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5 Mar 2010

Singapore's HIV/AIDS treatment dilemma: Multi-pronged strategy needed

Most of the medications used in first and second line therapy of HIV in Singapore are not subsidised by the government and can cost up to US$1,000 per month; while many new life-saving, life-changing treatments are not available in Singapore. HIV/AIDS needs to be treated like any other disease with regards to treatment, says Dr Stuart Koe, CEO of Fridae and long-time AIDS activist.

Bloomberg BusinessWeek reported yesterday that Francoise Barre-Sinoussi, winner of the 2008 Nobel Prize in Medicine for her co-discovery of the virus that causes AIDS, criticised Singapore for the lack of free treatment of HIV, saying this added to the stigma and burden of being HIV positive, and very likely drives the disease further underground. 

She compared Singapore to her home country of France and developing countries where HIV treatment is free, and said the situation in Singapore is "very difficult to accept". "The situation is even worse than in developing countries not far from here. In Cambodia, everything is free."

In Singapore, the cost of HIV treatment is high because generic versions of commonly prescribed anti-retrovirals are not available. And the reason generics are not imported here is because of TRIPS, an agreement to protect and enforce intellectual property rights, in particular those of the largest pharmaceutical companies, which in turn are one of the largest contributors to Singapore's economy by industry. According to the Biomedical Sciences Factsheet 2009 published by the Singapore Economic Development Board, the Singapore government has invested in more than S$5 billion (US$3.5 billion) in building up the industry and in turn, the biomedical sciences industry in 2008 contributed S$19 billion (US$12.7 billion) or 7.6% of Singapore’s total manufacturing output. So why provoke the ire of Big Pharma when we've already done so much to woo them here? Think of how much revenue they generate for Singapore!

All would have been palatable if Singapore actually used some of that revenue generated by Big Pharma for treatment and care of our HIV patients. Instead, none of the medications used in first and second line therapy of HIV are on the "General Sales List" - i.e. the list of medications that is subsidised by the government. So patients now have the double whammy of having to pay full price, and for the branded originals.

It is common practice here for patients to see their doctors at the Communicable Disease Centre at Tan Tock Seng Hospital (CDC/TTSH), but are secretly, "unofficially", advised to get their medications from either Malaysia or Thailand. In fact, doctors regularly lament the limited arsenal they have in treating HIV patients here, resulting in treatment regimens that are sub-optimal, with little recourse should the first line therapy fail.

How ironic – as Singapore promotes itself as a medical tourism hub, at the same time it’s sending patients to its neighbours to get affordable medication. We either cannot, or don't want to take care of our own.

State of the HAART 

Since the late nineties when "cocktail" therapy, now known as HAART (Highly Active Anti-Retroviral Therapy) became available, a plethora of HIV therapeutics have entered the market. Many are now fairly well tolerated, with regimens simplified to a few pills once or twice a day, compared to virtual handfuls every few hours when the first anti-retrovirals made their debut. Many of these new life-saving, life-changing treatments are not available in Singapore as they have not been registered (see point no. 4 below).

Research now shows that when patients receive appropriate and timely medical intervention, and are able to suppress their viral loads (the main objective of any treatment plan), most HIV patients can live out close to normal life expectancies. In fact, new treatment guidelines indicate that it's almost always better to start treatment earlier rather than wait till the immune system fails, and many are leaning towards starting treatment as soon as diagnosed, in order to halt the progression of HIV in the body.

Some mathematical modeling even suggests that treatment is a form of prevention, seeing that patients who have a low or undetectable viral load are effectively non-transmitters of HIV. Some research suggests that if everyone who tests positive can receive immediate treatment and adheres to it, it is possible to eradicate HIV in a matter of years.

What all this means is HIV/AIDS no longer spells "TERMINAL" as it did in the 80's and 90's. Yet, Singapore is effectively condemning HIV positive people here to such a fate without access to life-saving therapy. With costs going up to S$1500 (US$1,070) per month for medication alone (not including clinic visits and lab tests), this is out of reach of many Singaporeans. 

Even the Ministry of Health's announcement in January this year that MediFund could be used for some HIV medications is of little consolation to most HIV patients – in order to activate MediFund, you have to be effectively indigent, or fall below the poverty line to qualify.

In order to get around the myriad of issues and maintain every party’s "interests", a multi-pronged strategy needs to be considered.

1. Adding first line therapeutics to the GSL so that a majority of HIV patients can have subsidised treatment, even if they are the branded, more expensive versions.

2. Subsidising the cost of laboratory monitoring, which is significant. Yet close monitoring is an essential component of good clinical care.

3. Importing generic versions of selected drugs under a special exclusion criteria, to be administered solely through CDC/TTSH so that this is no longer done through underground "buyers clubs".

4. Expanding the selection of therapeutics available to clinicians so that they can practice at a level which is state of the art, not third-world standards. This has to be done by accelerating the drug registration process, and perhaps waiving the registration fees – the costs and time to register these drugs here are not worthwhile for distributors and pharma companies because Singapore is ultimately a small market.

In any analysis, the benefit of returning fully functional HIV positive people into contributing members of the economy far outweigh the costs. The solutions suggested above still fit within Singapore's way of doing things and don't really break any rules or challenge any sacred cows. They are simple, practical solutions which could save many lives. 

