April 1999

HIV and safer sex




The Health Ministry has just released the HIV data for 1998. As expected, last year saw yet another increase in the number of HIV cases detected in Singapore, to a new record of 199 cases.

Our first 2 cases were detected in 1985, and the rate of new cases remained under 25 per year up till 1990. Through this period, about half the cases were found in homosexual men, about a quarter in bisexuals, and another quarter in heterosexuals.

1991 was the year in which the infection pattern changed dramatically. First of all, the total number of new cases leapt up. It more than doubled to nearly 50, and almost all the increase was made up of heterosexuals. From that year on, heterosexual transmission became the main mode of infection in Singapore.


The steady climb in cases continues.  1994:
 86 new cases
111 new cases
139 new cases
182 new cases

Here are the figures for 1998:

How they were infected 1998
Heterosexual sex 163 81.9
Bisexual sex 19 9.5
Homosexual sex 12 6.0
Mother to child 4 2.0
Drug needles 1 0.5
Total 199 100.0

I have long wondered how reliable the information is about the mode of transmission. The patients' sexual history cannot be verified. Some of my friends who are AIDS volunteers have told me that many homosexual persons lie about their homosexual past, and that it takes much rapport and persistence to get to something resembling the truth. So my instinct is to warn homosexual persons not to be complacent with the low percentage of homosexual transmission in the above figures.

However, another friend of mine recently emailed me this nugget of information:


"I share your skepticism about people telling the truth about their sexual activities. Lord knows, I've been lied to numerous times while doing counselling at the anonymous testing site. Also I've wondered why it is that 90% of those infected are male whereas the majority were presumably infected through sex with women. My question was "Where are the women?" Heterosexual transmission requires that the virus go from man to woman or vice versa, meaning that the percentage of women should be more than 10%. Well, it turns out that a study was done a while back in which they took blood samples from HIV patients and sent them to the Centers for Disease Control in Atlanta for typing according to HIV strain. There are several strains of the virus that differ between population groups. If I recall correctly Strain B is the one most prevalent among gays whereas Strain E is found in sex workers in Thailand. When they compared the strain of the virus with the reputed mode of transmission they correlated. I.e. those who said they got it through heterosexual transmission had Strain E. Those who said they got it through homosexual transmission had Strain B. That doesn't mean that people don't lie when asked about their sexual activities but I am a lot less skeptical about the data on routes of transmission than I used to be."

Some other facts:

  • With the 1998 figures, the total of HIV cases detected in Singapore since 1985 is now 930. Of these, 311 have since died.

  • As pointed out by my friend above, the great majority of the cases in Singapore are male. Of the 930 total cases of HIV+, only about 100 are women, that is, slightly over 10%.

  • The age group with the largest number of new infections is 30-39, followed by the 20-29 group. So if you're in your twenties and reading this article, please don't think it can't happen to you.

  • The majority of the infected persons are single, but parallel to the increase in heterosexuals through the years, there has also been an increase in married patients. Only 14% of new cases detected in 1991 were married, but in 1998, 38% were.

  • This 38% figure, as an average between the two sexes, conceals the fact that most of the infected women -- over 70% of them -- are married. This strongly indicates that women are getting infected through their husbands.

  • This also raises the spectre of increasing numbers of mother-to-foetus transmission of HIV in the years ahead, a truly tragic scenario. In 1998, 4 babies were so infected, bringing the total to nine, since the first case in 1991.

HIV in Southeast Asia

Just in case anybody thinks that 199 cases a year is no big deal, I need to stress the bigger picture: the almost exponential growth curve of HIV cases locally, and the experience of nearby countries.

Locally, 199 cases represent nearly double the new infections detected in 1995, just a wink of an eye ago, and more than 4 times the cases of 1991, at the start of the decade. Can we afford to quadruple every decade?

Yet it can happen. At the AIDS conference held here last December, it was reported that as of end 1997,

Country Estimated
HIV positives
Est cumulative
AIDS cases
adult HIV rate
Thailand 780,000 260,000 2.2 %
Burma 440,000 100,000 2.8 %
Cambodia 130,000 18,000 2.4 %
Vietnam 88,000 8,700 0.2 %
Malaysia 68,000 6,900 0.6 %

Note: the above are estimated number of infected persons, not reported number of infected persons.

