the act issue 40 by Action for AIDS Singapore

ISSUE NUMBER 40 • JUNE 2010 • MICA (P) 018/11/2009 • FREE OF CHARGE

Cover Singapore AIDS Candlelight Memorial 2010 Photo by Gwendolyn Sim Yanqun

Editor-in-chief Roy Chan Editorial board Braema Mathi Dawn Mok Julie Matthews

Mission Statement “AfA is a caring NGO committed to AIDS prevention, advocacy and support. Our mission is to prevent transmission of HIV/AIDS through continuous education targeted at vulnerable groups; to advocate for access to affordable care and against HIV/AIDS discrimination; and to provide support for PWAs, caregivers and volunteers.”

contents 01 Editorial

02 A Review Of Sexual Behaviour And Epidemiology Of HIV In Men Who Have Sex With Men In Singapore The Act is published by Action for AIDS (Singapore), c/o DSC Clinic 31 Kelantan Lane #02-16 Singapore 200031 Tel : 6254 0212 Fax : 6256 5903 Email : info@afa.org.sg Website : www.afa.org.sg MICA (P) 018/11/2009

09 “Are You Clean” – Twenty-five years on, do we still suffer stigma and discrimination?

The views expressed in this magazine do not necessarily reflect those of the Editorial Board. To help raise AIDS awareness in the global fight against this disease, we encourage reproduction of the articles for non-profit educational purposes. Please inform us first and credit The Act as the source. If you are interested to be on our mailing list, please send us your contact details.

17 World AIDS Day And The Truth About What We Think

ACTION FOR AIDS

13 World AIDS Day Walk – Unmask AIDS Dec 09 13 Tanjong Balai Budget Hotels Outreach 14 Living with... Art Against AIDS Exhibition 2009 15 Love Gala – AfA Fundraising Dinner Event Dec 09 15 Fiesta Famili – Malay Community Outreach in Woodlands 16 Singapore AIDS Candlelight Memorial

19 Deafening Silence 23 More Than An Angel 26 Our ACON Study Trip 28 Projects & Programmes

EDITORIAL fficial figures reveal that in 2009, 463 Singapore residents were newly reported with HIV infection. About 90% of the new cases were males. This brings the total number of HIV infected Singaporeans to 4,404 as of end 2009. Of these, 2,089 persons are asymptomatic carriers, 1,037 have AIDSrelated illnesses and 1,278 have died. Sexual transmission remains the predominant mode of HIV transmission. Of the 463 cases reported in 2009, 449 cases acquired HIV through sexual intercourse, heterosexual sex accounting for 61% of infections, homosexual sex 30% and bisexual sex for 6%. Intravenous drug use (7 cases) accounted for 2% of infections. In 2009 57% of the new notifications already had latestage HIV infection when they were diagnosed. This was similar to the pattern in previous years. Over half of the new notifications in 2009 (57%) had HIV detected in the course of of medical care, 16% were detected as a result of health screening. 9% were detected through voluntary HIV screening, 7% of the cases were detected through screening in prisons and drug rehabilitation centres. The rest were detected through contact tracing and other forms of screening. When differentiated by sexual orientation, a higher proportion of MSM had their HIV infection detected via voluntary screening compared to heterosexuals (20% vs. 2%). This is similar to previous years as well, indicating higher awareness and readiness to go for HIV testing among MSM. Of interest is the 45 female notifications in 2009, representing an increase of 50% from 2008. More than half of them were aged between 20-39 years old, 58% were married and 18% were single. The majority of females acquired HIV through heterosexual transmission. 47% had their HIV detected when they had HIV testing done, in the course of medical care, while another 18% were detected as a result of health screening. 22%

were diagnosed as a result of contact tracing. 51% were diagnosed when they already had late stage infection. The increase in the number of women with HIV is a cause of concern for us – however the increase may be attributed to higher number of women who have gone for testing. We should also bear in mind that the number of female cases has been very low previously, so a modest increase in absolute numbers gives a big percentage change. Nevertheless we should enhance our efforts to reach out to women and girls. In order to do this, AfA has expanded its Women’s Outreach Programme and is collaborating with other women’s groups. Also of note is the fact that the number of new MSM notifications (homosexual plus bisexual) has dropped slightly, from 185 in 2008 to 166 in 2009. While it may be too early to conclude that there has been a reduction in transmission among MSM in Singapore, this trend is also corroborated by a drop in HIV positivity among MSM clients in the AfA ATS – from 5.7 in 2007, 4.7 in 2008 to 2.8 in 2009. The MSM outreach testing project over the last 3 years has also shown a fall in the number of positive tests – from 3.1% in 2007 to 2.6% in 2008 to 1.6% in 2009. If this trend continues it will be clear evidence that our programmes to stem the rising tide of HIV infections among MSM are showing good results. This issue of the ACT features a review of HIV risk behaviour and epidemiology among MSM in Singapore. The paper was prepared with the support of the Ministry of Health and features most of the available information correct to 2007. Data collection on MSM risk behaviour and HIV epidemiology have received significant attention in the last few years and we now have a better idea on risk factors and hence are able to design more effective prevention programmes for various subgroups. Happy reading!

Prof Roy Chan Editor-in-chief

A REVIEW OF SEXUAL BEHAVIOUR AND EPIDEMIOLOGY OF HIV IN MEN WHO HAVE SEX WITH MEN IN SINGAPORE

by Mary Stewart and Roy Chan

When it comes to HIV and Men who have Sex with Men (MSM) in Singapore – stigmatisation, discrimination and criminalisation all pose problems for research, education and interventions. It is not surprising then, that there is little published data on MSM in Singapore with regard to HIV risk behaviour. This is a review of both published and unpublished data. It has been undertaken as part of a Ministry of Health comprehensive review of available data on MSM and HIV risk behaviour, and includes an international comparison.

Figure 1 – Number of new diagnosis by mode of acquisition2:

BACKGROUND According to the WHO classification system, Singapore’s HIV epidemic is ‘low level’1. There is a fear that if the rising number of diagnosis is not addressed it could become a ‘concentrated’ epidemic and, potentially, ‘generalised’. In 2007, 423 Singapore residents (citizens and permanent residents) were newly reported with HIV infection. 93% of the new cases detected were males. Of these 145 disclosed themselves to be homosexual or bisexual (Figure 1). As of the end of 2007 the total number of HIV infected Singaporeans was 3,483. 1,535 persons were asymptomatic carriers, 804 had AIDS-related illnesses and 1,144 had died2. Like most developed countries in the world, HIV diagnosis in MSM in Singapore decreased in the 80’s and 90’s but has been rising in recent data3. Figure 2 – % Diagnosis by mode of acquisition2:

Heterosexual MSN

It is estimated that 2-5 % of males in Singapore are MSM4 and yet they comprise a disproportionate 34.4% of cases of HIV2 (Figure 2). It is estimated that the HIV prevalence in MSM in Singapore is between 0.70% and 3.6%4. In 2007/2008 the seroprevalence at gay venues was found to be 3.12%5. While sex between men is illegal (section 377A of the penal code) it has been stated by government officials that this law will not be enforced6. RISK FACTORS FOR HIV AMONG MSM IN SINGAPORE KABP SURVEYS BY ACTION FOR AIDS The most significant of all the surveys done to date are the Action for AIDS (AfA) Knowledge, Attitudes, Beliefs and Practices surveys. AfA is the main HIV/AIDS NGO in Singapore. AfA have done three large scale behavioural surveys of MSM in 2002/3, 2004 and 2006. The number of responses were 1,295 (2002/3), 1,529 (2004) and 1,479 (2006). The first two surveys were conducted mainly online but also through gay saunas, the HIV Anonymous Test Site (ATS), gay clubs/bars and from the DSC (Department of STI Control) Clinic, which is the only public sexual health clinic. The third survey was done entirely online. The three surveys used differing, although similar, formats. This has led to some difficulties when it comes to comparing responses over time and tracking trends. The recall period for the 2002 survey was 3 months, for the 2004 survey was 1 month and for the 2006 survey was 6 months. OTHER STUDIES, REVIEWS The earliest studies include Paul Van de Ven’s study in 1997 comparing gay men in Singapore and Sydney7 More recent studies that provide information on the current situation include, as yet unpublished, work done by Martin Chio. He shares some useful insights in his 2007 review of HIV and STIs in MSM in Singapore and his qualitative study of MSM in 20078 in which he reports on close focus interviews with MSM who have had a diagnosis of an STI.

