Mr K Kesavapany
Director of Institute of Southeast Asian Studies,

Distinguished Guests,

Ladies and Gentlemen,

Global Situation

About a year ago, Singaporeans were informed that we faced an AIDS epidemic. Our local epidemic is but one small component of the global AIDS epidemic.   While the war against AIDS continues worldwide, there have been few successes and everywhere many battles are being lost. There are now more than 60 million people who have been infected with the HIV virus. In the US alone, despite the country's massive resources and the scientific expertise located in CDC at Atlanta, more than a million people are HIV infected and the numbers continue to increase.

Closer to home, in Asia, AIDS is growing at an explosive rate in both India and China. The Chinese Vice Minister Wang Longde was quoted as saying that the epidemic in China is spreading from high risk groups to ordinary people. India is expected to overtake South Africa as the country with the the largest number of HIV infected persons. In Southeast Asia, WHO has sounded the alarm over the AIDS situation in Malaysia. The head of UNAIDS, Peter Piot spent World AIDS day 2005 in Indonesia to highlight Indonesia as the next frontline state.

To understand what the future holds for Southeast Asia, we need only to look at Sub-Saharan Africa.  Sub Saharan Africa is today burdened with an enormous social, human, economic and developmental cost as a result of AIDS. AIDS is the leading cause of death in Africa and in some countries the life expectancy gains of previous decades have been lost. If Southeast Asia does not bring AIDS under control, within a decade, it will face the same problems that Africa faces today.

ISEAS Forum

 I would like to commend the Institute of Southeast Asian Studies for recognizing the great danger that AIDS poses to Southeast Asia and for organizing this forum which will provide a common platform for the exchange of information on policy development and initiatives to prevent HIV/AIDS. Today"s forum looks at "Gender issues and HIV/AIDS in Southeast Asia."   While it is good to compare practices in different countries and learn from one another, we must be aware that the strategies that are appropriate for one country may not be appropriate or applicable in another.

There are several reasons for this:

HIV prevalence exponential curve and resource allocation

First, the prevalence of HIV infection in a country usually  increases exponentially with time.  Not all countries are at the same point on this exponential curve.  Japan is close to the starting point of this curve with an extremely low infection rate in adults of less than 0.1%. In comparison to Japan, the rate in Singapore is several times higher at 0.2%. But Malaysia's rate is double that of Singapore's at 0.4% while the US has a rate that is triple that of Singapore's at 0.6%. The prevalence rate in Thailand and Cambodia are about 5 to10 times higher than Singapore with rates around 1% to 2%.  The prevalence rate affects how countries with limited resources allocate their budgets. They have to decide how much should be spent on treatment and how much on prevention.  Money spent on treatment helps current sufferers while money spent on prevention reduces future problems. When the prevalence rate in a country is high, the needs of those infected are so over-whelming that there may be fewer resources left for prevention. Countries therefore have to make tough decisions on their resource allocation.

Different patterns of infection

Second, the pattern of HIV infection can be different. For example, in China, drug abuse is responsible for 41% of HIV infections and illegal blood selling for another 23% of cases. In Malaysia, more than half of the HIV infections are attributed to the sharing of needles. In contrast, in the US, only 21 % of infections are due to drug use. In Singapore, because of our successful anti-narcotic drug measures, about 1% of HIV infection is due to drug use.

Different Health care financing systems

Third, there are differences in Healthcare financing.  In some Southeast Asian countries, the health services are basic but almost free.  In others, like Singapore, the health services are more developed and so a more complex financing system exists that depends in part on government subsidy and in part on compulsory self savings. AIDS patients should be treated like other patients within the health system of a country. But because the health systems are financed differently in the Southeast Asian countries, there will be differences in the way AIDS treatment is funded.

HIV and Gender 

This forum discusses AIDS in terms of gender and so I will discuss the HIV epidemic in Singapore in terms of its impact on children, men and women.

HIV and Children

In Singapore, since 1985, there have been 25 reported cases of children who acquired the HIV infection from their HIV-positive mothers. HIV infection in babies can now be prevented with early screening of pregnant mothers and treatment of those found HIV infected.  It is sad to note that before 2005, less than 30% of pregnant mothers were screened for HIV. However, since HIV testing was made a standard of care during pregnancy at the end of 2004, for the first nine months of this year, about 14,000 women or 98-99% of women seen for pregnancy at the public hospitals and polyclinics were screened for HIV. In the private sector, the screening rates are similarly high. So far,11 women  were detected with HIV. All have been treated with antiretroviral therapy.  Of those who went on to deliver, their babies have so far tested negative for HIV. With antenatal screening, we can eliminate HIV infection in children.