Infection is spreading very rapidly in Southeast Asia. In Thailand and Cambodia, over 2% of adults are believed to be already infected. Since the estimates were from 1997, by the time you read this, they will be out of date, and there may be over a million HIV-positives in Thailand. This is no small matter.

Like in Singapore, the main mode of transmission in our neighbouring countries is heterosexual, though unlike Singapore, in many of these places, drug-use is also a major contributor. 

Use a condom!

In the light of this threat, the safer sex campaigns by Singapore's Health Ministry are often criticised for their timidity and moralism. Too much of the message is of abstinence, which is seen as preachy and unrealistic. Do you remember the "Just Say No!" and the "Be Negative!" campaigns?

Let's get real. Telling people to say No doesn't work. Sex is too powerful an urge, especially when people are young and hormones are raging. It's no use imagining an ideal world where people are such paragons of virtue (!) that they have sex only with their marital partners. It is completely head-in-the-sand useless to exhort people to go back into such a world, which has never existed. The reality is our teenagers in Singapore have sex, our twenty-somethings have sex. Our married men and women have sex, not always with their legal spouses, and our homosexual men and women have sex, whatever our law may say.

After many years, the ostriches at the Health Ministry wiggled their buried heads a bit, and changed the campaign to "Be Negative". OK, but how? Tiny print below says use a condom.

Right. Use a condom.

Is a poster or magazine ad telling people to use a condom enough to get people to use a condom?


Why do people brush their teeth?

Why, indeed, do people brush their teeth? To prevent tooth decay and being toofleff in your old age is one reason. But there are also many supporting inducements in play. There's the mint flavour, the freshness in the breath. Don't forget the convenience when toothbrushes and toothpaste are easily available from just about every corner store. Toothbrushes come in many shapes, and bristle-lengths come in soft, medium and stiff versions, so that everyone can find something that suits him.

Most important of all, there is social pressure to brush one's teeth. There is certainly no shame in it. Parents brush their teeth in full view of their kids. And the kids are taught to show proudly their white milk teeth to their parents.

The question of condoms is like a world apart!

The big, big problem is our gargantuan hang-up about sex in our society. Where there are plenty of inducements to brush your teeth, there are plenty of deterrents to knowing about condoms, getting them and using them. Lots of young men whom I have come across, aren't sure when they ought to use a condom, and what's safe and what's unsafe.

Condoms aren't easy to buy, though a little better now that the 7-Elevens stock them. However, many 7-Elevens have female shop assistants, and I suspect this deters some men from buying them. The condoms themselves are quite expensive, roughly a dollar each -- another deterrent.

Even when the young men have condoms ready and know when to use them, some will not know how. Studies abroad have shown that a certain percentage do not know which way to put them on so that they roll on easily. And very little is said about what to do about the foreskin. This is important in Asia when the vast majority of Asians are uncircumcised.

We also need to think through the dynamics of the sexual situation. Very often, sex is a hurried, furtive affair in a back seat, behind the bushes, or in a toilet. Young people can't bring their partners and lovers home. Their fathers will kill them! In such hurried, exposed circumstances, how many are going to pause for a moment and put on a condom?

Other people are so shy of nudity, they must have complete darkness to have sex. How are they going to sheath on a rubber, apply lubricant, etc, if they can't see?

All these impediments occur because of our inability to deal with nudity and sex. We need to be more open about sex before we have any chance of making it "cool" to go buy a condom and put it on. Otherwise, we're always going to have a problem battling HIV. 

Unprotected anal sex

There are figures to show that we have a problem. Unprotected anal sex is considered very risky behaviour, yet, among gay men, a Singapore survey done in 1997 [published in the AfA magazine, The Act] found that only about 42.6% of those who have anal sex with their regular partners, use a condom consistently. 57.4% did not use a condom on one or more occasions within the previous six months.

The figures for those having anal sex with casual partners are not much different. Only 44.2% of those having anal sex with casual partners use a condom consistently. 55.8% did not do so consistently.