AfA produces a publication called ‘The Act’ which has included useful insights into the HIV situation among MSM. The 34th issue focused on MSM, and included articles by academics such as George Bishop of NUS, MSM prevention programme coordinator Paul Toh and professionals in the field of HIV medicine in Singapore. It also provides poignant insights by way of testimonials of HIV infected MSM. The gay web site ‘Fridae.com’ publishes news articles on issues relating to MSM. This is a useful tool for education and intervention. The Annual reports for AfA and the Department of STI Control (DSC) Clinic are also useful sources as is information from the Anonymous Test Site (ATS) run by AfA. MOH CONTACT TRACING DATA MOH officers endeavor to interview all new HIV cases for the purpose of contact tracing. For 2007, 130 new cases of HIV disclosed to be MSM. Of those, 74 were interviewed. The information gained from these interviews provides useful qualitative data on newly diagnosed MSM. FINDINGS HIV KNOWLEDGE AND AWARENESS The 2004 AfA Survey identified vulnerable MSM subgroups including the less well educated, the young (below 21) and ethnic minorities. There was a lack of knowledge about condom use, appropriate lubricants and inaccurate risk assessment of HIV transmission11. In comparison, the 2006 AfA Survey showed a higher level of awareness of HIV and how it is transmitted: 97.8%; but this did not necessarily translate to safer sex practices12. Chio highlights a serious concern regarding the number of young MSM being diagnosed, indicating that education, awareness and prevention programmes have not been effective in reaching out to this group. His 2007 dissertation highlights a lack of knowledge and awareness of STIs/HIV, at the time of sexual debut: “subjects had limited awareness, knowledge and exposure to STIs/HIV education”8. An alarming statistic from Wong’s informal survey of newly infected MSM is that 86% of newly diagnosed HIV positive MSM claimed they were not provided information on AIDS/ STIs during their school days10.

Other interesting studies include a gay sauna survey done by Daniel Tung in 20079, although it was on a small scale (only 61 respondents), and the informal survey of newly infected MSM done by Brenton Wong in 200710. This survey was done through ‘Club Genesis’, an AfA support group for HIV positive MSM.

CONDOM USE BY MSM In his 1997 report Van de Ven found a much higher rate of unprotected anal sex among Singapore’s MSM compared to Sydney’s. Around half the Singapore men who had anal intercourse with casual partners had at least one unprotected instance in the past 6 months7.

A seroprevalence study done in 2007/8 by Roy Chan et al gives vital figures on seroprevalence of HIV among MSM who visit gay venues. It also gives some useful information on HIV testing history and demographics5.

In Bishop’s study in 1996/97, Sexual Practices Among Men Attending an Anonymous Testing Site in Singapore, he found that of MSM 25% reported unprotected receptive anal sex and 32.8% unprotected insertive anal sex13.

In the DSC 2006 Annual Report, figures showed that there is still a high prevalence of unprotected anal sex among MSM attending the DSC clinic. Over 50% did not use condoms for anal sex. 99% did not use condoms for oral sex14. By comparing the 3 AfA Surveys, it is evident that condom use has increased since 2002 but unprotected anal sex is still significant. Protected anal sex has increased amongst the respondents, rising from 19.6% in 2004 to 42.69% in 200612. Available data from 2006 AfA Survey shows of the 81.3% who reported having anal sex during the last 6 months 48.9% consistent condom use with regular partners and 67.2% with casual partners in the last 6 months12. These figures are similar to international data. (Figure 3) Figure 3 – % of MSM having unprotected anal sex (international comparison): (*AfA survey 2006 data)12

Condom use in saunas is of particular interest, especially in light of the higher prevalence of HIV found in sauna patrons compared to other venues in the recent study by Chan et al (4.13% HIV prevalence in saunas compared with 2.63% in bars)5. In the 2007 sauna survey by Tung 2007, the majority (67.3%) of respondents who had anal sex did not use condoms consistently and a significant number (16.4%) did not use condoms at all. Only 32.7% used condoms 5 out of the last 5 times they had had anal sex9. Looking at the AfA 2006 survey, Koe noted that knowing one’s partner prior to the encounter was the highest risk factor for not using condoms regularly. Other common reasons cited were that it feels better without a condom, impulsivity, the perception that the partner was healthy due to appearance, and alcohol and drug use12. The AfA survey data for HIV positive MSM in 2004 indicated possible evidence of serosorting. Of those who had unprotected sex, 65% reported it was with a regular partner, 35% reported HIV testing as a decisive factor11. Chio reported other reasons for not using condoms including the belief that sex with a condom was not as “intense, close or intimate”, self esteem issues, lack of negotiation skills, especially if the person was the “bottom” and complacency about HIV infection. Sexual impulsivity was also mentioned, as was a mistaken belief that if the sexual partner did not use or insist on a condom being used then he must be HIV negative. Unprotected sex with a regular partner after both having a negative HIV test was also common8. In Tung’s sauna survey, the most common reason cited for use of condoms was ready availability of condoms and lubricants in the sauna9.

US Data: Unprotected anal intercourse was reported by 58% with a main male partner and by 34% with a casual male partner15. Australian, 2006 Sydney GCPS data: 55.4% of men surveyed who had anal sex with a regular partner in the previous 6 months had not used a condom, 20.8% of men surveyed who had anal sex with a casual partner did not use a condom16. Hong Kong, 2006 HIV Prevalence and Risk behavioural Survey of Men who have sex with men (MSM): Consistent condom use with regular partners in past 6 months: 41% Consistent condom use with casual partners in HK in past 6 months: 73%17. UK, Sexual Health Survey of Gay Men London 2005: 50.3% of men had unprotected anal sex in the last year with either casual partners, regular partners or both. 28.7% had unprotected anal sex with casual partners. 22.2% had unprotected anal sex with discordant partners or partners of unknown status18.

HIV TESTING Awareness of the AfA anonymous test site has risen from 37% in 2002/3 to over 90% in 200612. The US CDC guidelines recommend annual STI screening for MSM19. Data from the AfA Survey 2006 showed that 81.3% of respondents had ever had an HIV test, however only 46.9% had been tested in the last 12 months12. This is equivalent to the testing rates in the UK18 but far below the US20 and Australian figures21,16. A study from Hong Kong reported only 24% had a test in the last 12 months17. Figure 4 – % MSM testing for HIV in last 1 year (international comparison): (*AfA survey 2006 data)12

US Data: The results indicated that >90% of participants had ever been tested for HIV. Of those, 77% had been tested during the preceding 12 months, i.e. 70%20.

Figure 5 Number of sexual partners over past 3 months for 2002, 1 month for 2004, 6 months for 2006 from AfA surveys24

Australian data: 80% of respondents had ever had an HIV test, 40-50% in the past 6 months21. Sydney GCPS 2006; of HIV negative men 63.4% tested in past 12 months16. Hong Kong data: 48% had ever been tested, 24% had been tested in the past 1 year17. UK data: 46.8% tested in the past 1 year18. There was an increase in those ever tested, from 60% in 2003 survey to 80% in 2006 survey12. We also have testing data from the 2007/8 seroprevalence study at gay venues. 53.2% of participants had tested before, 27% were testing for the first time, the majority of whom were in the 20-29 years age group, and 35.5% had tested in the last 12 months5.

Figure 6 – Where do MSM find partners? (AfA surveys)24:

Many international studies have shown that sexual behaviour changes after HIV diagnosis. The majority of HIV positive men adopt safer sex behaviours after diagnosis22, hence the impetus to increase testing and diagnosis. This is supported in Chio’s qualitative study: after diagnosis there was a “drastic change in sexual practices, with almost 100% condom use”8. NUMBER OF SEXUAL PARTNERS In Chio’s qualitative study he comments that multiple partners and frequent partner change are determinants of HIV/STI acquisition. He reveals that the number of lifetime sexual partners of his subjects ranged from 10 to more than 1008. In his seroprevalence study of STIs among MSM in 2004/5 50.5% had over 20 lifetime partners23. From the AfA surveys (Figure 5), there appears to be a reduction in the number of recent sexual partners among the surveyed population. There were fewer respondents who reported more than 10 recent partners in 2006 than in 2002/3 and 2004. From the MOH’s contact tracing data the majority of index cases reported multiple partners, some as many as >100 lifetime partners25. USE OF THE INTERNET TO FIND PARTNERS Since the turn of the century the Internet has become a common source of information and networking opportunities. The Internet is seen to be a safe and anonymous environment and, given that MSM behaviour is illegal in Singapore, this is especially important for MSM . There are several websites/portals catering to MSM. Results from the 2006 AfA survey show that the Internet was the most common way for Singaporean MSM to meet: 53.3% of respondents used the Internet to find sexual partners (Figure 6). Most sexual activity then occurred at home12.

