SPEECH BY
DR BALAJI SADASIVAN, SENIOR MINISTER OF STATE
Ministry of Foreign Affairs
AT THE 6th SINGAPORE AIDS CONFERENCE
ON SATURDAY, 8 NOVEMBER 2008
AT SUNTEC CONVENTION CENTRE
Dr Lim Suet Wun, CEO of NHG
Invited speakers and distinguished guests,
Ladies and Gentlemen,
Two years ago, when the Singapore AIDS Conference was last held, 357 Singapore residents were newly diagnosed with HIV/AIDS. Last year, there were 423 new cases. In the first nine months of this year, we already have 345 new cases. We expect this year s total to probably exceed last year s figure.
Some of this increase parallels the regional increase in the number of new infections. Our region, Southeast Asia, is home to some of the fastest-growing AIDS epidemics in the world, with rapid increases in HIV infections in countries like Indonesia and Vietnam.
The other reason for the increase is a more positive one, namely, that many more people in Singapore are being tested for HIV.
In Singapore, we know that more than half of our new cases are already in a late stage of infection when they are diagnosed. This means that they had probably not been aware of their infection for the past 7 or 8 years, and in that time, they may have unknowingly spread HIV to their partners. During this period, many may have been treated at a hospital but the hospital failed to make the diagnosis.
One of our key strategies to combat HIV is to promote early diagnosis of HIV. Early diagnosis of HIV benefits both the individual as well as society. For the individual, early diagnosis means that he can have earlier access to care and treatment that can prolong and improve the quality of his life. HIV-positive patients also receive counselling on how to protect their partners from infection, so society benefits when such patients act responsibly, and take proper precautions to curb the spread of the disease.
Voluntary opt-out HIV testing in the healthcare setting
In an unlinked HIV surveillance survey carried out among hospital patients last year, the Ministry of Health found that 0.28% of patients who were not previously known to be HIV-positive were actually infected. This is not an insignificant number. This means that about one in 350 patients being discharged from our hospitals was not correctly managed because the diagnosis of HIV was missed.
Such patients may not have been tested for HIV, perhaps because their doctors failed to take a detailed history which is often time consuming. Whatever the reasons for failing to diagnose HIV may be, this is not something our hospitals can be proud of. We need to change the mindset of the doctors in our hospitals. Good hospitals provide holistic care, and every failure to make the proper diagnosis of all the medical problems of a patient, including HIV, may represent a failure on the part of the hospital and the doctor to provide a proper standard of care.
Healthcare facilities represent a key point of contact for people who may be infected with HIV. However, many HIV-infected people may visit healthcare settings for years before they are finally tested and diagnosed with HIV.
The US CDC estimated that a quarter of the over 1 million Americans living with HIV did not know that they were infected, and that people who did not know their HIV status accounted for between 50 and 70% of new sexually transmitted HIV infections in the US. As such, the US CDC issued recommendations that HIV testing should be carried out as part of routine medical care for patients in healthcare settings, similar to screening for other treatable conditions.
In view of the findings of our unlinked survey, and the high proportion of our cases with late diagnosis, we decided that we should have a similar initiative in our local hospitals.
As many of you know, Changi General Hospital was the first hospital in Singapore to pilot voluntary opt-out HIV screening for inpatients just under a year ago. They have shown that it can be done. More than 3,000 of their patients have been screened so far, and around 50 have been found to be HIV-positive. The Ministry of Health has asked other acute hospitals to implement a similar opt-out HIV screening programme for their adult inpatients, and it should be in place in all public sector hospitals by the end of the year. Private hospitals should also study how they can implement opt out testing as this becomes the standard of care.
This screening programme will involve HIV testing being offered to patients who are admitted to hospital. Patients will be given the information they need to make an informed and voluntary decision on whether or not they want to be tested. If they do not want to be tested, all they will have to do is to opt out, and their wishes will be respected.
In this way, we hope to improve the clinical care provided by our hospitals. At the same time, we also hope that this programme will help to normalize HIV testing. By normalising the testing of HIV, we hope to make the ability to diagnose HIV a part of the normal spectrum of diagnostic acumen a doctor or hospital should have. We have to change the mindset of doctors in our hospitals so that they become better doctors with a holistic approach to patient care.
Fighting stigma
HIV is a complex disease, and many of the challenges we face fighting this disease stem from the stigma associated with it. This stigma makes people think twice about getting a HIV test, because they fear the social and economic consequences they may face if they are found to be HIV-positive. I want relate two true stories of the kind of stigma patients face.
There was a HIV-positive factory worker who had worked for his company for many years. When his employer began to enquire about why he had to go for regular medical appointments, he replied honestly that it was for his HIV condition. His employer wrote to his healthcare provider asking if he was fit to continue in the job. However, in spite of repeated assurances from his physician and social worker that he could continue working, his employment was terminated, even though his employer considered him a good worker.
Then there was a HIV-positive teacher who, after telling his principal about his condition, was relieved of his teaching duties and reassigned to administrative work. He was also told not to share food with his colleagues, even though we know that HIV is not transmitted through food. This teacher has been trying every year to return to his teaching job, but the principal has told him that unless there is a change in his HIV status , he will not be allowed to do so. Those of you who have worked with HIV-positive patients will be familiar with such stories.
