I left Tan Tock Seng Hospital at the end of 1993. The number of new cases that year was 64 giving a rate of 22 new cases per million population. When I returned to public service as Minister of State in the Ministry of Health in 2001, the number of new cases that year was 237 giving a rate of 71 new cases per million population. This year CDC expects the number of new cases to exceed 300 which will give a rate of about 100 new cases per million population. The number of new cases diagnosed appears to double every 3 to 4 years. At this rate of increase, we can expect more than a thousand new cases to be diagnosed in the year 2010. What is more, this is only the tip of the iceberg. According to WHO, there are about four thousand 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.

We are fortunate that at the present time, the explosion in HIV infection is occurring in two distinct groups of men. HIV has not entered the mainstream population in a big way. The two groups are MSM i.e. the gays, and heterosexual men having casual sex in other countries.

Of the two, the gays are the bigger concern. CDC briefed me on the AIDS situation in Singapore. CDC believes that there is a real explosion of the disease among gays. CDC doctors told me that the gays are themselves concerned by the increase in AIDS among gays. Last year, there were 54 gays who were diagnoses with AIDS. By October, this year, 77 cases have been diagnosed. There has been a high incidence of sero-conversion among gays diagnosed this year. This indicates that the infections are recent. This recent explosion of cases is due to the promiscuous and unsafe lifestyle advocated and practiced by some gays. Men who have sex with men are at extremely high risk because of the variety of their sexual practices, the large number of sexual partners with whom they engage with in these sexual practices, and the high percentage of homosexual men who are already HIV- positive.

Recently "Her World" had a feature story with a title that went "I slept with a hundred men and one of them could be your husband." It was a story of a gay who had sex with a hundred men, some of whom were married men. I asked doctors who are involved in contact tracing if this type of reckless promiscuous behavior occurs and they said "Yes". This means our AIDS prevention message is not getting through to the gay population.

Action for Aids is a Non Governmental Organization or NGO that does AIDS prevention education in Singapore. CDC has left much of the gay community education effort to this NGO. I went into their web site to see how educational it was. In Capital letters, there was the statement "NOT EVERYONE WHO HAS SEX CONTACT WITH AN INFECTED PERSON WILL GET INFECTED." The statement is true but the statement misleads and promotes the spread of the infection by giving assurance when alarm would be more appropriate [3]. The proper statement should be "YOU HAVE A HIGH CHANCE OF GETTING AIDS IF YOU HAVE UNPROTECTED SEX WITH AN INFECTED PERSON". Without clear messaging, we may actually make things worse by promoting unsafe sex.

I next went into www.fridae.com. It was started by a Singaporean and there was some hype about this site in the media. I was shocked by what I read. A "sexpert" called Alvin Tan, I presume "sexpert" means a sex expert, was advocating a promiscuous and reckless lifestyle. In an interview with the Far Eastern Economic Review, the CEO of the web-site said "Change at the grass roots is outpacing change at the policy level. But things are moving in the right direction." [4] However from a public health perspective, the lifestyle advocated in the website which is a life-style of reckless regard to sexual health and safety is dangerous. Those who follow such a lifestyle will run the risk of getting AIDS. There were also many advertisements for saunas. Why so many saunas? We are not Russians or Finns.

Randy Shilts, a gay journalist wrote a book called "And the band played on". He eventually died of AIDS. As a journalist, he covered San Francisco during the early days of AIDS and he describes the events in San Francisco in his book. San Francisco had many bath-houses where rampant reckless sexual activity occurred despite the danger of AIDS. This was one reason why so many in San Francisco died of AIDS. He was attacked by many in the gay community in the US for his honest and accurate description of the promiscuous behavior of some gays which was a contributing factor to the AIDS epidemic in the US. In response to the AIDS epidemic, the San Francisco Health Department eventually banned bathhouses in the city, a health measure that helped stem the epidemic in San Francisco. CDC must ensure that saunas in Singapore do not become San Francisco style bath-houses.

Recently, Taipei police raided an all male party and tested 27 people arrested at the party. Fifteen or 55% of them tested positive. We do not know how high the incidence of HIV is in our gay population. If we do not have champions to spread the anti-AIDS message among the gay, a high percentage of them will get infected and many will eventually die. Action for Aids needs to review its messaging so that it is simple, it is effective and it promotes safety. CDC should look for more community partners in its fight against AIDS.

The second group who are HIV positive are males who have casual sex outside Singapore. Fortunately, 70% do not have a Singaporean spouse. Many are poorly educated. Spreading the prevention message to them is difficult. Perhaps a different approach will be needed. If CDC can screen high risk Singaporeans at our borders when they return, we may be able to protect Singapore women from catching AIDS from these men.

* * * * *

The Straits Times leapt into action and a reporter contacted Action for AIDS ("AfA") for information.  AfA forwarded the email to me just in case I had something to say to the reporter. I didn't see the email until nearly midnight, and might have missed the deadline, but nonetheless I wrote an email reply to the reporter in case she was still working on the story the following day. For good measure, I sent a copy to the minister too.

This is what I said:

Hi [name of reporter],

My name is Alex Au. Roger Winder from AfA forwarded your message to me and I would like to share my thoughts with you.