The MOH contact tracing data of newly diagnosed MSM confirms that many of the men used Internet chat rooms to find partners. These men also frequented saunas, clubs and bars25. Aside from being a source to find partners, the Internet is also a useful tool for education and interventions. AfA has intervention programs in chat rooms and through gay portals. The Internet was reported as the main source of information on STIs and HIV by MSM attending the AfA ATS and the DSC Clinic23. USE OF ALCOHOL AND OTHER DRUGS The use of recreational drugs such as Ecstasy, ketamine , methamphetamine (crystal meth), gamma-hydroxybutyrate (GHB), marijuana, volatile nitrites (poppers) and erectile dysfunction medications have been significantly associated with unprotected anal intercourse, multiple partners, having sex with casual partners and HIV infection26. The use of recreational drugs among MSM appears to be less of a problem in Singapore (Figure 7) than other developed countries (Figure 8)16,18. However, Data for 2004 showed that those respondents who were HIV positive were more likely to have used alcohol and drugs during sex than those who remained HIV negative24.

Figure 7 – Alcohol and Drug use during sex, AfA surveys24:

Chio reported that alcohol and recreational drug use was mentioned by some of the participants in relation to inconsistent condom use8. The 2006 AfA survey revealed that 39.6% of those MSM who found partners in clubs reported inconsistent condom use, the reason “too drunk or wasted” was cited as a common reason for this12. OTHER SEXUALLY TRANSMITTED INFECTIONS (STIs) The presence of STIs increase the likelihood of acquiring and transmitting HIV infection27. The AfA Surveys asked which STIs respondents had ever had. The 3 main STIs reported were pubic lice, gonorrhoea and anogenital warts24.

Figure 8 – % MSM having sex under the influence of drugs: (*AfA survey 2006 data)12,16,18

The 2004 AfA survey compared history of other STIs for the HIV positive men with the HIV negative men. It was found that the HIV positive cohort reported a higher incidence of other STIs, especially syphilis (Figure 9)11. MSM STI data is available from the DSC clinic annual report. Of the 28,438 patients attending the clinic only 444 (1.5%) disclosed to be MSM. Of these 68 % were diagnosed with an STI. The most commonly diagnosed STI was gonorrhoea14. Considering that it is estimated that MSM make up 2-5% of males in Singapore there seems to be under-representation of MSM among the attendees of the DSC clinic. In Chio’s seroprevalence study: 25% reported a previous STI and 20% were found to be positive for at least one of HSV2, HIV or Syphilis. Of the 19 cases positive for Syphilis 13 cases were unaware that they had been, or were, currently infected with syphilis23.

Figure 9 – STIs, HIV positive compared with HIV negative MSM, 2004 AfA survey11:

YOUNG MSM Young MSM have been identified as being at greatest risk of contracting HIV infection. The 2006 survey of newly infected MSM revealed that 93% had their first sexual encounter at age 25 or below, and the most frequent way of meeting their first sexual partner was through the Internet. Only 50% used condoms on their first penetrative anal encounter, thus possibly establishing future sexual behaviour of unprotected sex10. Chio’s seroprevalence study supports the data of young sexual debut. 48.5% of MSM had their first sexual encounter below the age of 21. The first episode of anal intercourse occurred a few years after they became aware of their sexuality and was unprotected23. In 2006 the largest group of MSM attending the DSC clinic was in the 20-29 year age group14. The 2007/8 HIV seroprevalence study at MSM venues found that bars were more popular among the younger MSM than saunas5. Chan comments that “the younger MSM (below 25) were more reluctant to participate in the study, often stating that they were afraid or did not want to know their HIV sero status”.

Figure 10 – Testing and multiple partners correlated with age: (AfA Survey 2006 data)

MALE SEX WORKERS (MSW) There is very little information available on male sex workers in Singapore. An expose was shown on the television network Channel News Asia in 2006 entitled “$50 Men” about male foreign workers selling sex to men in Little India. This is a group that are difficult to reach. They are an economically and culturally vulnerable group that do not, necessarily, identify as MSM. As well as those working on the streets, there are known establishments both in Singapore and in neighbouring countries where male sex workers operate. However the number of MSW operating at any one time is not known. MOH contact tracing interviews have also elucidated the use of chat rooms by male sex workers to find clients25.

Young MSM are at particular risk, having multiple partners and little awareness of testing. The 2006 AfA survey shows that those below the age of 20 years old were the most likely to have had more than 5 partners recently and least likely to have ever had an HIV test or be aware of testing availability (Figure 10)24. HIV POSITIVE MSM There is very little data on the sexual behaviours of HIV positive MSM in Singapore. AfA’s support group, Club Genesis, provides counselling and support to HIV positive MSM. In a survey to assess the effect of the ‘cell meetings’ on sexual behaviour, Meyer reports that those who had attended counselling sessions in cell meetings reported fewer sexual partners after counselling28. Unfortunately, the fear of loss of privacy that many HIV positive people have limits reach and effectiveness of intervention programmes targeting HIV positive persons. BISEXUAL MEN Bisexual men are a bridging group for HIV transmission between the MSM community and the heterosexual community. There have been recommendations that this group needs to be more closely studied since Bishop’s study in 1996/7. That study suggested the need to develop targeted interventions for bisexuals, particularly with respect to unprotected sex with women29. In the 2002 retrospective study on MSM patients attending the DSC clinic 31 % identified as bisexual, 20.3% reported their last sexual partner was female, of these 55.9% reported not using a condom30. The AfA surveys have given some information about sexual orientation and identity. In 2002/3, 16.3% of respondents self-identified as bisexual, although, actually, 20.9% reported sex with women. Of these12% of the men surveyed had had unprotected sex with women. In 2004, 16.7%, and in 2006, 14.2% identified themselves as bisexual24.

MSM IN PRISONS AND DRUG REHABILITATION CENTRES (DRC) Currently, inmates in prisons and DRCs are screened for HIV. If positive they are segregated. Between July 2005 and December 2006, 980 inmates were screened, of whom 12 were found to be HIV-positive (1.2% prevalence)31. In 1995 a study was done by Lee on the sexual behaviour of male inmates of a detention facility in Singapore32. Mandatory testing for HIV and segregation of high risk or positive inmates was not recommended, health education programmes on HIV and risk reduction were recommended. DISCUSSION Sexual behaviour and epidemiology of HIV in men who have sex with men in Singapore is not unlike other developed countries. It is often believed that MSM have higher numbers of partners and higher rates of partner change than the general population. While we don’t have direct comparisons between MSM and non MSM in Singapore, both the AfA surveys and MOH contact tracing data have shown that there is a proportion of MSM who do indeed have very large numbers of partners24,25. In Singapore, HIV prevalence is higher among MSM than heterosexual males and females. MSM in Singapore, particularly those who frequent gay venues and Internet portals, have a good knowledge and understanding of HIV/AIDS. However less is known of those who do not identify as gay as these individuals have not been the target of most of the studies that have been undertaken on MSM. Young MSM have been identified as being at particularly high risk of infection. They often are poorly informed of the dangers of unprotected anal intercourse and do not possess the knowledge and skills to insist on safer sex at their sexual debut.