Most importantly, and I believe this will be the crux of the matter: We need to treat HIV/AIDS just like any other disease. The administration needs to follow its own rhetoric. Only then can we have a rational response to an increasingly urgent need – the rising numbers of HIV patients for whom we need to care for. 

Dr Stuart Koe is founder and CEO of Fridae. He holds a Doctor of Pharmacy from the University of Minnesota, specialising in HIV therapy and is currently a Board member of Hong Kong’s Aids Concern (since 2006), a founding Trustee of Singapore’s Action for AIDS Endowment Fund (since 2003), and a long time AIDS activist, having also served on AfA’s Executive Committee for several terms (since 1998). Prior to founding Fridae in 2000, he worked at the Economic Development Board where he contributed to laying the groundwork which resulted in significant investments in the Life Sciences as a key pillar of the Singapore economy.


Reader's Comments

1. 2010-03-05 18:41  
As someone who is outspoken about my own HIV positive status I have had people from Singapore seek me out when visiting Bangkok so they could disclose to a friend, a peer, that they are HIV positive, and I know other men from Singapore who travel for to Bangkok for anonymous treatment because they feel unsafe seeking such treatment at home.

I'm not an expert as to what the solutions are, but I admire Fridae.com for connecting us to each other about these issues.

As for my own campaign, it continues. Please check out the video in my profile of "The Power To Be Strong" HIV testing/safer sex anthem.

Have a great day!
2. 2010-03-05 21:30  

Would be good to have seen an immediate gov. response to these recommendations, in the article. Did no one phone up the Health Ministry for a comment on why they are letting people die unnecessarily, or is that not done in Singapore?
And what about this report that suggested everyone would be able to afford the drugs - what happened?
Comment edited on 2010-03-05 21:50:52
3. 2010-03-05 22:32  
Dont you all get it??? singapore governments members are sooo communists thinking or in some areas of how the singaporeans lives under those ANCENT politicians way of dealing with the HIV issues (as if the government there really think there are no hiv positive people living in singapore at all or HIV+ just dont deserve any treatment because its a gay virus ?? i feel sorry for the hiv positive guys or gals there.... until their governments elects some new screwed on members to starting dealing with this ISSUE ... or i am just frighten to imagine some dying hiv positive have to leave singapore to go die elsewhere?? sad... !!!!!!!!do something about it singaporeans...
4. 2010-03-05 22:37  
i have posted the above message simply out of self opinion and feel for those who are living in a very wealthy country and should deserve free if not subsidised hiv treatment .. not as any of personal attack..........i have somehow have personally heard from some very very upset and disturbed singaporean friends who have seeked refuged in medical assistance in other countries ...
5. 2010-03-06 02:25  
Indeed, Singapore is unique in this respect. It is the only advanced nation that doesn't subsidise HIV medication. It is the only advanced economy to keep sodomy law and ban gay societies.

The reason why I bring up sodomy law and gay societies in this discussion is to emphasise the link. Even if the government subsidises HIV treatment, we can't succeed in the fight against HIV itself if the government continues to criminalise gay sex and ban gay societies. The government must change its attitude. It's kept these poor policies which obstruct our progress in the fight. To succeed, it should do all three: allow PLU to register and work with it directly and closely to reach out to the LGBT community, repeal 377a and subsidise HIV treatment. Better still, it should introduce Comprehensive Sex Education in all schools after consultation with SECULAR educators, parents, and foreign experts. Learn from the success of Holland and other European countries that had seen their teenage pregnancies, STDs and HIV rates gone down, showing a clear correlation between CSE & these indices.

It's unjust to leave the HIV patients out of our healthcare financing system. We must treat every citizen as a part of our nation, and make policies based on justice and equality. Denying one class of patients of their rights to obtain subsidies for their most basic medical supplies is unjust. Worse, while most other diseases may be covered under the standard medical insurance plans, HIV and STDs are excluded. If one can't obtain reimbursement from insurers, and is denied subsidies from the government, how is he going to pay for his basic medical supplies? The government should either cover HIV under medical insurance plans or subsidise the treatment costs, or, better, do both.

This will remove the fear of going for regular screening for HIV. Many people who are sexually active refuse to go for screening because being diagnosed of this disease is so dreaded that they'd rather choose to avoid. When something is so fearful, people may choose to avoid it in order to not face it. This psychological factor presents a big obstacle in the fight because if people get HIV without knowing it and continue to act the way they had been acting that caused their HIV infection in the first place, then they will continue to spread the disease to many others unknowingly. A person with HIV may not have any symptoms for more than 10 years. If he doesn't find out about his infection during these years he may spread it to many others who, in turn, spread it to more others. This explains why we must create an environment which presents less fear for people to go for regular testing and medical treatment. The financial burden of living with the disease must be manageable.

6. 2010-03-06 03:38  
7. 2010-03-06 05:41  
Well, any nation state that forces conscription upon SOME of its citizens is already lacking in true consideration and equality for all her citizens - in this regard, turning a cold, blind eye on + citizens is indeed a modern disgrace, but thoroughly in keeping with Singapore's continuing and long-lasting international reputation of being a Benign (friendly) Dictatorship.

It's a pity - no, a tragedy - that + people get Nothing from the state, there, whereas (for example, here in Ireland) other first-world countries have a policy of free medicine, treatment and counselling/support for positive citizens, as well as accepting positive people from other states to live here (such as a significant number of Positive Nigerians in Ireland, for example).

