01 May 2008

HIV hits new high. Solution: punish

Singapore's HIV rates are high compared to neighbouring countries with similar standards of living. Even as infection rates climb, the government has no new ideas. Full essay.


Anonymous said...

it is not very clear whether you oppose penalty in principle, or because it is ineffective; in any case, do you have any solution to suggest?


HanSolo said...

More than 1/3 of the cases are transmitted through homosexual/bisexual intercourse.

This is way above what you'd expect by chance alone.

No wonder many people still have the perception that AIDS is a gay disease.

Yet you're silent on this issue. Any comments on this would be welcome.

Yawning Bread Sampler said...

SgSociety -

Because it is going to be ineffective. Because it's going to lull policy makers into a sense of complacency that they're doing something about the epidemic, when in fact, nothing will change.

Other countries have had successes in dealing with HIV. At one point, Thailand had 140,000 new infections in a year. They reduced it by 90% to the current 14,000 - which is still bad, but a huge improvement. (Then complacency set in and it's going up again).

Taiwan was mentioned in the article - it too reduced its new infection rate recently.

Cambodia too.

The solution? The intervention response varies with the mode of transmission. Where the mode is sexual, all successful strategies have been built upon the objective of 100 percent condom use. It means massive publicity, massive distribution, and making the idea of using a condom hip and cool.

For the message to get through, one must build a rapport with one's audience (it's true whether you're selling cars or a soft drink). You must show respect and empathy with the segment of population you're addressing. You cannot insult them one minute and hope to persuade them to buy your message the next.

How does Singapore get it wrong?

1. Refusing to accept the principle of "100% condom use" by prevaricating about abstinence.

2. Ruling out massive publicity and massive distribution. Forbidding condom use to be seen as "hip and cool".

3. Alienating audiences instead of building rapport. They use Christians to talk to non-Christians about abstinence, and the Christians exploit the opportunity to subconsciously sell religion. The govt alienates the gay community through keeping 377A and other discriminatory policies. It treats promiscuous heterosexuals as dirt but maintaining a tone of disapproval over sex outside marriage. Who is going to absorb your message when you treat your audience with such disdain?

Yawning Bread Sampler said...

HansSolo -

No disease affects all segments of the population equally. Hand, foot and mouth disease (HFMD) affects young children most. Diabetes affects Indians and Arabs disproportionately. Nose cancer is almost always confined to people of southern Chinese ancestry, and breast cancer affects women far more than men (in case people are wondering - men have breast tissue too).

Depending on which country you look at, HIV has different profiles. In Taiwan, Malaysia and Yunnan, for example, injecting drug users are way, way, disproportionately represented in the statistics. Across Subsaharan Africa, heterosexual females are the biggest affected group.

Even in Singapore, you can slice data in many ways. It's true that gay men appear to have an incidence rate about 3 or 4 times higher than straight men. But it's also true from the same data that the Chinese have a per capita HIV rate about 4 times higher than Indians.*

(And HIV is unknown among gay women so you could say heterosexual females have an infinitely higher incidence rate compared to homosexual females).

However, as you pointed out, one slice of it gives people cause to think of Aids as a gay disease, but since that impression is but a selective artefact of the data (and ignoring gay women too), why should I be obliged to focus on it? Why am I not asked to comment on how HIV in Singapore is a disproportionately Chinese disease? Or a disproportionately male disease?

The intervention principles are the same, as described in my above response to SgSociety, so I'd much rather deal with the HIV threat on the basis of broad principles that apply across the board.

* See racial breakdown of HIV stats and racial piechart of Singapore residents.

Anonymous said...

Alex, you are usually very analytical and numeric when you talk about trends and data. But in this case, you seem to be strangely reticent about the fact that infection by heterosexual between 2003 and 2007 had gone up by 44%, but during the same period, infection by homosexual had gone up by 225%.

Care to comment?

Anonymous said...

By having discriminating laws like S377A and denying the safe sex message to gays and anything that could depict gays as normal, should the government or any thinking person be surprised to see much a higher infection rate among gays? Don't kill the messenger. This is what will happen for any disease if you do the same thing to any sub-group of the population. What is there to gloat about?

Yawning Bread Sampler said...

anonymous 01 May, 21:31 -

Indeed the figure for homosexual transmission is climbing very seriously and more so than heterosexual transmission and I don't hide it, though the fact that I write about HIV tells you I am concerned that our govt and society don't care enough about it. But I don't have enough information about the 'why' to comment on the difference.

The Ministry of Health statement had a cryptic remark that "When differentiated by sexual orientation, a higher proportion of homosexuals had their HIV infection detected via voluntary screening compared to heterosexuals (29% vs 5%).

The rest were discovered when already ill.

This difference is consistent with the pattern seen in previous years in that homosexual men come forward for screening more readily than heterosexual men, and may be a reason for the higher numbers in the statistics.

The corollary is that there are a lot more heterosexual men out there who are HIV-positive, who are not captured in the statistics.

I doubt if this fully explains the difference, but again, what other explanations... I don't have the answer. It is not my style to speculate without basis.

