HIV: Time for the Medical Community to Move Forward

Abstract

1 December 2008 marks the 20th anniversary of World AIDS Day. The HIV epidemic was first recognised in 1981. Twentyseven years on, there are 33 million people living with HIV worldwide. Last year there were 2.7 million HIV infections and 2 million AIDS-related death. In Asia, an estimated 5 million people are living with HIV as of end 2007.1 In Singapore, the first HIV seropositive case was documented in 1985. Locally, the number of HIV infection is increasing significantly. Last year, there were 422 new cases identified compared to 357 in 2006. As of October 2008, there were 382 diagnosed HIV cases bringing the total close to 4000.2 The revised recommendations issued by the US Centers for Disease Control (CDC) in 2006 focused on increasing routine HIV screening of patients in healthcare settings to achieve earlier detection of HIV infection. Previous CDC and US Preventive Services Task Force guidelines for HIV testing recommended routine counselling and testing for persons at high risk for HIV and for those in acute-care settings in which HIV prevalence was >1%.3 In February 2007, the Ministry of Health (MOH) carried out an unlinked anonymous HIV seroprevalence survey in 5 public hospitals which showed that the prevalence of undiagnosed HIV infection was 0.28%.4 MOH has recently recommended an expanded HIV testing including providerinitiated HIV testing or opt out HIV testing in hospitals in Singapore.5 World Health Organization (WHO) guidelines on opt out HIV testing in healthcare facilities recommend testing for all patients, irrespective of epidemic setting, if their clinical presentation might be related to HIV infection. In addition, testing is recommended as part of medical care for all patients attending health facilities in generalised HIV epidemics (areas where HIV is firmly established in the general population defined if the HIV prevalence in pregnant women is over 1%). WHO guidelines recommend that opt out testing should be offered more selectively in concentrated and low level epidemics. Similar to the US CDC recommendations, WHO recommends that testing must be accompanied by a package of HIV-related prevention, treatment, care and support services. Likewise, efforts should be made to ensure that supportive policies need to be in place to benefit patients as well as minimise potential harms to patients.6 It is essential that there should be a critical review of opt out HIV testing in Singapore. This should include an analysis of patient acceptance, follow-up and linkage to care, any effect on length of stay in the hospital or access to medical care for primary medical condition, additional tests or effects, false positive results, as well as the cost effectiveness of this screening strategy. Hospitals currently drafting their own individual policy should be guided by principles of patient confidentiality, voluntary process, informed consent, adequate training of healthcare personnel involved in HIV testing, counselling as well as linkage to care and treatment. The Health Promotion Board (HPB) has increased its efforts in HIV prevention campaigns and at the time of this paper, MOH is reviewing its policy on subsidy of antiretroviral drugs.7 However, more work needs to be done specifically in relation to HIV stigma and discrimination. HIV-related stigma and discrimination are the greatest barrier that prevents individuals from finding out about their HIV status and therefore preventing them from receiving treatment and care for themselves as well as for their partners. A recent survey conducted by the HPB showed that there are widespread negative attitudes within the general population against people living with HIV. Only half of the 1768 respondents would care for an infected relative, and one fifth would share a meal with someone who has HIV.8 In relation to the healthcare professional’s attitudes and behaviour regarding HIV, there have been 3 published studies and at least 2 unpublished studies done in Singapore.911 The studies were conducted in 1987 and 1996-1997 when the reported number of HIV infections in Singapore was relatively low.2 The results of those studies showed significant stigmatisation and fear of treating people living with HIV. In 2008, a survey of 80 medical and nursing students in their first and second year of training was conducted on their attitudes and beliefs regarding HIV