But, well... Singapore's government has proven time and again in various issues that as long as the citizens knuckle down and do what they're told, it's really not bothered about its poor reputation (for many reasons) amongst her international peers...
8. 2010-03-06 08:20  
just had a chat with another singaporean friend after reading this forum, its so educating reading and knowingly there are many other countries in the world are so accommodating and supporting of + citizen and some whom have seeked medical refuge elswhere. singaporean government some how gave me the impresssion that they are very proud and carrying with this traditional confusious (YU JIA) way of thinking... brings back the tragic memories of the SARS when many many infected cases and deaths been covered up and not reported to WHO organisation so necessary prevention or education be introduced until it had hit hong kong and other asian coutnries that caused thousands of lives.. place like hong kong had learnt a very expensive lesson and continued carrying out extreml hygiene precaution in many public place like shopping mall, train station etc.. and i know for fact that they have an exellent system in supporting those in need of support and hiv+ medication at a very very affordable price to their citizens and those who are permanent resident reside in hong kong. Sunthenmoon made a very valid point.. the fear of those who cant disclose themselves or tests and unaware of their status, and lack of educational campagnes and supports...spreading to many many many more is just beyond imaginable........sighhhhhhh!!!!
9. 2010-03-06 09:33  
I have been supportive of my friends who are HIV+. Some issues stated here are incorrect.

1. The Singapore Government is caught between the big pharmacetical companies who invested in billions of dollars into Singapore on R&D and the need to provide health care to Singaporean HIV sufferers. To allow generic drugs into the market will affect this investment, vital to the economy. Think that by not actively preventing generic HIV medications from entering Singapore, we as Singaporeans should be thankful and not rock the boat at the moment. It will make the life of Singaporean HIV sufferers worst off.

2. From unconfirmed sources, Singapore has successfully developed her own HIV, viral load and blood count testing. I was told by HIV+ friends that it is promising and will be available at a fraction of cost in Singapore middle of this year. If this is true, it will benefit not just Singapore but the whole world.

The problem in Singapore is that there is no dialogue between the advocates and the Government. In fact the government is suspicious of AFA of other agendas as the whole organisation is prominently gay. The Singapore Government allocate funds based a sound statistics. Due to the stigma associated with HIV, there is no sound statistics but guessworks. This is unlike other desieases like cancer or diabetes, where statistics are more than 95 % accurate.

From what I know, no one who seek treatment at TTS/CDC has been turned away and left to die. Its difficult and frastrating at times as the answers are not straight forward from them, but the doors are always open and those who still succumb to HIV are those who seek treatment too late.

My take on this issue is this, be safe and get yourself tested. If you are negative, stay that way. If postive, seek treatment immediately.
Comment edited on 2010-03-06 10:00:55
10. 2010-03-06 10:29  
Excuse me, but there are no homosexual men in Singapore and if there were they would be immune to such deviant entities as the HIV virus. I dont know what this woman is going on about
11. 2010-03-06 12:08  
Just another indicator that Singapore is STILL in the dark ages. When will the powers that be realize that HIV/AIDS is a global epidemic? When so many countries already provide free medication and treatment, and with Singapore wanting to be a force to be reckoned with world-wide, how is it that the Singaporean government still shortchanges their people???
12. 2010-03-06 12:22  
Just my two cents worth of thoughts. There will always be stigma associated with HIV, regardless whether its in Singapore or elsewhere. The only difference is how pronounce the stigma is. It is the government's duty to look after the nation. They should not be compared to a profit making organisation. What I mean is, while they need to ensure that the economy of the whole nation is being managed, the introduction of generic drugs will certainly not be affected. If there are other developed nations doing it, why not us?
Furthermore, singapore is a financial hub and placing herself in the R&D of bio-medical science. Such contributions could only form a small negligible percentage towards the effect on our economy.

Again, I can't stressed enough the duties and responsibility the government have towards the nation in terms of housing, transport, healthcare and economy.

Desnseaus, this is so true, we are sort of adopting the "Don't ask, don't tell" attitude for now but I believe all these will change as the newer generation of GLBs seems to be more vocal and active in partaking in issues close to our heart.
13. 2010-03-06 16:43  
Compulsory conscription, death penalty, over regulated by government, very little freehold property, being gay still illegal, and now dicsrimination against HIV+ve people - who would live in Singapore? - No wonder so many get out and find freedom! -
14. 2010-03-06 17:22  
One topic that was overlooked is the christian element at play here. As we know, the Singaporean government has been infiltrated by evangelical Christians (I stress evangelical), who hold high positions of power and who have a poor track record in dealing with gay issues.

While the government and pharmaceutical companies are working against the gay community, we cannot neglect the need to be responsibility, which a fair number of us aren’t. How infuriating is it every time we hear a story of someone who loses control of his senses off some A-level drug, only to bareback and contract HIV. Because of his actions, taxpayers are forced to step in and cover the cost of his medication. We never blame ourselves – only governments. Furthermore, we are all familiar with stories of someone who barebacks knowing full well what excellent medication awaits should he contract HIV. When are we going to look inward?

I’m not an apologist for the Singaporean government simply because their policies are driven by homophobia. But I’m starting to believe (although I would never advocate such a position simply because a significant loss of life would occur – how many people can actually avoid $1000/month for medication?) that government funded medications are the cause of high HIV rates.

