Law change in S’pore to nudge more with HIV to get tested, treated

Currently, 85 per cent of those living with HIV in Singapore know they have the virus, said the Ministry of Health. PHOTO: ST FILE

SINGAPORE - A recent law change that removes the requirement for some people living with the human immunodeficiency virus (HIV) to disclose their condition to their sexual partners, provided they maintain an undetectable viral load, will help Singapore meet global targets to end HIV as a public health threat, said health experts.

This is because the amendment to the Infectious Diseases Act that passed in Parliament on March 7 is likely to encourage more individuals living with HIV to get tested and start treatment, said Assistant Professor Dariusz Piotr Olszyna, director of the HIV Programme at the National University Hospital.

The Joint United Nations Programme on HIV/Aids’ (UNAids) 95-95-95 targets for 2025 emphasise viral suppression among HIV patients, with 95 per cent of people living with HIV/Aids knowing their status, and 95 per cent of this group undergoing treatment. The third goal is for 95 per cent of people undergoing treatment to be virally suppressed.

Currently, 85 per cent of those living with HIV here know they have the virus, said the Ministry of Health (MOH). Of these, 94 per cent are on HIV treatment and, among those on treatment, 94 per cent have achieved viral suppression, the ministry said in response to queries.

Essentially, Singapore’s main challenge in meeting UNAids’ 2025 targets is to get more people who may be living with HIV to come forward to be tested, which the legal amendment incentivises, said Assistant Professor Rayner Tan at the Saw Swee Hock School of Public Health.

“The fact is that the first 95 (per cent) is the most important, and stigma has been a key challenge to getting people tested,” he said.

This is a point recognised by the authorities: The 2023 National HIV Testing Recommendations state that the Republic needs to, in particular, improve efforts to meet the first UNAids target, and that more needs to be done to increase the uptake of HIV testing.

Prof Tan noted his research found that key populations vulnerable to HIV have been fearful of testing because of the current laws.

“With the updated exemption, it incentivises people living with HIV to stay on treatment and monitor their viral load regularly,” he said.

“If everyone did this, we can expect zero HIV transmission and zero new cases of HIV arising from local transmission thereafter.”

MOH told The Straits Times that it aims to achieve the 95-95-95 targets, and is working with partners such as the National Centre for Infectious Diseases (NCID) and non-governmental organisation Action for Aids (AfA) to implement initiatives that increase access to testing and care for people who test positive for HIV, and to make antiretroviral treatment more affordable.

HIV drugs were included in the Standard Drug List and Medication Assistance Fund scheme in September 2020 to lower the cost of antiretroviral treatment, it noted.

“We are lowering barriers to testing through anonymous HIV test sites, making HIV self-testing kits available at pilot sites, and rapid HIV testing at GP (general practitioner) clinics,” added MOH.

On what else needs to be done to tackle HIV transmission in Singapore, experts said overcoming public stigma of HIV is key.

Dr Wong Chen Seong, director of the National HIV Programme at NCID, said discrimination is still a pressing problem for people living with HIV, and may discourage those at risk of infection from getting tested and diagnosed.

“It is critical that we continue to work to reduce HIV-related stigma and discrimination at every level of society, through efforts to increase awareness and understanding, as well as encouraging individuals, organisations and the community at large to be more welcoming of all persons, regardless of HIV status,” added Dr Wong.

AfA president Roy Chan said laws that specifically criminalise the possibility of HIV transmission have not been shown to reduce the spread of HIV.

Instead, the prospect of prosecution and public shaming should one fall foul of such laws results in people putting off testing and treatment and in continued HIV transmission in the community, he said.

Another UNAids target for 2025 is for fewer than 10 per cent of countries to criminalise HIV non-disclosure.

To benefit from the amended law, which has yet to take effect, people living with HIV will have to have maintained an undetectable viral load for at least six months.

They must also have test results showing an undetectable viral load dated nine months or less before the date they have sex, and must have adhered to their medical treatment during this time.

The law will continue to criminalise HIV non-disclosure for people living with HIV who have not suppressed their viral load.

This is as the aim is not to relax public health safeguards against HIV transmission, but to encourage infected people to come forward to be tested and treated, thereby better protecting their sexual partners, Senior Parliamentary Secretary for Health Rahayu Mahzam told Parliament during the debate on the amendment.

“Irresponsible behaviour that can lead to the transmission of HIV remains an offence in Singapore, and appropriate enforcement action will be taken as required,” she said then.

askST: Can HIV-positive people under treatment spread the virus?

The Straits Times speaks to infectious disease experts on what the recent legal change means, and how Singapore is tackling human immunodeficiency virus (HIV) transmission.

Q: What is an undetectable viral load?

A: When a person is infected with HIV, the virus will replicate in their bloodstream and attack the immune system, said Dr Wong Chen Seong, director of the National HIV Programme at the National Centre for Infectious Diseases (NCID).

By taking a blood sample, a doctor can find out how many copies of the virus there are per millilitre of blood. This measurement, called the viral load, lets people living with HIV and their doctors determine how well antiretroviral therapy is working.

A person who is not on treatment will have a viral load that ranges from thousands to hundreds of thousands of copies of the virus per millilitre of blood. A person who has been taking his medications is expected to have a level of virus so low that it is below the threshold of detection by laboratory tests, also known as an undetectable viral load.

Q: How do HIV medications work? Are they subsidised?

A: HIV medications, also known as antiretroviral therapy, work by preventing the human immunodeficiency virus from replicating in the cells of the infected person, said Dr Wong.

This prevents the virus from attacking the immune system of the infected person, allowing him to return to a good state of health.

Currently, almost all HIV medications are taken orally every day. There are medications administered as long-acting injections, but these are not suitable for the majority of people living with HIV, said Dr Wong.

The most commonly used medications are subsidised and are on the Standard Drug List maintained by the Ministry of Health. Singapore citizens and permanent residents can use MediSave to pay for the medication. Singaporeans who cannot afford subsidised medication can rely on MediFund.

Assistant Professor Dariusz Piotr Olszyna, director of the HIV Programme at the National University Hospital, said that with government financial assistance schemes in place, the clinic has no Singaporean patients who cannot access medication due to cost concerns.

Q: Can those with an undetectable viral load spread HIV?

A: Multiple large, international studies have all showed that a person living with HIV who has achieved and maintains an undetectable viral load – or less than 200 copies of the virus per millilitre of blood – does not transmit the virus to his sexual partner.

Under the amended law, HIV patients must meet this requirement of less than 200 copies per millilitre of blood for at least six months, based on test results from a recognised laboratory, to be exempted from disclosure.

They must also have test results showing an undetectable viral load dated nine months or less before they have sex, and they must have adhered to their medical treatment during this time.

Assistant Professor Rayner Tan at the Saw Swee Hock School of Public Health noted that in July 2022, the World Health Organisation (WHO) published guidelines that recognised unequivocally that people living with HIV with an undetectable viral load cannot transmit HIV through sex.

“We are now encouraged by the WHO and UNAids to avoid using terms of ‘effectively’ or ‘virtually’ no risk because it should just be ‘no risk’,” said Prof Tan.


Q: How much do viral load tests cost? How often are they required?

A: The cost for HIV viral load tests is subsidised for Singapore citizens and permanent residents, under the same framework of healthcare financing assistance that covers other medical conditions. Each test is around $140 after subsidies at NCID.

A person living with HIV is expected to undergo these tests about twice a year, the same frequency as their regular consultations with their HIV doctors.

NCID’s Dr Wong said: “HIV infection is now treated as a manageable chronic disease, and much like other chronic diseases, patients will have regular follow-up visits with their healthcare provider.”

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