In order to increase access to young MSM, it is recommended that online interventions specifically target young MSM in the time period between sexual identity formation and sexual debut/exposure to HIV risk. Partnering with groups that have programmes catering for young MSM will be vital to implementing effective outreach activities and to influencing behaviours before infections occur. It appears that the Internet is very important to the MSM communities and networks in Singapore. Greater efforts must be made to utilise the Internet and new media for education and preventative interventions. Singaporean MSM do not appear to have high rates of use of recreational drugs. However, this is an area that needs to be studied further. It is present and should be addressed in intervention programmes. Education on STIs needs to be increased as many more MSM will contract an STI than HIV infection. This strategy may also lead to increased safer sex behaviour as the fear of STIs other than HIV may circumvent the complacency of condom use to reduce HIV risk. There are good systems in place for HIV testing in Singapore, however more regular HIV testing as well as STI testing needs to be advocated for MSM. The AfA Anonymous Test Site (ATS) is well utilised by MSM. There is definitely room for improvement with regard to general sexual health services for MSM: services that are ‘gay-friendly’ and which, therefore, MSM feel comfortable attending. There is much to be learnt from international experience, especially from Australia. Australia has a well established system of monitoring the HIV epidemic among MSM. Consequently, their interventions appear to be showing success, especially in Sydney33. There is a need for further research into the epidemiology of HIV and risk behaviours among MSM in Singapore. To this end the Ministry of Health has been actively supporting further research and intervention activities. These include regular behavioural surveillance surveys, venue based seroprevalence studies and studies/ interventions with HIV positive MSM (involving qualitative and quantitative methods). MOH has also expanded its financial and organisational support of educational and prevention activities in conjunction with community partners. This review paper was supported by Ministry of Health Singapore

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clean?” Are you

Twenty-five years on, do we still suffer stigma and discrimination? David Menadue finds that, in some areas particularly, we do. Reproduced with kind permission from Positive Living March 2010 A publication of NAPWA Australia

A friend said to me recently that he thought stigma and discrimination against HIV positive people must have decreased in recent years in direct proportion to the way our treatments and prognoses had improved. My friend is well-connected. He has supported many of us through our trials and tribulations over the years while managing to remain HIV negative himself. ‘Surely society is more accepting of people with HIV in an era when it is not such a fearful disease and when people are more out about their status?’ he said. I would like to agree with him. But while acknowledging that things are generally better in the lives of HIV positive people, recent research into levels of stigma and discrimination against us suggests that in some ways, it may actually have got worse. A report prepared by consultants for AFAO and NAPWA last year came up with some rather startling findings about the attitudes of HIV negative gay men towards people with HIV.1 These findings were supported by a survey conducted by NAPWA and co-authored by Ronald Woods and myself. The survey found high levels of stigma were still being experienced outside the gay community, and that many felt that negative attitudes had not changed much in the last twenty years.2 The consultant’s report surveyed approximately 90 gay men from metropolitan and regional locations, used discussion groups and some telephone interviews. Some groups were segmented according to HIV status, others according to age and some included HIV positive and negative men together.

The consultants found a particular lack of awareness and knowledge of HIV amongst gay men in their early twenties, and this only changed for people in their late twenties and older if they knew people with HIV. According to the report, ‘those who claimed to have little or no personal experiences of anyone living with HIV were often openly negative and discriminatory in the way they discussed PLHIV.’3 Most HIV negative men readily admitted to being aware of a labeling and stereotyping of HIV positive men among gay men generally. Many younger men in particular believe they can identify someone as HIV positive by their physical appearance, strongly believing in the stereotype of an older thin man with sunken cheeks. Many readily articulated an ‘us and them’ attitude. Some negative men openly refuse to engage with positive men via the Internet and try to avoid any physical associations with them. The language they use clearly differentiates us, associating positive men as belonging to different ‘clubs’ or ‘teams’.4 The consultants found that it was common to identify HIV positive men as ‘unclean’, and to liken sexual interactions with them to ‘loaded guns’, ‘playing Russian Roulette’ and ‘poison’. In the view of the consultants, this language likens HIV positive men to criminals, and as a criminal would be marginalised from mainstream society and stripped of certain rights, so are some HIV positive men in the view of others5. It is not surprising then to hear that the positive men surveyed reported that within the gay community, discrimination occurred in sexual situations (both potential or realised) more so than elsewhere. This discrimination occurred with both physical rejection and within the language used to ask about serostatus, with many believing that there was an increasing prevalence of other men asking ‘Are you clean?’ Some HIV positive gay men also spoke about having their status discussed as a warning to others at a venue. And that the prospect of these details becoming known amongst gossipy gay men in their social circles was possibly a greater fear than one on one rejection – a form of social ostracism that could lead to feelings of shame and low self-esteem. One of the few bright notes to come out of the discussions was when participants admitted to being in a serodiscordant (positive-negative) relationship. Both HIV positive and negative participants were surprised to hear these revelations and it seems the ability of some people to have successful relationships with someone of a different status had a positive influence on changing some attitudes.

Why could stigma and discrimination be increasing? When I read the above report, I was quite shocked about its findings. Personally, I don’t feel this level of ostracism from the gay community or society in general. I think that most HIV positive people feel safer and more accepted compared with the early years of the epidemic. HIV is treated far more sympathetically by the media these days and there is less general fear about the ways it is transmitted. The problems though, as the consultant’s report points out, are in the climate of sexual negotiation for HIV positive people - where the stigma about revealing your status is still a major issue. The consultants give their reasons about why they believe stigma and discrimination is increasing. They suggest that there is less need for gays and lesbians to come together as a community. Greater social and legal acceptance means we mix more freely with mainstream society, including at social venues – and that this leads to less exposure to HIV positive people. There is also the impact of the Internet where gay men are much more likely to meet a sexual partner online than at a gay venue. This anonymous environment makes it easier for people to express opinions and to discriminate against those who are prepared to identify as HIV positive. (It must also be said that the online environment can make it easier to meet someone of the same serostatus and to ‘serosort’ which can be useful for positive people who want to meet other positive people). The consultants also suggest that the improvements in HIV treatments — and the reduction in their side-effects (such as the tell-tale signs of lipodystrophy) — has possibly contributed to HIV positive people not feeling the need to tell others about their status. If you can’t tell by looking or you are not likely to become seriously ill with HIV, do you need to tell the world? In my opinion, this is where the implications of stigma and discrimination really impact. If it is increasing against positive people and the acceptance and experience of HIV positive people is also diminishing in the gay community, there must be implications for HIV transmission as a result. If you are not going to disclose for fear of very negative repercussions then you are caught in a bind if an episode of unsafe sex happens, maybe by accident for instance. If you get serious with a sexual partner, there is no hiding the need to disclose at some stage in your relationship.

The psychological effect of holding secrets inside you can be detrimental. I’m not suggesting that everyone needs to come out to all and sundry (as I have done over the years, with no real regrets) but having a good group of friends (and family) who know and who are supportive is a wonderful backstop in your life. It can give you the confidence to accept being HIV-positive and to not to develop feelings of shame or worthlessness because of your status – negative sentiments that some of the participants in the survey above expressed. Living with HIV outside the gay community NAPWA asked Ronald Woods and me to interview a range of HIV positive people around the country to complement the research done by the consultants on gay men. We conducted 20 in-depth interviews with representatives from the following affected communities: women, heterosexual men, people from a culturally and linguistically diverse (CALD) background, Aboriginal and Torres Strait Islanders and people with haemophilia. Our interviews produced no brighter revelations than the consultant’s. In fact, I think our interviews revealed that a more pervasive stigma and discrimination is still being experienced by people living with HIV outside the gay community. Without the awareness in the broader community created by prevention campaigns about HIV, positive heterosexuals report a much greater sense of isolation about their HIV status and a great fear of increased stigma and discrimination if these details were to become known. Positive women still have to deal with ill-informed medical professionals making judgments about their lifestyle when told about their status. Positive heterosexual men we interviewed expressed the huge difficulty they experienced finding partners with whom they felt confident enough to disclose. People from CALD backgrounds live in constant fear of rejection by their families and communities if their status becomes known, with parents refusing to seek out childcare or translators from others in their communities in case details of their HIV are somehow revealed. People with haemophilia and HIV will often not tell anyone but their immediate family for fear that they will be ostracised by their community. Most people with haemophilia are not HIV positive (with the blood supply now protected) but misinformed community perceptions from the eighties still affect this population.

How can we change this situation? Many interviewees we spoke to said there had not been any mainstream anti stigma and discrimination campaigns around HIV since the early nineties and they think the time is ripe to remedy this situation. AFAO and NAPWA are working with the Federal Government to develop responses that will address the issues during the implementation of the next nation HIV strategy. What form these responses will take and what outcomes they will deliver is going to be a major talking point for HIV sector agencies over the next year or so. The consultants suggest that, to begin with, the equation of “HIV=prevention” which has so dominated AIDS Council campaigns for years needs to be changed in subtle ways so that the negative perceptions of HIV do not include people with HIV. Basic information about how HIV is transmitted and the experience of people living with HIV needs to be included in these messages. A staged campaign which sets about showing people the ugliness of HIV-related stigma and discrimination could follow with messages that promoted inclusiveness and openness amongst gay communities over the issue of serostatus.