Yes, the developed nations of Asia, Europe, and North America provide free medication. What isn’t mentioned in this article is that HIV is also on the rise in all of these places. HIV is growing in Montreal, Toronto, London, Taipei.

In the early 90s HIV rates were falling in the developed world. Unfortunately, such is no longer true.
15. 2010-03-06 17:52  
Instead of digging its head in the sand, ignoring AIDS patients and their miseries, the appalling Lee government would be well advised to seek advice from the Council for the AIDS Trust Fund, Centre for Health Protection,Department of Health, in Hong Kong.
For how long will AIDS patients, in this miserable puny island, have to feel they are on death row ?

16. 2010-03-06 21:15  
Singapore is NOT an advanced nation-period!.

The self appointed government mole, anti-gay kampong tart, gymhotbod, is back it seems to spread more propaganda. Do no pollute these forums with your unconfirmed sources and repeat history again with all your self appointed knowledge of "inside" information on anything. You are spewing trash as usual. The world certainly DOES NOT need more new methods of testing, we need a CURE. That's a no brainer.
You can always reprise your role of posting with several nicks again to rally self support. This is from confirmed past sources. Zzzz.

domacyan & sunthenmoon are correct to observe that backward Singapore is run by vile x-tian fundies and are behind many legislation that attack the healthy homosexual profile from media to medicine to education. Many things are very wrong in Singapore currently and until the people of Singapore takes the proactive mandate of voting OUT this dictatorship, nothing much will improve.

Meanwhile, the only sustainable way for those needing meds will have to depend on runners or go buy them themselves in Bangkok or Malaysia. My best wishes to our Singapore GLBT brothers & sisters on staying and keeping well. Don't hold your breath to depend on the Singapore government for anything. You are much better off finding a support group and managing your own life with meds. Many are doing it, you can too. Good luck. God speed to better health.
Comment edited on 2010-03-06 21:34:48
17. 2010-03-07 00:41  
All I can say is that the Sg Gov is economically advance but socially conservative. While advocating science and technology, social precepts and awareness has remained in the middle ages.

It beats me that the MOH is expending gargantuan efforts to promote health screening and health promotions with regards to chronic diseases such as cardiac disease, diabetes, osteoporosis and dementia. Of course we all know the rationale is health economics - investing $X today to prevent disease A saves you $10X in the next 20 years by reducing costs associated with disease A complications.

Makes sense?

Errr isn't HIV also a chronic disease? If osteoporosis is managed as a chronic disease with the acceptance that there will be occasional acute relapses (fall and fractures) needing hospitalisation, can they not see HIV as a chronic condition to be managed and the need to treat occasional acute flares (i.e. AIDS defining disease?)? Viewed in this way, is HIV not the same as treating osteoporosis, diabetes and heart failure?

And there are a lot more diabetics than HIV+ve folks. And anyone who knows a diabetic relative will tell you that diabetes management is not any cheaper - heavy pill burden, insulin injections, managing added complications such as cholesterol problems, eye problems and foot care. Not to mention the time spent in screening, self monitoring of blood glucose and blood tests. Of course the difference is that diabetic patients and insulins are all heavily subsidised - at least in the public setting for citizens.

So if the same can be extended to HIV, there is a chance. But no. Theres the irrational thinking that HIV = sexual transmission = Promiscuity = Guilty = You are at fault = You deserve it. Meaning HIV = You deserve it. Thats pretty lame really when you consider that lousy diet, sedentary lifestyle and couch potato behaviour = weight gain = higher chance of obesity = higher chance of diabetes. Will anyone then say diabetes = obesity related = lousy diet and lifestyle = guilty = you deserve it and diabetes = you deserve it? Is this justification for not reimbursing treatment? Of course not. Utter nonsense.

But HIV just gets labelled with the sex thing and the powers that be can't seem to get down the moral high horse. The consequence is our HIV+ves run off to MY and TH to seek treatment and buy HAART drugs. Shame shame when we even dare boast of a world class health system that stigmatises certain group of chronically ill people.

Just some technical clarifications to the article. The term "GSL" or "General Sales List" actually refers to drugs that can be sold without supervision of a pharmacist or medical practitioner. This is as opposed to prescrition only and pharmacy only medicines. In the context of the article, subsidised drugs under the national scheme are labelled as "Standard List I" (heavily subsidised) and Standard List II (50% subsidy). Of course all the registered HAART drugs are currently "Non Standards". By the way, it is MOH that determines what goes into the standard list.

I know Stuart raised the point that doctors have their hands tied as certain drugs are not registered yet in Singapore. In actual practice, we do have patients with diseases that require certain drugs that are not licensed and registered locally but are brought in for treatment under an "exemption status". Of course the approval of the documents allowing for import of "exemption status" drugs lies with the powers to be. No prizes for guessing the decision with regards to exemption drugs for treating HIV.

But all is not bleak. I am confident that if we continue to push for and educate, eventually, we will get the HIV treatment reimbursed to a certain extent. So for a start, lets all raise awareness of HIV as a chronic disease that needs to be managed life long and AIDS as acute attacks associated with HIV that can be treated. This way, we stop seeing HIV as being a terminal thing. Otherwise, you will have to label osteoporosis and diabetes as terminal as well.

