Yawning Bread. 1 May 2008

HIV hits new high. Solution: punish




Last year, 422 people were diagnosed as HIV-positive in Singapore, an 18 percent increase over the figure for 2006. As you can see from this graph, annual new infections have more than doubled in ten years; in fact, the increase is accelerating.

Almost all HIV infections occurred through sexual transmission, as this table shows:

This next table shows how men continue to outnumber women by 13:1. Most striking, however, is the fact that in 2007, nine teenagers (6 boys and 3 girls) were found infected with HIV.

Most Singaporeans do not conceive of Singapore as a hotspot for disease; perhaps we too often buy into the notion that we're a clean and orderly place.

But when it comes to HIV, we are a moderate hot spot. Fortunately, the situation is not as bad as in Thailand, Myanmar, Cambodia and Vietnam, but in three of these countries, things are actually improving. As UNAIDS said in its most recent report, "the epidemics in Myanmar, Thailand and, most profoundly, Cambodia, all show declines in HIV prevalence." [1] 

Singapore and Vietnam are the opposite, experiencing increases.

Singapore looks even worse if we compare it to countries with similar wealth and effective governmental reach.

Hong Kong reported 414 new cases in 2007, an 11 percent increase over 2006, figures that are marginally lower than ours. But Hong Kong has nearly twice as many people as Singapore. [2] 

Australia (population about 20 million) saw 960 new infections in 2006 [3],  about 2-and-a-half times our 2006 figure. But it has 5 times our population.

In Taiwan, "the 2,942 new HIV infection cases in 2006 represented a drop of 457 cases from the 3,399 cases in 2005, reversing a twenty-year growth trend," according to the BiotechEast website [4].  Its figure of 2,942 is about 9 times our 2006 figure, when the island has about 6 times our population. So overall, Taiwan's trend is worse. However, about 60 percent of new infections in Taiwan come from injecting drug use, only about 40 percent comes from sex. Thus, in terms of sexual transmission, Singapore's figures are much worse.


What are we doing about it? Same old, same old.

There is still a great reluctance to bring sex out of the shadows, hence high-profile campaigns to normalise the use of condoms are not allowed. On the other hand, Christian crazies are permitted to write to the newspapers scaring everybody away from condoms, with the false statistic that it has a 10 percent failure rate, when the truth is that studies have shown the failure rate to be negligible. See box at right.

Some of these letter writers claim to be doctors, and I have often wondered how long we have to wait before the Singapore Medical Association takes an interest in such unprofessional conduct by one or more of its own and considers disciplinary action.

There is still no safer sex campaign targetted at gay men with any meaningful message. In fact, the Health Ministry has an unwritten rule not to be associated with any campaign targetted at the gay community, perhaps because it is afraid of Wong Kan Seng's Home Ministry scolding them for "promoting homosexuality", which as you know, is still illegal in Singapore.

For heterosexuals who enjoy sex, there is no meaningful campaign either. What campaign there is, is always done in a furtive manner, like handing people a leaflet or condom very quietly, which only reinforces the unspeakability and stigma of "promiscuity". As the past 25 years' worth of literature tells us, cloaking the subject with shame is a serious barrier to effective prevention.

This poster would be far too explicit to be allowed in public view in Singapore. The people in power think that (a) it would offend the public with its near obscenity and (b) it would encourage people to have casual sex.

What is left? Abstinence campaigns, which study after study has shown is no strategy at all when it comes to fighting Aids. See salmon-coloured box below. Worse: the abstinence campaigns are mostly left to Christian fundamentalists, who in the course of it cocoon the entire subject of sex with guilt and disapproval.

But what's wrong with abstinence? Surely you can't get infected if you abstain from sex? That's true. For you. What I mean is that telling other people to abstain doesn't work, because people will not listen to you, especially if people sense that you're preaching a religion at the same time. Abstinence is not a strategy.

* * * * *

Constrained as the government is by its ultra-conservative aversion to openly talking about sex, condoms and homosexuality, it reaches for its usual toolkit Ė punitive measures.

In announcing the 2007 data, the Ministry of Health also stressed that,

It is an offence under the Infectious Diseases Act for persons who know that they are infected with HIV not to inform their sex partners of their HIV status before sexual intercourse.