Turning around societal attitudes is I was heartened to see a website called “StigmaWatch” developed by SANE Australia to try to combat the stigmatising descriptions and portrayals of mental illness in the media – and to read that, by using personal stories from a number of celebrities and others, that the experience of living with depression has become more accepted by the community than in the past.

never simple.

Maybe it will be possible to influence broad community perceptions and ignorance around HIV as well through similar means. I do think that any campaign must also concentrate on giving positive people the confidence to tackle their own internalised sense of stigma about having HIV. Many of us have built up such a fear about people’s reactions if we disclose that we imagine all sorts of repercussions that are not likely to happen at all.

V. Parr, C. Burkitt, and A. Jennings, Formative Research for the National HIV Stigma and Discrimination Pre-campaign Development, Qualitative Research Report prepared for AFAO and NAPWA, GfK bluemoon, August 2009

Despite the negative emotions expressed by some people in the surveys above, there are many people who will be totally supportive if you reveal details of your status.

R. Woods and D. Menadue, Stigma and Discrimination towards HIV-positive people in diverse communities around Australia, Report to NAPWA, October 2009

If AIDS Councils, PLHIV organisations and other HIV sector agencies can come up with ways to support people on disclosure, people will find it easier to get rid of their own sense of stigma about having HIV.

3. Op cit. Parr et al, p 6

4. Ibid. Parr et al pp 6 and 7 5. Ibid. Parr et al, p 7

World AIDS Day Walk â&#x20AC;&#x2DC;AIDS Unmaskedâ&#x20AC;&#x2122; 28 November 2009

Over 400 participants gathered downtown for this year's WAD Walk. The theme, 'AIDS Unmasked', reflects the stigma of the disease that drives PWAs and their loved ones to hide under anonymity. At the end of the walk, participants symbolically unmasked to signify removal of the stigma.

Volunteers pose with celebrity host, Ms Pam Oei with AfA President Prof Roy Chan, Guest of Honour MP Mr Baey Yam Keng, Tangs Senior VP Ms Juliet Ting, and MAC General Brand Manager Mr Michael Goh.

Outreach to

Tanjong Balai Budget Hotels

The HMO team working with industry partners to distribute safe sex materials to budget hotels.

Living With... Art Against AIDS photography exhibition 20 to 29 November 2009

This year's Art Against AIDS exhibition featured compelling images taken by 10 amateur photographers who are on the frontline of the ongoing fight against HIV/AIDS. Held at VivoCity Mall, the exhibition attracted a large and diverse audience.

Prof Roy Chan with Tan Ngiap Heng (left), who sponsored the venue for the basic photography workshops, and Matthew Koh (right), from Canon, who sponsored digital cameras for the project.

Love Gala:

Live.Laugh.Life 4 December 2009 @ Hilton Singapore

Fiesta Famili Jan 10 Malay Community Outreach in Woodlands

AfA's red carpet fundraising event of the year was graced by glitterati and celebs, including Royston Tan, Alfian Sa'at, Dick Lee, Hossan Leong, and other local personalities. Â

Volunteer conducting HIV survey with a resident. Â

Singapore AIDS Candlelight Memorial “Many Lights, One Community” 16 May 2010

Held at the Telok Ayer Hong Lim Green Community Centre’s Open Stage @ Hong Lim Park, this year’s event attracted a strong crowd of about 300 despite the wet weather. Co-organised by AfA and Tan Tock Seng Hospital, the event included the support of the Inter-Religious Organisation of Singapore, the Singapore Red Cross and First Hand from City Harvest Community Service Association. Ms Denise Phua, MP for Jalan Besar GRC, was the Guest of Honour.

Photos courtesy of Chung Hui Keng, Gwendolyn Sim Yanqun & Jacqueline Tang

WORLD AIDS DAY AND THE TRUTH ABOUT WHAT WE THINK

A Joint effort by M.A.C Cosmetics & Action for AIDS

CORPORATE • SOCIAL • RESPONSIBILITY It was an ordinary Saturday in town, when the make-up mavericks from M.A.C. Cosmetics gathered at their counter in Tangs. They then marked their foreheads with the letters A.I.D.S with prominent black eyeliner. Their work as we know is to paint, powder and primp the ladies (and some gentlemen); however on this particular day they also had another important mission to carry out, as they dispensed their services.

M.A.C, whose head offices are in New York, and through their local teams at M.A.C Cosmetics worldwide, have been have been staunch supporters of the funding of HIV/ AIDS projects. On World AIDS Day this year, they pulled out all the stops to sell as many VIVA GLAM lipsticks as possible. This M.A.C. initiative saw a 100% of the profits from worldwide sales of these lipsticks going towards supporting HIV/AIDS projects and programmes.

Customers visiting the counter later would discover that this particular Saturday – December 1st – was World AIDS Day, an international date set aside by different groups who are united in a common purpose, which is to remind governments worldwide and their people that we all need to remain committed to the fight against HIV/AIDS.

What other mission would the M.AC. Cosmetics artists carry out? With a survey provided by AfA, the M.A.C. team approached a total of 289 people to gather their opinions and attitudes about people living with HIV/AIDS, to uncover the truth about what people really thought.

What the M.A.C – AfA Attitude Survey says about how much (or little) people know about AIDS in 2010 Who are they? • Young Singaporean women made up the bulk of the survey (68%) • Majority of the respondents were Singaporean citizens: 79% • Majority of the respondents 29 and under: 68% • Women in the 30-39 years age group made up 17% of the total surveyed. Awareness of condom use • Widely Accepted: 71% agreed that the correct and consistent use of condoms is an acceptable method of prevention. • Least Accepted? 36.7% agreed that abstinence from sexual intercourse was either the least acceptable, the most misunderstood or the least popular method of prevention strategy. Understanding HIV transmission through use of needles and blood • Relatively high level of awareness regarding blood as a mode of transmission. • Average of 94.3% understood correctly that a blood transfusion may pose a risk of transmission and that the sharing of needles was also a high risk activity. • In contrast many had lower levels of awareness regarding non- transmission modes. • Average of 85% correctly agreed that the sharing of meals, toilet seats and mosquito bites does not transmit the virus. What do the mothers of the future know? • 94% are aware of the mother to child transmission of HIV. • However 63% did not know that breastfeeding is a mode of transmission. What are our thoughts and feelings towards HIV+ people? • 23% felt that a person living with HIV will not look healthy. • A significant number of the respondents would not interact socially with PWAs.

• • •

45% were unsure if they would share a meal with a HIV+ person. 47% would not or were unsure if they would purchase food from a HIV+ food stall holder. Interestingly, a majority of 90% would accept relatives and loved ones with HIV/AIDS who need care.

The key issues that arose from the survey There is a gap between the knowledge of HIV and the attitudes displayed towards HIV+ people There is a high level of awareness of what constitutes a risk, but a lower level of what does not. This combined with the negative perception towards those who are HIV+ has lead to cases of stigmatisation, discrimination and a general lack of acceptance of PLHIV. People are prevented from going for a HIV test by the misinformation that surrounds the virus and the irrational fears that this creates. The majority of those who took the survey were women. If we look at the gap between their knowledge of HIV and how much they actually understand about HIV, it may help to explain the significantly lower test rates amongst women in Singapore compared to the men. The lack of awareness of regarding the mechanics of mother to child transmission The majority of the respondents understood that HIV can be passed from mother to child; however there were many who did not know that HIV can be transmitted through breast feeding. The survey does not indicate if the knowledge of mother to child transmission is supported by the information regarding its prevention. This lack of depth of knowledge needs to be addressed within the female community, especially for those women who are HIV+. Attitude. The prevalence of stigma The level of acceptance in social situations of those who are HIV+ does not rank highly; this may be accounted for by ignorance and the anonymity of those who have the virus. Due to the gaps in knowledge surrounding HIV and its transmission modes, also the unwillingness to interact with those that have HIV/AIDS, indicates that stigma is still prevalent in today’s society.