As children grow into adulthood, we must prepare them for a world threatened by AIDS.  Young people need to be educated on the danger of AIDS and taught family values that promote abstinence and fidelity. We must discourage promiscuity and casual sex. Thailand, which has often been praised for its AIDS program, now faces a resurgence of AIDS.  Thailand's leading AIDS activist, Senator Mechai,   believes that the main factor causing the resurgence is the growing appetite for casual sex among Thai teenagers. We should learn from the Thai experience. We must ensure that our AIDS prevention  message does not give the young the impression that casual sex is OK as long as you use a condom. Teenagers are impressionable and an unstructured AIDS prevention program that emphasizes  condom use as its primary message will send the wrong signal to the young.  AIDS prevention education must stress family and community values and make it clear to teenagers that casual sex is wrong. My Ministry works closely with the Ministry of Education on sexuality education in schools.

HIV in Men

HIV infection in Singapore is predominantly a male disease with about 90% of new infections occurring in men. There are two high risk groups - gay men and men who have casual sex outside Singapore.

HIV and Gay Men

Although the prevalence of HIV infection among gays in Singapore is many times higher than that of the rest of the adult Singapore population, HIV is less prevalent in the local gay population than in gay populations in many other countries. In Singapore, 30% of HIV infection occurs in gay men. In the US it is around 68%. In the UK, among those who contracted the HIV infection within the United Kingdom, about 60% were gay.  In Singapore, our data suggests that 1 in 25 gay men is positive. In Thailand, 1 in 4 gay men is positive. The public health challenge for gay men in Singapore is to make sure that gays here do not go down  the  deadly path taken by their colleagues in Thailand. 

Working with gay activists and NGOs

My Ministry has regularly met with gay activists and others with knowledge about the social life of gay men and discussed our  AIDS prevention measures with them. Their input has been valuable. We will continue to consult with them and take in their feedback when developing AIDS prevention programs directed at gays. We realize that AIDS education material will have to be customized for this high risk group. We will work with NGOs like Action for AIDS (AFA) to develop these customized prevention programs. For next year, we have budgeted about a quarter million dollars for this effort.

HIV Self Test Kits

The FDA approved oral fluid based rapid HIV test kit is now available in Singapore. It is a non-invasive, convenient and quick method of testing for HIV without the need for blood taking. The result is known within 20 minutes. In many ways it is like the pregnancy self test kits.    As a pilot project, we are introducing these HIV self test kits at locations where gays tend to socialize. This will empower gay men  to know their own HIV status. I believe that once people know their HIV status is positive, they will take precautions to ensure they do not infect others.

HIV and heterosexual men

The second and larger risk group among men is those who visit sex workers abroad. Our HIV prevention program for sex workers in Singapore has been effective and last year no sex worker tested positive for HIV.  However, these men have casual sex with sex workers outside Singapore and so they are at risk.  We hope to reach this group of men at their workplace through our recently launched AIDS Business Alliance. This is an alliance between the Ministry businesses and the unions and it is chaired by Dr Wang Kai Yuen, the Member of Parliament for Bukit Timah.  Through the AIDS business alliance, we are bringing to the workplace an AIDS education program that will educate workers on AIDS prevention and fight discrimination against HIV positive workers by teaching workers how to work with their HIV positive coworkers.

HIV and Women

Although less then 10% of new infections occur in women, they are a vulnerable group. It is often women with little or no income who are most at risk.  Marriage and the women's own fidelity are not enough to protect them against HIV infection.  Most have been infected despite staying faithful to their partner. Not only are women more susceptible to HIV infection than men, they also bear much of the social burden of this devastating disease.  When the infected men fall ill, it is usually the women, who have to care for the sick, manage the households, meet the financial needs and suffer the stigma.  When she falls ill, there is no one to look after the children and if she dies, the children become orphans. They are known as AIDS orphans. There are 18 million AIDS orphans in the world.  We are starting to have our own AIDS orphans. These women and children need help. KK Hospital will be setting up a "HIV women and children fund" to help these women and children The public can help by donating to this fund. The cheques can be made to KK Women's and Children's Hospital. We will also protect the identity of these women and children to ensure that they can lead normal lives.

HIV prevention in married women

HIV infection in married women can only be prevented if their husbands behaved differently. I am told that, very often, the husbands had not intended to infect their wives and were not aware of their HIV positive status. If these men had known of their positive HIV status, they might have acted differently. MOH is working with GP clinics to make instant anonymous HIV testing available through the use of self testing kits. A person who has exposed himself to the risk of HIV infection will be able to test himself. The doctor will advise the person on how to self test and the result of the test will be known only to the person being tested.  By making HIV testing widely available, we hope fewer women will become infected by their spouses.

Informing spouses
Previously, some wives were not aware of their spouse's HIV status and so they were at risk of the HIV infection. Since July this year, we have informed the wife when the infected husband had not informed her of his positive HIV status. Over the last 5 months, 41 women have been informed by hand-delivered letters that their partner is infected and that they should go to CDC for testing.

Many of the initiatives I have discussed were launched recently. We will need more time to evaluate their effectiveness. In 2004, there were 311 new cases of HIV infection. For the first 10 months of this year, there were 198 cases. We project the total number this year to be around 250 cases. In effect, this year we will have achieved a 20% decrease in the number of new cases. This is encouraging but there is much more that we need to do.
   
 I wish you a successful and fruitful forum.