Your request is for feedback "... as a follow up to Minister Balaji Sadasivan's assertions that Sg is on the brink of an Aids epidemic and that gay men are among those at highest risk..."

The other danger about misfocussing comes from the fact that AfA's MSM project has been successful in getting gay men to go for testing. Naturally, when you test enough people, you will find HIV-positive ones. The more people you test, the more you may find. So the rise in cases among gay men may actually be from a rise in testing. Are heterosexual men coming forward to be tested to the same extent? If not, then of course they will be relatively invisible in the test findings. It then becomes very easy to say that gay men are the leading risk group.

Having said that, AfA themselves have pointed out that HIV infection is rising among gay men (though as I pointed out above, that shouldn't be read as only gay men), and the Minister made it a point to say that "gays are themselves concerned by the increase in AIDS among gays". Furthermore, he took care to say "some gays" when referring to "the promiscuous and unsafe lifestyle". So I think we should credit the Minister for being objective and evenhanded.

But I think he could have done better. There seems to be an automatic linkage between the words "reckless" and "promiscuous". However, promiscuity is much less directly linked to infection. "Recklessness" is the key.

I feel this distinction is very important, because it's very easy to slip into a preachy moralistic mode, which, as we all know, turns people off any attempt at public education. Stamping out promiscuity is hard. But getting even promiscuous people to practise safe sex, and thus reduce the transmission rate, is, as the experience of Thailand has shown, achievable. Thus it is important that we think clearly and, as the Minister said, review our messaging "so that it is simple, it is effective and it promotes safety."

To put it concisely, if we want people to respond positively to what we suggest, then don't castigate people for what they are. Don't pass judgements. Just ask them to do something that is do-able. This is no big secret. As any organisational leader knows, this is the way to motivate people and gain their co-operation. So don't castigate people for being gay, or being promiscuous. Just ask them to do something simple: use protection.

For some reason, the Minister only referred to AfA when he made this comment about messaging. I don't think that is fair at all. I think the Ministry of Health has been even more guilty of mixed messages, or rather, of mis-messages.

The government has been extremely reluctant, for its own queasy moralistic reasons, to address the issue of gay sex. It would rather pretend such things didn't happen. But the fact of life is that there are gay men in every country, and gay men have sex.

But what messages have the government been giving men? That they should be faithful to their (opposite-sex) wives, failing which, they should abstain from sex altogether. Any time visual graphics are used in their safe sex messages, it's always a heterosexual couple.

Two consequences inevitably follow

The safe sex messages appear irrelevant and unrealistic to gay men. What opposite-sex wives are we talking about here? In which case, the message is reduced to "don't have sex!" As humans, that is impossible. Well then, how much attention do we expect people to pay to messages that are so not do-able?

Secondly, by being so overtly heterosexist, the government's safe sex messages reinforce the feeling that the government is homophobic. The government is anti-gay. Do we seriously expect people to be amenable to messages that come from a source that hates them in the first place? Of course not. If the government continues to display antipathy towards the gay minority, don't be surprised that the government cannot successfully engage with them in other, more essential, life and death, areas.

The other element that is worryingly fuzzy-minded is a tendency to focus on easily identifiable venues as proxies for effective action. We must never forget, the venue is not the issue. Unsafe sex is. As with any kind of prohibition, you close off one option and the activity moves elsewhere.

As it is, most people in the gay community think the private parties are the scariest places. Arranged through internet contacts, these parties often mix alcohol, drugs and sex, with questionable hygiene facilities and provisions. Mind-altering drugs and alcohol lowers the threshold for risky behaviour.

As an important aside, I must stress that only a small proportion of gay men have any interest in such private parties, so please make the effort to point this out and take care not to tar all gay men with the same brush. Most gay men, like me, are horrified by the idea of drugs, booze and sex.

The Minister's example of bath-houses being closed in San Francisco may no longer be reproducible today. In the 1980s, the Internet didn't exist. Today, it is the primary mode for looking for sexual partners.

Coming back to the point, because these parties are private, irregular and organisationally dispersed, there is no effective way for the government to regulate them. So at the end of the day, it has got to boil down to each and every person being aware and individually determined to protect himself. Which means education, education and education.

For education to be effective, the authorities must examine how they position themselves vis-a-vis the gay community. If the government is perceived as prudish and homophobic, then half the battle is lost. Worse yet, defiance of the government's message, however self-destructive, acquires the cachet of being hip.

The government is tempted to want it both ways: that they should keep their preachy, moralistic stance, and leave it to NGOs to do the job. But when the NGO's hands are tied, through limited funding, and denials of public avenues for sending out a gay-friendlier message ("promoting homosexuality!", some will scream) and when the government's heterosexist messages drown out the NGO's, it's not terribly fair for the Minister to then accuse AfA of not being as effective as they should be.

I wish the Straits Times had picked up on an important example of official stupidity. At the Nation '04 Party last August, AfA had planned to set up a booth to distribute safe sex messages and condoms. However, the Police stepped in and on the excuse of there not being any mention of an AfA booth on the Entertainment Licence, effectively shut out the booth. The whole thing was witnessed by the journalist from the Far Eastern Economic Review and reported in its recent cover story. This incident crystallises the "mixed message" issue that is the crux of the problem.

Regards,  

[A few typographical errors in the email have been corrected in this version]

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