But you won't do that will you?
18. 2010-03-07 03:32  
TRIPS agreement are not designed to protect and enforce intellectual property rights, in particular those of the largest pharmaceutical companies.

On the contrary, TRIPS are design so that governemnt can issue compulsory licenses to manufacture generics ARV even if the pharmaceutical industry still has license on the drugs.

It is these TRIPS that Thailand has used to manufacture its generics at the heavy cost of being bullied by the USA.

If Singapore wants to produce cheap medicine it can.
Comment edited on 2010-03-07 03:34:40
19. 2010-03-07 09:42  
The people who posts their comments here are not helping to get PLUs in Singapore to get themself tested. Is that what most in Fridae is trying to do here ?

I spend my free time who are HIV+ people. Those that I know who succumb to HIV are those who are afraid to get tested and for treatment at TTS/CDC.

Talk all that you can here. While some try to save lives, there are those who simply wants HIV to spread further in Singaopre for other agendas.

Get yourelve tested , be safe, responsible and stop the spread of HIV.
20. 2010-03-07 10:30  
We all have a responsibility for talking and addressing HIV and ensuring prevention treatment care and support remains a top priority and advocated for at all levels.

Time that the SG gov started to pull its head out of the sand and look at the evidence all around.

As Stuart rightly points out other far less developed countries are light years ahead in terms of free treatment for its people. Even Thailand has programs that provides treatment for displaced and migrant populations this is seen as a necessary and cost saving public health intervention.

21. 2010-03-07 12:45  
#18 TRIPS is indeed for protection of intellectual property rights. However, in 2003, in what is known as the Doha Declaration, there was strong opposition from developing countries on the grounds of making pharmaceuticals more accessible to countries in need that could not afford them, and thus exceptions were made for *developing countries* to have generic versions without violating TRIPS.

Singapore is excluded from these exclusions.

We are thus in a no-win situation. By virtue of our "developed country" status, we are disqualified from much of the international aid that is available for HIV/AIDS. Everyone assumes Singapore can afford to take care of it's domestic healthcare. But the reality is very little is invested in the prevention, treatment, care & support for HIV/AIDS in Singapore.

Gay men, or MSM in public-health speak, are at an even greater disadvantage. 377A which makes sodomy illegal, is also used as a justification to prevent gay groups from organising, and hence the gay community response is muted, lacks funding, and has very little capacity to mount a scaled up response.

Whilst we are not looking for handouts, it would be a humane start to not discriminate AGAINST HIV/AIDS, and really treat it like a public health issue.
22. 2010-03-07 12:51  
I sincerely wish governments would get out of the human service business and let the private efforts of the market, individuals and charities engage in what they do best.
I resent any level of goverment spending on providing healthcare in any form to individuals.
I am proud to be a member of a private organization that provides in excess of US $750 million annual funding for healthcare provided at no cost to those in need.
Regrettably, the repressive tax sytem that confiscates from workers and earners and gives to others often prevents more charity and in many cases prevents those same workers and earners from even providing health insurance for themselves .
As a business owner it is unfortunate that my needs come last. I have to pay the government first, before I even pay any of my bills and they take more and more each year. I have nothing left to pay for mine, so I run the risk and accept being uninsured until such time as my revenues increase sufficiently to pay for it. I would never expect any public bureacracy to provide care or funding for care.
Comment edited on 2010-03-07 13:06:47
23. 2010-03-07 17:10  
i'm intrigued by this argument that singapore is an advanced, first world economy. for all i know singapore rely its economy entirely on foreign investment, service industry and a reputation for a tax free heaven for corrupt malaysians and indonesians. if one day all the europeans, japanese and especially americans found a new country they can use as a base, singapore will no longer enjoying the status like now. in terms of infrastructure, yes, singapore is world class, but u can say the same to bangkok and KL too, and they even have managed to steal some of these investments already. besides, as Paul Theroux wrote in his book, how come someone acts and speak like a french president when their country is only as big as marseille ?
by having a lot of easy money from foreign investments and corrupt neighbours while not producing anything u can call your own wont qualify u to be advanced or first world. in regards of the discussions, having a first world mentality and awareness is much more valuable than being a rich paternal despot, insecure, and negative abt everything.
24. 2010-03-07 19:53  
AI YA!!!!!!!!!!! How fcked up .. i would encourage anyone who visit singapore and or living in singapore.. go to some well know bookstore in town.. and look around on those educational teaching subjects like.. confucious way of thinking.. ( KHUN ZHI SI SIAN).. 2010 now my dears.. yet still encouraging the so call chinese confucious teaching and thinking... i agree to his family value passed many generations, but i disagree how fccked up his philos in binding up millions of women feet for over thousands of years... and sin government is adopting that way of thinking.. what hopes do the sin's have in terms of HIV/AIDS education or prevention.. its now year 2010 my dears sins.. otherthan the country may have a fantastic system in housing, pension care, superannuation funds etc.. and oh... a sort of freedom of speech in a way...........really.. the governments are very very COMMUNIST
25. 2010-03-07 21:06  
Still waiting for an official response to the sensible recommendations in the article? Any journalists at Fridae with a phone?
26. 2010-03-08 03:29  

As I mentioned earlier, the approval of MediFund for HIV treatment doesn't solve the problem. To qualify under this scheme, a person must be very poor. But the purpose of helping HIV-positive individuals is not to let them be caught in such a situation in the first place. Should we wait until they have spent the last penny in their bank before we help them? I don't think such is the treatment that persons who suffer from other diseases get. So why should HIV patients be singled out?

