We are facing an 'Aids epidemic', said Senior Minister of State Balaji Sadasivan in a recent speech. He threw up some challenges for the Communicable Disease Centre and the Action for Aids group.

In Part 1 of a three-part series, we ask if CDC can do more?

By Ng Wan Ching

SINGAPOREANS are the ones who shy away from HIV/Aids issues, not the Communicable Disease Centre (CDC).

That's what CDC director Dr Leo Yee Sin said when asked if the CDC has been too quiet.

Said Dr Leo 'Effectively, Singaporeans do not open their mouths. They are very quiet and they don't give comments.

'We need to engage opinions and feedback. We need to talk in order to bring the message of prevention across.'

It's not enough to have just one segment of society such as the Action for Aids (AFA) talking about HIV/Aids either.

'We need to get all Singaporeans to talk about sexual behaviour. I do not want to associate HIV/Aids with any one particular group of people such as homosexuals. I think it is associated with behaviour,' she said.

For example, if a homosexual practises the ABCs - abstinence, being faithful and condom use - chances are he will not be infected by HIV.

'It's no longer about what group you belong to, whether it's heterosexual or homosexual. It's about sexual behaviour,' she said.

She cites Thailand as a good example of a society which is more open and accepting of many things, one them being HIV/Aids.

'Thai campaigns are effectively in-your-face, they give explicit examples and engage different sectors of society to talk about it,' she said.

There are many issues involving HIV/Aids which need to be brought up for discussion.

'We tend to brush many HIV problems under the carpet. The disease carries many other implications,' she said.

She gave an example What if someone in your office came to you and confided in you that he or she has HIV? What would you do next? Should you tell your boss? What should you do when you see that person getting physically close to someone else?

'Bring up the issues and people will start thinking,' said Dr Leo. 

Researching sexual patterns
And that's just for starters.

Dr Leo throws up another huge area in which Singapore is lacking - researching sexual patterns here.

The current information that is gathered at the CDC is only what is apparent - such as the increasing trend, from the estimated projection of 300 new cases this year compared to over 200 new cases in the past few years.

'We are severely lacking in research to find out the sexual behaviour of local residents. Although we may have small surveys here and there, and some of them are more commercially targeted, the last survey that we can quote on national sexual behavioural patterns was done in 1989 by epidemiologist Dr Heng Bee Hoon,' said Dr Leo.

'We are lacking certain key information. I hope resources can be put into gathering more information,' she added.

'We must have the ability to analyse whether or not the measures put in place are effective.' 

Can the CDC do more?
There is always room for improvement.

The CDC has established a whole series of care programmes including in-patient acute care and out-patient care.

Doctors and medical workers have to keep up with HIV/Aids being a very dynamic condition.

Before 1996, the disease was widely accepted as a deadly disease where there is no cure available. But then new drugs became available to treat the disease.

Then the planning and development of terminal care for HIV patients became rather irrelevant.

'But now we also realise that after long- term treatment some patients fail all treatment regimens, and the disease will progress. Then we have to brush up our terminal care delivery again. Hence there will always be room for care delivery,' said Dr Leo.

But she does not deny that the CDC has a role to play in prevention.

'We practise positive prevention, in other words we give active messages to people diagnosed with HIV, counsel them to cope with the diseases and prevent further transmission of the disease. This can all tie into our care delivery,' she said.

But it should not be the CDC's burden alone.

The entire nation needs to be mobilised not least because HIV/Aids is not just a health issue. It impacts on many areas - socio-economic, business and travel.

'The ministry needs to mobilise all public and private sectors to get involved in prevention.'

Dr Leo has seen many HIV/Aids patients.

The average length of time it takes to work through the issue is about two weeks.

Only after the patient has accepted the diagnosis can treatment begin.

But the most common refrain Dr Leo has heard over the years 'Don't tell anyone'.

'HIV/Aids patients are not being accepted. But if there is no stigmatisation, then there will be no fear. I am hoping that with people talking about it, something positive will come out of it.

'What are we aiming for? That Singapore does not follow the trend of many other regions to the point where the epidemic can be devastating.

'I am hoping things will change for the better slowly.'

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THE main focus of Singapore's programme against Aids is on health education.

So has the Health Promotion Board (HPB) shied away from giving out condoms to avoid the impression that promiscuity is all right?

'We encourage high-risk groups to use condoms to reduce the risk of transmission. Freelance sex workers are among the target audience that HPB focuses on,' said an HPB spokesman in an e-mail reply to The New Paper.

But although knowledge is important, it is not enough to bring about the desired behaviour changes, said the spokesman.

Also crucial are factors such as

• An individual's values and beliefs;
• Life circumstances;
• Personal motivation;
• Perceived susceptibility;
• Peer pressure; and
• Existing social norms.

These are the factors that determine whether an individual will abstain from casual sex and adopt safer sex practices.

HPB recognises the gaps between knowledge, intention and behaviour change.

'We are, hence, embarking on another survey this year to assess the sexual behaviour and practices of Singaporeans,' the spokesman said.

HPB will review the Aids programme next year based on what it finds in a survey this year.

In addition to education, prevention of HIV/Aids requires a multi-pronged approach.

There have to be laws, protection of the national blood supply, treatment of the infected, counselling those with high risk of infection, monitoring the disease, training of personnel and conducting research and studies.

HPB sends out messages to its target audiences through the mass media and various face-to-face Aids education activities.

It also works with other organisations such as Action for Aids in its public education efforts.

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According to WHO, there are about 4,000 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.

CDC should look for more community partners in its fight against Aids.

- Dr Balaji Sadasivan, Senior Minister of State for Health, at the Tan Tock Seng Hospital Doctors' Night 2004 on Nov 10

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