Deafening

Silence by May Yong

On the 30th of October 2009, AfA motivated a number of youths to rally together in support of those people in Singapore who live with HIV/AIDS and the silence that surrounds them. To help bring attention to this silent world, these young people participated in the Pledge of Silence. They chose to pledge between 4-24 hours of silence and collected donations for pledges. At dusk the silence was broken all over Singapore, because by using our voices we can speak for those whose voices have been silenced by public judgement.

The Pledge of Silence was a fund raising initiative and campaign supported by those who understood the difficulties of being silent for life – a plight shared by many people who live with HIV/AIDS, due to the society’s stigmas. From May to October, we concentrated our efforts on reaching out to those who could contribute in some way. These included volunteers who helped by communicating with others and raising awareness of the campaign, the tertiary youths with their unwavering support and our corporate sponsors’ generous funding. Our mission became a personal challenge for each of us. We were going to point the spotlight on stigma and encourage others to help eradicate its pervasive hold on society. In the end, around eleven groups of students from the local universities, junior colleges and international schools heard our clarion call and prepared for action. They distributed over 1,000 pledge cards and held individual fundraising drives. Information booths were erected on their campuses, flyers given out, and roadshows went to town. Many pledged their silence and canvassed far and wide for donations. One events company held a small exhibition cum auction of work from 10 emerging artists, the theme of the work was silence.

In total we raised over $17,000 through this campaign. As one voice we spoke to the public through the Pledge of Silence, and we became the voice of those who cannot speak out. However, not everyone responded to the campaign. Some groups that we approached felt it was a tedious exercise that required too much effort to support. Others felt that it was ironic or pointless to pledge silence, some were afraid of being mocked or ridiculed for their silence. Many did not wish to support our cause purely because it was HIV/AIDS related and not about children, the elderly or those who are handicapped. This was not an easy fundraising effort to participate in, but those that did represent a group of young Singaporeans who are ready to bid “adieu” to the culture of moral judgement reserved for those who have fallen as a result of HIV/AIDS. Why do they care? Testimonies from Campaign Supporters • Everyone deserves a second chance. Muhd Imran, NUS Nursing Faculty • Stigma should be eradicated. We need to start doing that. Thenuga, POS website creator • I have a friend who is HIV+. Student Participant, SMU • I wish to at least give moral support. Jin Lu, National Institute of Education • Because others don’t. Haikel Lim, NUS • I know the pain of being left behind … I want these people to know that they’re not alone in this. Jasmine Tan, NUS Nursing Faculty

Pledges of Silence (POS) Adzmey Asmom

Adzmey was one of the key students who campaigned for a group of trainee teachers from NIE. Despite heavy commitments in and outside of school, they decided to pitch in for our fundraising event, by raising the volume of support towards PWAs from those on campus. The 30th of October 2009 was both eventful and memorable for the group of 19 trainee teachers from the National Institute of Education (NIE).This was the day to champion a cause by speaking out for those who are stigmatised because they have HIV/AIDS. It may have seemed like an oxymoron, but these trainee teachers gave their support by pledging their silence. They also rallied others to join them in this worthwhile cause. On the 2nd of September, as part of the NIE Group Endeavour Service Learning Programme, these civic minded trainee teachers came together to discuss what to do for this project. By consensus, we decided to support a campaign that involved creating awareness to the plight of people living with AIDS, (PWAs) and the stigma they faced on a daily basis.

Symbolically, we wished to somehow become the “voice” of the PWAs. We believed it was not easy to live a life shrouded in silent fear of what others may do if they discovered our condition. How would we feel if we had to face possible rejection from our loved ones, family members or friends? One of our other main objectives was to create a platform to promote the practice of Safer Sex, especially amongst the youths. The first step we took was to research the cause and we came across the Pledge of Silence, an event which seemed to be a match for our aims. To learn more, we contacted Action for AIDS. Their Fundraising Executive, Ms May Yong came and gave us a briefing session on the Pledge of Silence and the cause it supported. This proved to be an eye-opener for some; however it also cemented our decision to take up this cause for our NIE project. Weekly meetings and discussions were held to enable us to update everybody on the group’s progress. We were in constant communication with May regarding the information that we needed to share, which would help to create awareness about both the cause and the event. Items such as pledge cards, bandanas, stickers, posters and flyers advertising the Pledge of Silence were distributed to raise the profile of the event.

The process of finding people who would pledge their silence and those that would give monetary support was carefully explained to us. We were also instructed on the use of the pledge cards. It proved to be a daunting task getting people to sign up to support this event. Preparations for the midterm exams were underway, so all the students we approached at NIE and NTU were otherwise engaged. Despite the fact that we too were in the midst of exams, we still urged on to engage the support of fellow trainees, students, tutors and lecturers. Some supported the event by pledging their silence, others by giving financial support. We also made the effort to collaborate with our counterparts at NTU, but we came across a glitch when it came to the canvassing of donations from the public. Our hard work and determination as a team paid off, the Pledge of Silence event we held on the 30th of October in 2009 was success. Armed with whiteboards, markers, writing pads, pens and mobile phones, the team went about creating awareness for the event without speaking a single word. Initially we experienced curious stares and communication problems, but regardless of this we succeeded in getting perfect strangers to join in this event. They signed up to pledge their silence, make a donation or helped to paint a colourful mural on a banner, which was one of the activities during the event. A booth selling handmade jewellery was also set up, part of the profits were donated to the event. The event took place at NIEâ&#x20AC;&#x2122;s main concourse so a live band performed to attract the crowds into this area. When the clock struck seven, resounding cheers and claps rang out, as we broke our silence. Words cannot express the joy and satisfaction felt by the team at the success of this event. By maintaining silence, the members fulfilled their own personal pledge that they had undertaken for this worthy cause. By running this event we hoped that our humble contribution along with others will one day enable us to return the voice of those who have lived in silence for far too long.

more than an

Angel

Madam Lalitha Nair shares the highs and lows of her 18 years of volunteering at Action for AIDS, and gives us advice on how to be responsible for our own lives.

Madam Lalitha is a natural friend to everyone. Stepping into the room, she brings her presence of liveliness and warms up to you quickly. Which is probably why she’s the perfect fit for the job - without the least scrutiny or judgement, Madam Lalitha says the most important start is to make an “honest and respectful connection” with her patients; and sometimes, even run the extra mile for them.

Usually they will wait for me and after my clinic duties, we will go to the coffeeshop,” she says, “Sometimes they need to call on someone who has the knowledge and I’ll be their best advisor and friend. Reproduced with kind permission from Lifewise, November/December 2009

Running the extra mile Madam Lalitha Nair is a Senior Health Advisor with the DSC clinic which specialises in the prevention, diagnosis and treatment of sexually transmitted infections (STI). This was a job that she had entered “by chance” and had turned out to be her true calling after all. A year after she began working for the DSC, she decided to devote even her rest days by volunteering at the Action for Aids (AfA) as a counsellor. And although this is her 19th year on her job and 18th year volunteering in a role that most people shun, still the optimist in her finds renewed meaning and joy in her vocation everyday. But her journey hasn’t been just about making friends and enjoying the company. Madam Lalitha remembers her initial years volunteering as a counsellor at the AfA and says she will never forget the emotional trauma she experienced whenever a patient of hers died of the infection.

photo by Ealbert Ho

“There was this guy I could never forget because he was my first patient at the AfA. His test had come back positive and as a counsellor, I had to break the news to him. But I couldn’t take it and I was crying and he had to counsel me. “That was so touching. I went to see him when he was dying at the hospital. He was still the same cheerful guy who had accepted the fact that he was infected and knew he was dying.” Madam Lalitha shares, her gaze wistfully solemn, “Handsome looking guy, I’ll never forget his looks.” That episode happened 15 years ago. But to reminisce on it still brings heartache to Madam Lalitha. Back then, with little drugs to suppress HIV infection in addition to a poor public’s opinion of the disease, often there was very little Madam Lalitha could do for her patients and their families who would rather be left alone. “There was this other guy who was dying and he wanted the room to be filled with fresh flowers. So I could only do that. When I went to see him, he was already in a coma. All I can do are just these small things,” she says. After witnessing several deaths, Madam Lalitha decided to give up counselling for HIV-positive patients and just focus on her clinical duties at the AfA instead. “I couldn’t take it after too many deaths,” she shares, “Now the drugs are so promising so the patients can live for a very long time. But at that time, you see one dying after another.”