In regards to Stuart's 4 proposals, I have some comments:

I agree with this. I think a more formalised approach would be for the MOH to allocate an endowment fund for this purpose. The first consultation and the prescribed counselling and medications should be 100% free for every citizen. This is to ensure that people feel more assured to go for regular testing.

After paying for first consultation, the balance in the Endowment Fund is used to subsidise subsequent treatments. Following the first consultation, each HIV patient should be told the treatment options available to them. Should they choose to be treated locally, the costs for subsequent consultations would be subsidised using the balance in the above-described endowment fund.

The subsidies would be rationed according to the person's ability to pay. The level would depend on how much is left in the endowment fund. In other words, the less newly infected citizens there are, the more is left to subsidise the subsequent treatment costs of the surviving citizens. This provides a clear incentive for all HIV patients to work jointly with the government to reduce the number of new cases. By practicing safer sex and duly informing their sex partners of their status as required by law, HIV-positive persons may reduce the chances of infecting others. Every year, a figure for newly infected cases would be announced to the surviving HIV patients, and a report explaining how much subsidies they are entitled to would also be given by a committee. This will provide a clear incentive, because the number of new cases is directly linked to how much subsidies they can get for their local treatments, announced annually.

I also suggest that the government to consider giving the same level of subsidies in terms of dollars to them should they choose to seek treatment in overseas approved facilities on a reimbursement basis. For example, in year 2010, the level of subsidies allocated to John, a Singaporean HIV-positive patient, based on his financial assessment, is $500/month for his subsequent treatments. The same $500.m may be reimbursed to him whether he seeks treatment in Singapore or in an approved HIV clinic in Thailand. Supposed the cost of treatment in Singapore is S$1,200 while the treatment in Thailand is S$400, then he would be reimbursed up to S$400 should he choose to be treated in Thailand, or up to S$500 should he choose to be treated in Singapore. He would pay S$700 from his own pocket and Medisave should he choose to be treated in Singapore, or NOTING should he choose to be treated in Thailand. He would pay for the return air ticket to Bangkok from his own pocket for every consultation instead.

Typically, John would travel to Thailand once every 3-6 months because the doctor would supply him with 3-6 months' medicines each time. The average cost of travelling to Thailand for treatment would be under S$300 per trip. Seeking treatment in Thailand is a much better deal because it helps John to conserve his Medisave and cash savings for emergency use. Which is why the government should encourage John by giving him up to the same $500/month whether he chooses to be treated in Singapore or Thailand.

One important advantage of being treated in Thailand is, by conserving more Medisave, John can cope better with emergency treatments in Singapore. It is also a more economically viable option to outsource our HIV treatments from Thailand because it supplies cheaper generic medicines, has much more experienced doctors specialising in HIV, and is conveniently located at just 2 hours' flight away. With the advent of budget airlines, a return ticket to Bangkok may be as cheap as S$150. Add 2 nighs' accommodation in a hostel, inter-city public transport, food, and travel insurance to this, and the total costs could be under S$250/trip, so the S$300/trip budget mentioned above is quite a conservative one.

This arrangement saves our Trade Minister the trouble of negotiating for exemptions like what Stuart proposes. As long as the generic medicines are not sold on Singapore soil, there is nothing to prevent our citizens from consuming them here.

Further to Stuart's suggestion of the importance of lab monitoring, I propose that our HIV patients obtain lab monitoring and medications from 2 sources. Should timely lab monitoring be required, they could be monitored by a Singapore-based clinic and continue to obtain their medicines from Thailand or India unless they are so sick they can't travel. The most costly component of the treatment package is the medicines. As long as we can have them obtain these from Thailand or India, we can, as a nation, conserve our financial resources to deal with this epidemic.

I think that outsourcing would have to be seriously considered because of a few reasons. First, because of Free Trade Agreement with the United States, and the heavy reliance of US drug companies to sustain our pharmaceutical sector, the Singapore government we may not want to support the sale of generic drugs on Singapore soil. Second, Singapore is essentially a small market, so there is no economies of scale to speak of. Third, we can take full advantage of our superior geographical location to tap into, at low cost, the economies of scale, knowledge bank and healthcare infrastructure of India and Thailand, two countries that produce cheap generic drugs and serve millions of HIV patients.

The key is to encourage our patients to seek treatments in India or Thailand tacitly so that the US drugs companies won't feel being intentionally cut off. We still depend on them to provide employment to thousands of Singaporeans and to drive our pharmaceutical industry. Which is why I suggested that the Singapore government should remain a neutral approach by providing the SAME level of subsidies whether Singaporeans seek treatment in Singapore or overseas, without outwardly promoting either choice. Show the HIV patients the facts-- the respective costs and pros and cons-- and let them make their own choice. As a nation who collectively believe in individual rights, the American drug companies should be able to respect that our HIV patients, too, do have the right to choose where they want to be treated.