When the Infectious Diseases (Amendment) Act 2008 comes into force, a person who has reason to believe that he has, or has been exposed to a significant risk of contracting, HIV/AIDS must take reasonable precautions to protect his sexual partner, such as by using condoms, even if he is ignorant of his HIV positive status. Alternatively, he can go for a HIV test to confirm that he is HIV-negative. Otherwise, he must inform his partner of the risk of contracting HIV from him, leaving the partner to voluntarily accept the risk, if he or she so wishes.

In simple terms, it will be an offence to have unprotected sex with someone if you are not sure that you're free from the virus.

This law is not without justification. You should use your common sense and not put other people at risk, if you have reason to believe that there is risk. However, in practice, there will be problems:

  • What in the minds of ordinary people (as opposed to legal experts who draft laws) would constitute "reason to believe"?
  • Wouldn't people still feel that they'll never be caught? "It won't happen to me" is a very common belief.
  • In order to ensure they're not traceable, wouldn't the law then nudge people towards anonymous, casual sex?

Basically, punitive actions cannot have much effect in matters of intimate private behaviour, and to expect a law like this to make much difference is unrealistic. Yet our government seems to prefer the punitive route, perhaps because it's the path of least resistance. There are well-trodden paths in halting the epidemic, with good results in other countries, except that the sex-phobia and moralism of this government will not allow us to take these paths.

Instead, it is using punitive action as a substitute for doing nothing else. I'll wager that the infection rate will continue to rise. 

© Yawning Bread 


Why "10% failure rate" is false

Check out this website, which unlike so many others, is not associated with the fanatic anti-sex religious rightwing:

It tells you that "Condom failure rate" as an expression is "often imprecisely used to refer to a percentage of women who become pregnant over the course of a year in which they reported using condoms as their primary method of birth control, even if they didnít use condoms every time they had sex."

"10% failure rate" means simply that one in ten of these women, who had sex numerous times through an entire year, sometimes with condom, sometimes not, found themselves pregnant.

What sort of statistic is that?

In contrast, studies with couples, one of whom was HIV-positive and the other HIV-negative found that condoms protected the HIV-negative partner very effectively. "Among those who used condoms consistently, there were 0, 1.1, and 1.0 seroconversion per 100-person years" in the three studies respectively.

That is, if 100 HIV-negative partners had sex with their HIV-positive partners many times over a course of one year, on average, only 1 among that 100 would be found to have been exposed to the virus.

If we assume that those 100 partners had sex twice a week, or 100 times a year, then there would have been 10,000 intercourse events. On average, only 1 such event resulted in the transfer of the virus to the partner. That, surely, is not what you would call a 10 percent failure rate, is it?

The caveat is that you need to use the condom correctly. That's the easy part actually. People can be taught that, and through practice get very good at it, even in the dark.

The only thing is that to teach it, we need to be relaxed about talking about sex, demonstrating how it's done, and also be uninhibited about buying and handling condoms.

Singapore seems to be determined to do the opposite. By glorifying abstinence, we cast sex into shame and embarrassment. So if people don't know how to use a condom properly, whose fault is it?


Do abstinence programs work?

This 2002 paper by Douglas Kirby for the National Campaign to Prevent Teen Pregnancy examines critically claims made by Robert Rector of the Heritage Foundation that "abstinence education programs for youth have been proven to be effective in reducing early sexual activity". The Heritage report identified ten studies it said demonstrated that abstinence-only programs can reduce sexual activity among youth.

Kirby cautioned that in this area of research, many studies "are not based on generally accepted standards of good research, and therefore little can be learned from these studies about the impact of these programs on actual behavior."

When he subjected the ten studies cited by Heritage to vetting for their design, he found serious deficiencies. In conclusion, Kirby wrote: "Of the ten studies identified by the Heritage Foundation paper as providing proof that their respective programs reduced early sexual activity, nine of them failed to provide credible evidence ... that they delayed the initiation of sex or reduced the frequency of sex.

"One of the studies suggests that the program, Not Me, Not Now, may have delayed the initiation of sex among youth 15 and younger, but not among those 17 and younger."



  1. Source: UNAIDS 2008 report
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  2. Source: Xinhua/Chinaview report 26 Feb 2008 New HIV cases record high in Hong Kong
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  3. Source: Avert.org website.   
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  4. Source: Biotecheast website.  
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