and compassionately about HIV.
By : Dr Chen Yiming
Family Physician, MBBS (Singapore), GDFM (NUS), GDFP Dermatology (NUS)