Beside making the subsidies available for overseas treatments, the government should quickly work on the following areas:
1- Accreditation of overseas facilities in Thailand, India and/or Malaysia
2- Work out formalised collaborative relationship between Singapore hospitals and the accredited overseas hospitals. For example, the health records of our patients should be shared electronically. The part of lab monitoring could be done by Singapore hospitals while the part of prescribing of medicines and follow-ups could be done at the overseas end. This means that one important criterion of accredited overseas hospitals is whether they have a good electronic health records system that may be linked with external entities.
3- Communicating this HIV Support system to minimize the perceived fear among Singaporeans for the disease. HIV should not be perceived as a death sentence in Singapore should the government want to encourage more Singaporeans to voluntarily go for regular screening.
4-A national campaign targeting at Human Resource professionals should be launch to educate HR managers about the myths and facts about HIV, so that they may not discriminate against HIV patients for no good reason. Certainly, it is understandable that HIV positive persons may not be suitable for certain professions. But they should be able to hold most jobs. One important suggestion is to advise against asking job applicants to reveal their HIV status where it is not occupationally or legally required for companies to know it. If there is no substantial reason for a company to know whether a job applicant is HIV -positive, then it shouldn't ask. The most obvious sector that should lead in this effort to reduce discrimination is the civil service.
27. 2010-03-08 08:02  
Is it true you pay your Health Minister an annual salary of over a million pounds?
28. 2010-03-08 10:05  
hmm. lack of free treatment? yikes, nothing is free and it shouldn't be free, yet it shouldnt cost 1000 USD a month either-- hopefully, a happy medium can be achieved that's affordable and in line with other normal treatments

Singapore is pretty affordable compared to other countries for healthcare and sounds like a good deal, lots of friends going there now for plastic surgery, laser eye treatments and yes buying low cost drugs

in the USA lots of people go to Canada or Mexico and yes even Singapore for lower cost health care and medicines, but maybe an alternative channel can be developed to buy from Thailand or Malaysia--

hmm, even Bill Clinton the USA couldn't tackle this one and Obama has has his hands full with an unpopular health care reform program

as a practicing part time dentist, we have made big strides in reducing gum disease in China and improving overall dental wellness, but its because people's behavior to brush and floss and water quality has improved

but this part time dentist isn't passing out free candy, gum and chocolates on the side with the free tooth brushes

anyway, I have this fetish for nice teeth and good orthodontics

29. 2010-03-08 17:17  
Got the figure. You pay your Health Minister 2.6 million sing dollars (1.25 million pounds) a year. Probably the highest paid Health Minister in the world.

So it's obvious you can afford to subsidise the real drugs at least to the same extent that you do for drugs for other diseases. So what is the official reason given for the (illegal?) discrimination?
Comment edited on 2010-03-08 18:21:58
30. 2010-03-08 19:50  
Dec 1, 2008
Treat HIV like other diseases
Sufferers also deserve subsidies on drugs that help them live normally


The Ministry of Health's argument against providing subsidised HIV medication is that such medicines do not provide a cure.

But the same could be said of medicines used to treat many other illnesses, such as diabetes, where the medicine merely controls blood sugar, preventing it from doing damage to the body.

Another argument is that the Government only provides subsidies for proven medicine. But some HIV medicines have been around for more than two decades and these drugs can no longer be classified as experimental.

The high cost of the medicines is also not a valid reason. Among the more expensive subsidised medicines today is one for hepatitis B. The Government pays half the cost of the medicine, which comes to more than $2,300 a month.

There is an underlying belief that people with HIV have only themselves to blame. HIV is transmitted via bodily fluids, usually through sexual intercourse.

HIV transmissions are more prominent among the gay community. Homosexuality is illegal here, and frowned upon by the majority of society. The more conservative ask whether society is obliged to help people who lead such a lifestyle?


Helping HIV patients through Medifund
Jan 15, 2010 , Posted by Ministry of Health at Friday, January 15, 2010
by Gerard Ee, Chairman, Medifund Advisory Council

I am sure nobody wishes to contract HIV or any other sexually-transmitted disease if they can help it. I believe in this old adage – Prevention is better than cure. It may sound old-fashioned of me, but I believe that we should be faithful to our partners and refrain from having casual sex. Some of the younger and more-pragmatic individuals would also add that to be safe, use a condom during sex, and get your partner and yourself tested for HIV and the other sexually-transmitted diseases.

(Every good to know isn't it?)
Comment edited on 2010-03-08 19:51:23
31. 2010-03-09 00:48  
Thanks Kellen, it helps paint the unbelievable picture. I hope some of these people believe in karma. I expect there is a ton of it headed their way.

I also noticed that the Ministry had announced it would subsidise the medicines, only to subsequently reverse its position (though the Ministry press person denied it was a reversal). The minister was quoted as saying it would "open the floodgates", though I have no idea what was meant by that. Is it possible he wanted to do the decent thing, but was overruled?

By the way I worked out you pay your Health Minister nearly 10x what we pay our Prime Minister (£1.25 million versus £139k). You must have absolutely loads of dosh available for subsidising the medicines.

Some people might be surprised to know what the real biblical definition of "sodomy" is; it's not what you've been led to believe:

"Now this was the sin of your sister Sodom: She and her daughters were arrogant, overfed and unconcerned; they did not help the poor and needy." (Ezekial 16 v.49)

So, I wonder who in Singapore are the real sodomites?
Comment edited on 2010-03-09 03:06:08
32. 2010-03-11 18:56  
Courtesy of the gay uganda blog:

"In a statement marking World Aids Day last December 1, Ban Ki-Moon, the UN secretary-general urged for an end to the criminalisation of homosexuality, which he argued made it more difficult to fight Aids.