  Sex with regular partners Sex with casual partners
  Persons Percent Persons Percent
No anal sex 67 21.1 108 34.2
One or more instance of anal sex 251 78.9 208 65.8

of which:

318 100.0 316 100.0
     Always protected 107 42.6 92 44.2
     One or more times
144 57.4 116 55.8
SubTotal (those with anal sex) 251 100.0 208 100.0

Take care how you absorb this information, though. I do not mean to imply that all gay men have anal sex. The same survey found about 21-34% of them do not have anal sex. Even those who do, do not always have anal penetration each time they have sex. I don't want young gay men, reading this, to think that anal sex is somehow a required norm in gay sexual behaviour. It isn't. Asking around my friends, I believe less than 1 in 5 of gay male sexual encounters involve anal sex. Many gay men never do it, or haven't done it for years, and still enjoy fulfilling sexual lives. Don't feel pressured to do it. 

Safer sex in plain English

When should we use a condom?

Before a cock enters a vagina, anus or mouth, it must wear a condom. It's as simple as that.

A lot of safer sex literature (including Singapore's) use jargon like "avoid exchange of body fluids". What????

The "body fluids" with high concentrations of the Human Immuno-deficiency Virus ("HIV") are semen (i.e. cum, the whitish liquid that is ejaculated when the guy reaches orgasm) and blood. Other body fluids which can carry the virus are vaginal secretions and pre-cum (i.e. the lubricating fluid secreted from the penis by most men when aroused, prior to orgasm). Saliva also carries the virus, though in much, much lower concentrations.

When you have an opening into your body, e.g. the vagina, the anus, the penile orifice, the throat, or more dangerously, any cut or injury, that opening is a very easy entry point for the virus. Never risk letting your partner's semen, blood or vaginal fluids come into contact with your body through these entry points.

Intact skin (that is, no cuts or scratches) is generally a very good barrier to the virus and if a partner ejaculates onto your tummy or thighs, there's nothing to worry about. You should however wash up and dry yourself well as soon as possible. The virus dies very quickly when dry.

Understanding the above, it is a simple rule of thumb: if the cock enters the mouth, anus or vagina, it must wear a condom. If you have a cut on your hands, mouth, genital area, or any part of your body likely to come into contact with your partner, please postpone sex till it has healed.

How to put on a condom and use it correctly?

Please see the cartoons on this site: http://www.safersex.org/condoms/how.to.use/. It even tells you that you have to pull your foreskin back before putting on the condom. It advises that you put a little water-based lubricant inside the tip of the condom, so that it does not abrade against your glans penis (the cockhead).

How much protection does a condom offer?

A hell of a lot. Read more about it from this site: http://www.safersex.org/condoms/ss3.2.html.

Basically, it says that in the laboratory, latex has been shown to be extremely effective as a barrier against the HIV virus. In real life use, it has also been shown to be very effective, provided people use it correctly and consistently. Incorrect use contributes to the possibility that the condom could leak from the base or break.

"The degree of protection that proper use of latex condoms provides against HIV transmission is most evident from studies of couples in which one member is infected with HIV and the other is not (i.e. "discordant couples"). Among the 44 couples who used condoms inconsistently, 6 of the uninfected partners became infected. In contrast, among the 24 couples who reported consistent condom use, none of the uninfected partners became infected."

No condom, but we withdraw before we come

This is still a no-no. The pre-cum or vaginal secretions can carry the virus, whether one ejaculates or not. In any case, sometimes, we can't withdraw in time. Please don't take this kind of risk. If the cock goes in, it must wear a condom.

What about deep-kissing? Is it safe?

Although theoretically, saliva contains the virus, the concentration is very low. There have been no documented cases of HIV transmission through oral sex (i.e. cock in mouth) despite the theoretical risk -- but this is not to say that undocumented cases have not occurred. Deep-kissing, which is mainly saliva-to-saliva contact is considered such low risk, that there is no need to get paranoid about it.

If you have more questions about how to be safe, check out Action for AIDS' website at www.afa.org.sg

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