HIV-related stigma and discrimination in our society is a real and disturbing problem. The National Behavioural Surveillance Survey on HIV/AIDS carried out by the Health Promotion Board (HPB) in 2007 found that fewer than a quarter of respondents would share a meal with a person living with HIV, or buy food from a shopkeeper or hawker living with HIV. These results are not surprising. Despite HIV being in our vocabulary for the past 27 years, there is still a lot of fear about it.
Misconceptions about HIV abound, and these form the foundation of a lot of stigmatizing behaviours. People also tend to associate HIV with marginalized members of society sex workers, or drug users, for example and therefore think that if they have nothing to do with such individuals, there is no need for them to know anything about HIV, and even less reason for them to accept anyone living with HIV. We have to work hard to change this mindset.
Consequences of stigma
The theme of this conference is very apt because truly, to fight the disease, you need to also fight the stigma. Since this epidemic first began, stigma and discrimination have been major roadblocks on the path to effective responses. In many communities, HIV-infected people suffer adverse consequences of stigma and discrimination, such as social ostracism, abandonment by family and friends, and loss of jobs and property. Fear of these consequences makes it less likely for people to come forward for testing, to access treatment, care and support, or to adopt HIV preventive behaviours.
Changing mindsets
In order for us to successfully control HIV, we have to create an environment where such fears are reduced to a minimum, and hopefully even eradicated. We are well aware that as we continue to promote HIV testing, more and more positive people will be detected. We have to do our utmost to help change society s mindset, so that people living with HIV will not be shunned, but treated and cared for like any other person living with a chronic illness.
Earlier, I shared with you two examples of HIV-related discrimination in the workplace. However, I am very encouraged by stories of employers who have shown very positive and caring attitudes towards HIV-positive people, like in the case of a HIV-positive patient who was doing administrative work in one company. Looking for a career change, he applied to work in another company. That company had a policy of offering HIV tests to employees, so the patient was faced with the dilemma of whether he should tell them that he was already positive. In the end, he told them the truth, and not only was he hired, but his new job paid a higher salary than his previous job. Such employers serve as positive role models for other employers to emulate.
More than 90% of people living with HIV in Singapore are adults in the prime working ages of 21 to 59 years. We have therefore identified businesses as a key target audience in our educational efforts against HIV-related stigma.
Workplaces can and should create a supportive environment to change mindsets and promote greater understanding of HIV/AIDS among working adults. Support from senior management and HR officers is critical for this to succeed. Members of the AIDS Business Alliance aim to highlight this, and raise support among their peers through an upcoming workplace poster campaign. It is important for employers to realize that people living with HIV can still lead a regular life and continue to be active and productive workers. The campaign will encourage working adults to know their HIV status, and aims to create a supportive environment for not only those at risk who may be infected, but also for those who already know that they are infected.
We have also worked with the Singapore National Employers Federation to set guidelines on managing HIV infection at workplaces. The guidelines advocate the provision of HIV education at the workplace, as well as provide guidance on the management of HIV-infected workers at the workplace.
HPB has also rolled out several initiatives to address HIV stigma and increase HIV awareness in the general population. Some of you may have already watched the Chinese drama serial By My Side , currently showing on Channel 8. This show was conceptualized to raise awareness on HIV, and to dispel the myths and misconceptions surrounding this disease. We hope that this dramatization of the struggles faced by people living with, and affected by HIV, will strike a chord with the viewing audience, and encourage them to adopt more accepting attitudes towards people with HIV.
Another project initiated by HPB is the Positive Living community arts project, which is currently touring the heartlands and community places. The focus of this project is on dispelling the myths and misconceptions about HIV and about people who are living with HIV.
Conclusion
To win the battle against HIV, we require not just the government and parliamentarians to play a role, but also healthcare professionals, businesses, community and religious organizations. But most importantly, we need every ordinary citizen to do their part, to learn more about HIV and know how to protect themselves. At the same time, we hope that they will open their hearts, and support those who are living with HIV, so that those who may be infected will not hesitate to come forward for testing, treatment, and counselling.
We all have AIDS, if one of us does. That was the message of a campaign launched a few years ago by international shoe designer Kenneth Cole. That slogan was emblazoned on a black-and-white photograph of 25 prominent AIDS activists, among them former President Nelson Mandela, Elizabeth Taylor, Richard Gere, Will Smith and Tom Hanks. Their message was to show solidarity in the fight against HIV/AIDS and the destructive stigma associated with this devastating disease.
The fight against stigma must be at the centre of any AIDS response. I hope that with time, we can change the public s mindset, and I look forward to the day when a person s HIV status does not define how he is treated by society.
I congratulate the Organizing Committee of the 6th Singapore AIDS Conference for putting together a comprehensive and stimulating programme covering a wide range of topics, and I am sure that many valuable insights will be gained from this conference.
To all of you here today who have dedicated yourselves to fighting the battle against HIV/AIDS, I salute and thank you for your tireless and inspirational efforts.
Thank you for inviting me to speak at this conference, and it is now with great pleasure that I declare the 6th Singapore AIDS Conference open.
Thank you.