THE AIDS PANDEMIC, FINDS A BREEDing ground where the closet door meets the stiff arm of government oppression.
"I urge all countries to remove punitive laws, policies and practices that hamper the Aids response," the secretary-general said in reference to laws that criminalise homosexuality. Because they are criminalised, people assume it acceptable to visit on gays untold forms of violence.
Similar sentiments were expressed by Michael Sidibe, the director of UNAids who said: "As a social movement, the gay community changed Aids from simply another disease to an issue of justice, dignity, security and human rights."
The gays in Kenya have placed Kenya in an enviable position of a global leader in HIV vaccine research."
33. 2010-03-13 02:56  
I wonder what Nobel peace prize-winner Archbishop Desmond Tutu of South Africa would say about a such a rich country as Singapore discriminating in the provision of health care to HIV patients. Here he is, today writing in the Washington Post about discrimination against gays generally, and in relation to HIV health care, in Africa. The discrimination may not be so violent in Singapore, but it appears to be cut from the same cloth, and is, for some people, just as deadly.

“Hate has no place in the house of God. No one should be excluded from our love, our compassion or our concern because of race or gender, faith or ethnicity -- or because of their sexual orientation. Nor should anyone be excluded from health care on any of these grounds. In my country of South Africa, we struggled for years against the evil system of apartheid that divided human beings, children of the same God, by racial classification and then denied many of them fundamental human rights. We knew this was wrong. Thankfully, the world supported us in our struggle for freedom and dignity.

“It is time to stand up against another wrong.

“Gay, lesbian, bisexual and transgendered people are part of so many families. They are part of the human family. They are part of God's family. And of course they are part of the African family. But a wave of hate is spreading across my beloved continent. People are again being denied their fundamental rights and freedoms. Men have been falsely charged and imprisoned in Senegal, and health services for these men and their community have suffered.... Kenyan religious leaders, I am ashamed to say, threatened an HIV clinic there for providing counseling services to all members of that community, because the clerics wanted gay men excluded.
“Our lesbian and gay brothers and sisters across Africa are living in fear. And they are living in hiding -- away from care, away from the protection the state should offer to every citizen and away from health care in the AIDS era, when all of us, especially Africans, need access to essential HIV services. THAT THIS PANDERING TO INTOLERANCE IS BEING DONE BY POLITICIANS [my caps] looking for scapegoats for their failures is not surprising. BUT IT IS A GREAT WRONG. An even larger offense is that it is being done in the name of God. Show me where Christ said "Love thy fellow man, except for the gay ones." Gay people, too, are made in my God's image. I would never worship a homophobic God.
“ "But they are sinners," I can hear the preachers and politicians say. "They are choosing a life of sin for which they must be punished." My scientist and medical friends have shared with me a reality that so many gay people have confirmed, I now know it in my heart to be true. No one chooses to be gay. Sexual orientation, like skin color, is another feature of our diversity as a human family. Isn't it amazing that we are all made in God's image, and yet there is so much diversity among his people? Does God love his dark- or his light-skinned children less? The brave more than the timid? And does any of us know the mind of God so well that we can decide for him who is included, and who is excluded, from the circle of his love?
“The wave of hate must stop. Politicians who profit from exploiting this hate, from fanning it, must not be tempted by this easy way to profit from fear and misunderstanding. And my fellow clerics, of all faiths, must stand up for the principles of universal dignity and fellowship. Exclusion is never the way forward on our shared paths to freedom and justice.”

(The writer is archbishop emeritus of Cape Town, South Africa. He won the Nobel Peace Prize in 1984).

I’ve shortened it slightly, but the whole thing can be read here:


34. 2010-03-14 05:10  
Everything ArchBishop Desmond Tutu said is true but EVIL does not reason nor listen. Only way is removal of such evil asap or persist in the courage of one people to keep on fighting to be heard.

The basic 1st step is to identify and ban deliberate dissenters that pollute genuine efforts to assist the afflicted community with irrelevant chaos disguised as free speech to probate logic. We can start right here in such forums to weed out these troublemakers.
Tolerance for such travesties like gymhotbod, kuman and lagunabro must be terminated-period!
35. 2010-03-17 08:09  
What wrong with you jammyboi ? You do not know how to read ?? The rule here clearly states "Please note: Stay on topic, and be polite. Personal attacks will not be tolerated. Action may be taken against members who do not follow these rules".

By the way, have you read "The Story Of Ah Q" yet ?
36. 2010-04-05 10:30  
I agree thats gay,lesbian, bisexual are a part of human family in Singapore but i dont agree and let criminal free around in Singapore, this guy name Patrick Chin name id in facebook, he already broken teenagres life bcos Patrick Chin already SODOMISE this teenagers in his house and the teenagers is his neighbour. hope you guys can find him and bring him to Police bcos if let him free around in Singapore, he will SODOMISE many children...its CRIMINAL.

Patrick Chin live in Choa Chu Kang, becarefully with this guy...he is criminal and sodomise children. you can see his face on facebook name Patrick Chin. find him and call Police.
37. 2016-02-28 18:38  
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