Anonymous said...

Thanks Alex for the reply - anonymous 01 May, 21:31 here.

If what you said about the MoH's comment abot voluntary screening is correct, then the true situation is even scarier. If there had been more voluntary screening among heterosexuals, then the infection rate may be much higher than that shown. And now with kids and teenagers getting infected, are we sitting on a time bomb?

Anonymous said...

i hope you agree that gays need to do more to protect themselves from HIV; if they are not doing this voluntarily, then some form of compulsion from some authority is needed; the question is which form of compulsion is more effective and less unacceptable


Yawning Bread Sampler said...

anonymous 01 may 08 21:31 (same as 02 may 08 11:12)

I'm glad at least one more person sees how serious the situation is becoming.

A blind study done in 2007 found that about 1 in 350 persons in Singapore is HIV-positive and does not know it himself. See this essay.

SgSociety -

Why are you singling out gays in your comment?

Weiye said...

sgsociety overlooked an important problem in the HIV/ AIDS debate. People keep harping on the fallacy that HIV/ AIDS is a gay disease and they failed to realize that such thinking actually reduces their risk perception.

The more people (especially the non-gays) think that HIV/ AIDS is a gay disease, the less they perceive themselves to be at risk. This is already so over-proven in communication researches on the disease.

And I believe that lower risk awareness leads to the greater participation in risky activities and lower voluntary screening rates.

It's a serious problem. Unfortunately, the society prefers to dwell on the sexuality discourse and not on the core of the problem. HIV does not recognize whether you're straight or gay or bi or male or female. Start recognizing that everyone is equally at risk. It is then, and only then, will we be able to devise appropriate solutions.

Anonymous said...

why? those with higher infection rates need to take the problem more seriously

but if it would make you happier: since infection is also increasing among non-gays, government measures to increase detection should also be considered; what kind of compulsion would be needed, and which measures would be more effective and less unacceptable, are unfortunately beyond my domain of expertise


Anonymous said...

Hey Alex - interesting data, and I still see nothing substancial in our official press...

I like to slice the data this way:

114 married man are newly infected, almost 1/3 of all man cases. WOOW! Since very few woman in Singapore have AIDS, its quite easy to conclude that they got infected when engaging with prostitutes from other countries, either in Singapore (Geylang, etc), or "overseas" (in Batam etc).

Now THIS is the biggest threat to society, family, etc - and follwing your assumption that this rate is vastly underestimated, it is a REALLY BIG THREAT. I think we can safely multiply this group. Becasue, its quite obvious, a gay person would often check their status, a married man would really rather avoid that.

So what would be interesting is to get a better data set on this side of the problem, and discuss how to tackle this problem.... fingerpointing at one group that is obviously overrepresented in this statistics for obviuos reasons is realy not helping much. But isnt this exactly what the health minister did last time if I remember correctly?


Robert L said...

Dear YB

Sorry to chip in so late. I have one nagging doubt over your use of data. Hope you could revisit the matter.

The data used is the absolute numbers of HIV infection in Singapore. However, we know that the resident population is increasing over the same period. Even more important, the increase of population tended to concentrate on the sexually active range of age, since a major contributer to the population increase is the foreign labour.

So if the increase of HIV cases is compared with the corresponding increase of the resident population within the sexually active age, I'm very sure you'll find that the rate of increase has not been so alarming.

Yawning Bread Sampler said...

Robert L - your point about the population base steadily increasing and what that means for incidence and infection rate is valid. However, it needs to be clarified that when the govt uses the word "resident population", they mean citizens and PRs only. They do not mean "resident" in the normal sense of the word. Persons here on Employment Passes and Work Permits are not considered as "resident" and are therefore, I believe, excluded from the figures.

Robert L said...

Dear YB

Thank you for your clarification.

You are perfectly correct, the MOU press release did indeed specify that the numbers are for citizens and PR. (moh.gov.sg/mohcorp/pressreleases.aspx?id=18958) Therefore foreign workers are not in the figures.

Sorry, I hope I have not caused any confusion to your readers.

Robert L said...

Dear YB

Excuse me, but I'm having second, no third thoughts about this matter. Blame my good nature for having agreed too readily with your response. I hope I'm not being a nuisance.

We are agreed that the aids figures are for the local citizens and PR, and that the figures are rising.

We also realise that the local resident population has been boosted in a very significant way by foreign workers. Now let's not dismiss this factor so easily.

I don't have the figures, so I'll just speak my mind with some imaginary numbers. If for example, the foreign workers have grown from, say, 100,000 to 800,000 over the same period, doesn't it make sense that the aids figures will also grow due to interaction with the large increase of foreign workers? The thing is, workers are also the exact age group who are sexually active. So the 800,000 foreign workers could be as impactful as 1.6 million locals.

When we see the aids figures increasing, it could be due to the natural result of these population numbers instead of any hunches that the aids education is losing its effectiveness. In fact, my gut feeling is that the aids figures have been increasing less than what pure arithmetics would suggest.