Her source of motivation Since then, Madam Lalitha has continued to counsel patients who are tested negative for HIV, sharing with them knowledge on protective sex methods and encouraging them to lead a healthy lifestyle. Initially, her job caused some unhappiness among her family; especially her in-laws who were worried that she was working with “sex workers”. But after reassuring them that STI is only transmissible via sexual intercourse and transfer of bodily fluids, they eventually gave their full support in her good work. “I am who I am. Just because I work with sex workers doesn’t mean I’m going to change,” she says, “Their only concern was whether HIV was infectious or not. But I explained that STI is only transmitted through sex.” Today, she prides her joy in being able to help others, “I think some people really, really deserve it (help). There are a lot of worrywarts who come to the clinic looking like it’s the end of their lives. But after talking to them and they leave feeling happier and much more refreshed, it really makes me happy.” An extraordinary spirit Although the public’s perception of HIV has taken a gradual improvement over the years, still more has to be done to protect the interest of people living with HIV and to educate our children from an early age on how to prevent the spread of STI. “People have to accept HIV and AIDS as another infection. Look at it as it is another medical problem,” she says, “Give them all the support and not stigmatise them.”

WHAT ARE STI? There are 30 various types of sexually transmitted infections (STI) that are spread predominantly through sexual contact. The common conditions caused by STI are gonorrhoea, syphilis, genital herpes, hepatitis B, and the human immunodeficiency virus (HIV). HIV VS.AIDS HIV leads to AIDS (Acquired Immune Deficiency Syndrome), which is a disease of the human immunity system where the body is unable to fight off any infection leaving the person vulnerable to the most common ailments which may lead to death. Today, there are treatments and drugs which can significantly reduce the progression of HIV, but there is still no vaccine or cure for the disease.

“Really, as young as that,” Madam Lalitha remarked, “What are you all waiting for? I think at least by 10 years old, children should be taught that this is your temple so you should be responsible and take control of your life.”

HOW IS HIV TRANSMITTED? HIV is not an air borne virus and is primarily transmitted through sexual contact or exchange of body fluids, i.e. blood, semen and vaginal fluids, breast milk of infected mother, cerebrospinal fluid, or amniotic fluid surrounding unborn child of infected mother.

In recognition of her efforts, Mdm Lalitha received a Life Award for being the longest serving volunteer at the AfA’s 20th Anniversary celebration last year. And now with more volunteers at AfA, Madam Lalita is thinking about making a change and turning her attention to help children with STI.

Normal social gestures like shaking hands, dry kissing on cheeks, drinking from the same cup and eating off a same plate do not leave you susceptible to catching the virus.

Madam Lalitha recalls a conference she had attended where the guest speaker was asked at what age should children be taught about sexual education and her reply was: “When they’re on their mother’s lap!”

Madam Lalitha’s extraordinary spirit has definitely touched many lives and helped make a big diff erence in a conservativesociety. But for her, the bittersweet memories of her patients continue to live on in her. “I’m upset that I didn’t spend more time with that young man. I could have made him happier, talk to him, know what were his feelings, his memories; so that I can have a better picture of him and remember him better.”

by Avin Tan

Our Study ACON Trip Donovan and I went on a study trip to ACON (AIDS Council Of N.S.W ) in Sydney this February. A great deal was learnt from the intensive knowledge sharing session that spanned 4 days. We left ACON breathless, with our heads spinning from the information overload and falling in love with HIV work all over again. ACON is Australiaâ&#x20AC;&#x2122;s largest community-based gay, lesbian, bisexual and transgender (GLBT) health and HIV/AIDS organisation. ACON was started some 25 years ago to help fight the spread of HIV and to provide care and support to people affected by the pandemic. The first case of AIDS in Australia was diagnosed in 1982 and the number of HIV diagnoses peaked in 1987. 12 years of declining rates followed, after which the rate increased again to reach 973 in 2008 (after adjusting for multiple reporting). Transmission in Australia continues to occur primarily through sexual contact between men. Around 66% of people newly diagnosed with HIV in 2008 were among men who have sex with men; 27% were exposed through heterosexual contact; 3% were due to injecting drug use; and a further 3% were men with a history of both injecting drug use and sex with other men. In Sydney, the reported number of new notifications in the MSM community rose to 285 cases in 2003 but has been steadily decreasing over the years. 2008 saw 235 new notifications. ACON reports that while Australia as a whole is seeing an increase in new notifications, Sydney on the other hand, is experiencing a steady rate of infection. ACON has grown over the years, reinventing themselves to stay ahead of the epidemic and remaining relevant when huge advancements in antiretroviral medication means that people no longer suffer or die of AIDS.

On top of its core work to reduce HIV transmission and helping people with HIV to maximise their health and minimise the effects of HIV through a range of services and programs, ACON focuses on improving the health and well being of the GLBT community. This is reflected in all aspects of their work, including campaigns that they roll out, and policies that they fight for. Everybody has a role to play in making this happen.

I was very impressed by the amount of work they did and the ground that they managed to cover. Every department was incredibly busy, but they all took the time to share what they have accomplished with us. Nick Parkhill, the CEO of ACON, even took 5 minutes from his busy schedule to drop by and say hi, and make sure we were ok.

There is a fully stocked kitchen for anyone to cook breakfast or lunch. This kitchen is partially stocked by their own garden that is managed by PLWHA, which I personally find very fulfilling and therapeutic. Many of these classes are run by volunteers or community partners, such as gyms that offer 3 months of free membership and a personal trainer.

I realised quickly that they were very open and more than willing to share all of their materials, which only reinforced the fact that the quality of their work is so good – all backed by some form of research – that it can be shared with the world.

ACON’s Education Team develops a range of social marketing campaigns aimed at promoting the health and well-being of their community. The Education Team works with volunteers who double up as models for new and upcoming campaigns or to work as facilitators in workshops.

Their research was either conducted by themselves or in partnership with universities, institutions or youths in their own community. A fund has been set aside to allow youths to carry out research within their own communities, and contributing to evidence-based materials and workshops. This is all guided by an ethics committee, of course.

They actively seek out potential volunteers or members of the public who have attended their workshops to equip them with knowledge and skills to run their own workshop. They become peer educators and help run workshops such as the Arse Class, which is very popular amongst young MSM.

Client services, such as one-to-one and group therapies, home-based care and nutritional support, also form a backbone of ACON’s mission. Their services have benefitted people and families who have been affected by HIV. Those who have lost their jobs due to HIV are able to receive free or low cost therapies and vitamins to help them get back on their feet. While they do experience people who abuse the system, the Positive Living Center makes sure that they are just a pit stop for the newly diagnosed and not an exclusive club house.

Strong volunteer engagement and high sustainability with clear volunteer career paths allow many volunteers to gain professional development – as facilitators, materials developers or care and counselling providers. Enrichment programs are conducted twice a year to validate and acknowledge their hard work.

This is essential to make sure PLWHA take ownership of their lives and not become dependent on the system. It is a working, sustainable program that has successfully integrated many PLWHA back into society. THE PLC offers a full suite of programs and services, often at no cost to the participants. A white board in the hall with scribbles all over shows programs that range from yoga, fitness and life coaching.

All in all, ACON shows great sensitivity and responsibility for PLWHAs and the affected communities that they serve. Even with 150 staff members, none of the work is duplicated, and each staff member’s job scope is very streamlined, allowing them to focus what is at hand. Everybody does a good job, so nobody needs to worry about the rest. A national strategy has helped all partners know their area of work so that limited resources can be used effectively. HIV work is never easy, even if there are no laws that criminalise MSM. NGOs, community partners and other supporting agencies must work closely together and to build on each other’s strengths to empower the community.

PROJECTS & PROGRAMMES Formed in 1988, Action for AIDS (Singapore) is a non-governmental organisation and a registered charity. Activities are planned, implemented and coordinated by volunteers and a small number of staff. AfA is funded, through the generous donations of private individuals and organisations. In order to realise our objectives, the following are some of our main activities. I

EDUCATIONAL PROGRAMMES

The ACT This publication has articles dealing with medical, social, cultural and personal issues. It also reviews and updates AfA's activities. It is distributed free to members and volunteers, to schools, libraries, community organisations, medical and dental clinics and hospitals. Editor-in-chief Roy Chan • info@afa.org.sg www.afa.org.sg The webpage contains information on HIV/ AIDS, AfA activities, the latest HIV/AIDS statistics, a Q&A page, and links to other AIDS web pages – both local and foreign. Do visit the website for information on our activities or for updates on HIV/AIDS in Singapore and the region. Coordinator Avin Tan • avin.tan@afa.org.sg HIV Education in the Workplace Education is the most important strategy to prevent the spread of HIV. We provide trained educators who can speak to groups and organisations to help raise AIDS awareness. Coordinator Jesse Koh 62540212 • jesse.koh@afa.org.sg High Risk Heterosexual Men Outreach Programme To encourage heterosexual men who engage in high risk sexual practices, volunteers distribute safer sex packs at venues frequented by this target group. The programme also conducts online outreach – in websites, e-bulletin boards and chatrooms.

Coordinator Edwin See 62540212 • edwin.see@afa.org.sg

MSM Outreach Programme The Programme conducts research projects on MSM in Singapore, runs outreach at real and virtual MSM venues & events; develops MSM-specific safer sex material, and conducts safer sex workshops. Volunteers do not have to be MSM, or even male, to help out. Coordinator Donovan Lo 96836694 • donovan.lo@afa.org.sg AMPUH (Anak Melayu Islam Melawan Penyakit Unik HIV/AIDS) AMPUH was set up by a group of Muslim volunteers to tackle the rising numbers of Muslim patients infected with HIV virus or suffering from AIDS. It hopes to raise community awareness of HIV/AIDS, encourage active community participation and enhance community support for Muslim HIV/AIDS patients. Coordinators Nooraini Abdul Rahim/Anwar Hashim anwar@afa.org.sg

II SUPPORT AND WELFARE PROGRAMMES Medication Assistance Fund ARV medications are all classified as non-standard drugs. The AfA Medication Assistance Fund provides financial assistance to needy PWAs who cannot pay for these medications. Pregnant Women’s Fund We also maintain a separate fund for pregnant HIV+ mothers who cannot afford ARV Drugs to prevent mother-to-child transmission. The Care for the Families Fund Launched on 29 November 2007 – The Care for the Families Fund is an inaugural fund initiated by Rockeby biomed to provide financial support to the affected families of persons with HIV infection.The objectives of the Fund are to:

a. assist families of persons with HIV infection, particularly those who have been severely impacted financially; and b. provide for areas that other AIDS assistance programmes may not have covered in the past, e.g., children's school & transport fees, single HIV+ parent's household expenditure, etc. Coordinator Siti Nura’ain • 62540212 • siti@afa.org.sg The Buddies Programme Volunteers in the Buddies Programme offer emotional and practical support to HIVpositive people and their loved ones through weekly visits to the ward, and by befriending those who are healthier and appreciate company and friendship. Coordinator Alan Tan • 98252552 • info@afa.org.sg Life Goes On (LGO) LGO is a self-help patient support groups funded and supported by AfA. Through LGO, PWA interests and rights are represented in all of AfA’s activities, at both organisational and participatory levels, with confidentially preserved. LGO caters to infected heterosexual men. PWAs plan, coordinate and perform hospital, home support and welfare activities, and also to assist in AfA activities. Contact • 62540212 • info@afa.org.sg Club Genesis (CG) CG is a self-help patient support group for MSM. It also networks with self-help groups regionally and share experience and Information that are mutually beneficial. CG, PWA interests and rights are represented in all of AfA's activities, at both organisational and participatory levels, with confidentially preserved. Members plan, coordinate and perform hospital, home support and welfare activities, and also to assist in AfA activities. Coordinator Shawn Lee • shawn_lee82@yahoo.com.sg Project Hope Project Hope is a patient support group. This group helps HIV+ patients and their family members to come together in a safe and emotionally supportive environment to share their thoughts and experiences of dealing with the infection. HIV+ patients with no family support are also welcomed. Personal counselling is provided to HIV concordant and discordant couples (regardless of sexual orientation) and HIV+ pregnant women. Harm and risk reduction information and advice are also made available. Coordinator Phil Loh • phil.loh@afa.org.sg

Muslim+ This peer support group brings together Malay/Muslim HIV+ patients within a safe and emotionally supportive environment to share their thoughts and experiences in coming to grips with the infection from an Islamic perspective.

Initial Treatment Subsidy Scheme Patients tested positive at the ATS will receive up to $200 off their first treatment bill from Tan Tock Seng Hospital – CDC. This scheme is a one-off subsidy for initial treatment and is only applicable to Singaporeans and Permanent residents.

Coordinator Nooraini Abdul Rahim 98351982 • info@afa.org.sg

Clinic Managers Anwar Hashim • Julie Matthews • Phil Loh anwar@afa.org.sg

Women and Girls Outreach This programme aims to address issues peculiar to women and young girls through research and targeted material and campaigns.

Coordinator Jesse Koh • jesse.koh@afa.org.sg IV OTHER PROJECTS

AfA Prison Outreach Programme Since 2006, AfA in conjunction with the Singapore Prison Services launched two programmes within the Singapore Prison in Changi for both the male and female prisoners. One of the programmes targets the inmates that are about to be released. This programme provides vital information on HIV and STI prevention, safe sex and condom use. Inmates are also encouraged to get a HIV test after they are released. The other programme is specifically for HIV positive inmates within the prison. The programme provides HIV information, onward prevention efforts, counselling and care to inmates in the prison and their families. Training and education are also given to the prison staff who handle HIV inmates. Coordinators Geoffrey Goh • geoffreygoh@gmail.com Norani Othman • norani.othman@afa.org.sg

III CLINICAL SERVICES Anonymous HIV Testing & Counselling Clinic Experienced counselors are on hand to provide pre-and post-test counselling for our clients. Test results are available within 20 min of doing the test. The DSC Clinic Blk 31, #01-16 Kelantan Lane Singapore 200031 Operating Hours: 6.30 to 8.00 pm on Tue & Wed, 1.30 to 3.30 pm on Sat (except public holidays)

Coordinator Phil Loh • phil.loh@afa.org.sg

HIV/AIDS Hotline – Tel: 62540212 The hotline provides information and counselling services on all aspects of AIDS.

Coordinator Norani Othman 62540212 • norani.othman@afa.org.sg

The Candlelight Memorial This is an annual international event held to remember those who have died from AIDS. The Memorial provides an opportunity to come to terms with death and AIDS. It has become a powerful symbol of the presence of AIDS in Singapore , and a timely reminder for the community to renew its commitment to fight AIDS discrimination. The memorial is held on the last Sunday in May.

Legal Assistance We provide free legal advice and assistance to PWAs and their families on how to deal with difficult employers and workplace issues, draw up wills, and advice on issues related to the Advanced Medical Directive, we have also been asked to assist and investigate in specific instances where discrimination against PWAs has occurred. Coordinator Thomas Ng • info@afa.org.sg

Singapore AIDS Conference These biennial multisectorial conferences on AIDS were successfully organised in 1998, 2000, 2002, 2004, 2006 and 2008. Over 600 delegates from government and nongovernmental organisations, volunteers, the press, and businesses attended the last one. The 6th Singapore AIDS Conference was held on 8th November 2008 at the Suntec Convention Centre. Secretariat Nina Sharma • comcon@pacific.net.sg Art Against AIDS Started in 1996, this biennial competition uses art as a medium to help raise AIDS awareness and encourage community participation in AIDS prevention. Coordinator Dawn Mok • info@afa.org.sg

Executive Committee

Staff

President • Roy Chan Vice-President • Braema Mathi Secretary • Dawn Mok Asst Hon Secretary • Thomas Ng Hon. Treasurer • John Woo Committee Members • Lee Cheng Chuan • Arthur Lim • George Bishop • Caroline Fernandez

Hon. Associate Director • Paul Toh Snr Programme Manager • Donovan Lo Programme Coordinators • Jesse Koh • Avin Tan • Aaren H. Shaffi • Edwin See • Vincent Oh Admin Executive • Siti Nura’ain Fund-raising Executive • May Yong Clinic Managers • Anwar Hashim • Julie Matthews • Phil Loh

If you would like to make a donation, please make your cheque out to:

“ACTION FOR AIDS, SINGAPORE”,

and post it to

35 Kelantan Lane #02-01 Singapore 208652 As all donations are tax deductible, please include your NRIC, FIN or RCB number and full name. You may also donate online through the NVPC Donation Portal – www.sggives.org/afa If you would like to be a volunteer, write to us at the above address or send an email to

Alternatively, please call

volunteer@afa.org.sg

62540212 for enquiries.