In Singapore, notification of HIV/AIDS is a statutory requirement. Under the Infectious Diseases Act, all medical practitioners and laboratories are legally required to notify every case of HIV/AIDS infection to the National HIV Registry using the MD131 form. Notifications can be carried out via the Internet, fax or mail.

Epidemiological information on HIV infection and AIDS can be obtained from the National HIV Registry at the National Public Health Unit (NPHU), which is under the purview of the Communicable Diseases Division (CDD) of the Ministry of Health (MOH). Demographic and relevant clinical information of these cases are maintained in the Registry for the purpose of surveillance, monitoring and contact tracing.

History[]

1980s[]

Main article: Earliest cases of HIV/AIDS in Singapore

The first HIV-positive cases in Singapore were reported in April 1985 (see Archive of "Three in S’pore found with Aids-linked virus", The Straits Times, 10 April 1985). These patients were warded at Middle Road Hospital, which later became the Communicable Disease Centre (CDC). Soon after this, two more cases were reported. All the first three cases were discovered by Dr K V Ratnam, a dermato-immunologist at Middle Road Hospital (see Archive of "Aids virus: Doctor who 'found it'", The Sunday Times, 14 April 1985).

The government reacted immediately to the discovery of these HIV-positive cases by forming the Advisory Committee on AIDS in the same year, 1985. This committee formulated an action plan, called the National AIDS Control Programme (NACP), to implement control measures for the prevention of HIV incidences in Singapore. The advisory committee was subsequently replaced by two boards in 1987 – the AIDS Task Force and the National Advisory Committee on AIDS. The two boards took on different tasks to help implement the action plan. The AIDS Task Force advises the MOH on scientific and medical matters pertaining to AIDS, while the National Advisory Committee on AIDS provides community feedback to MOH as well as advice on AIDS education to the public. HIV-infection was deemed a notifiable disease by the Infectious Diseases Act in 1985, and since then, it is compulsory to notify MOH when a person tests positive for HIV infection. The act was later amended such that any action by an HIV-infected person that may result in the transmission of the infection becomes an offence. The first AIDS death in Singapore was reported in April 1987 (see Archive of "Aids claims first victim here", The Straits Times, 8 April 1987).

The first case of AIDS in Singapore was diagnosed in a male patient in September 1986 by Drs. Chew Suok Kai and Edmund Monteiro at the Communicable Disease Centre (CDC) along Moulmein Road. He was admitted into ward 76 at the CDC. He was a heterosexual seaman who died on Sunday, 5 April 1987 and who also infected his wife with HIV. As at October 1987, she was one of the 12 Singaporeans who had been diagnosed with the infection.

The predominant mode of HIV transmission in Singapore since 1985 has been via the sexual route. The HIV epidemic in Singapore was initially identified in the earlier period between 1985 and 1990 mainly in homosexual and bisexual men, and less frequently amongst heterosexual men. This was the result of homosexual and bisexual males contracting the virus from industrialised countries, namely the United States, Australia and Western Europe, and returning home with the infection. At the end of the 1980s, there were still no cases of HIV infection detected in haemophiliacs and intravenous drug users.

In 1985, ten men and women, mostly gay healthcare professionals, who were concerned that there was no government initiative to tackle the growing HIV epidemic as the early cases occurred only in the very marginalised MSM community, came together to form the informal core of a group which they subsequently named Action for AIDS (AfA). It nominated Dr. Roy Chan of the National Skin Centre as its president.

The first public symposium on AIDS was held on 16 April 1988 at the Westin Plaza hotel. About 1,000 people paid the registration fee of $10 to attend the symposium, jointly organised by the Singapore Medical Association (SMA).

On 30 November 1988, Action for AIDS was registered with the Registrar of Societies.

On 1 December 1988, AfA organised the first ever World AIDS Day (WAD) fundraising and awareness event called Charity Jukebox st Centrepoint. It featured many top local entertainers and was sponsored by The Body Shop.

With the exception of 1989, the number of cases of HIV infection and AIDS has shown an upward trend since then.

The pattern of HIV being detected mainly in homosexual and bisexual men changed in the late 1980s, when increasing numbers of heterosexual men were diagnosed with HIV, far outstripping the numbers of gay and bisexual males. This was an expected observation, as there were much larger numbers of heterosexuals in the community, and given the epidemiology of HIV infection in the surrounding region. It was thought that the large majority of infections amongst heterosexuals had been contracted via sexual contact with sex workers in neighbouring countries, particularly Thailand. The Thai epidemic amongst female sex workers took off in the mid-1980s.

With the increasing numbers of straight males getting infected, more females with HIV were detected, and also paediatric cases, the result of mother-to-child transmission. In 1991, a two-year-old boy, whose parents were both carriers, was diagnosed as HIV-positive. This was the first such case in Singapore, bringing to total number of carriers to 99.

1990s[]

From 1991 onwards, heterosexual transmission became the dominant mode of HIV transmission in Singapore until 2011.

In 1999, Paddy Chew came out to the general public as Singapore’s first person living with HIV/AIDS (PLWHA), finally giving a face to the epidemic. His efforts are still remembered vividly today - his interviews with the press, his collaborative writing and performance of his play with The Necessary Stage, “Completely With/Out Character”.

2000s[]

In 2000, three significant changes in official policy with regard to HIV/AIDs occurred, largely due to the efforts of AfA's advocacy both behind the scenes and in public forums and Paddy Chew's coming out.

Singapore hospices began to accept HIV-positive patients.
The Ministry of the Environment ended its unscientific practice of burying the dead bodies of HIV-positive people like toxic waste.
It was affirmed that foreign HIV-positive spouses of Singaporeans would no longer be deported.

From 2000 to 2007, the annual incidence of HIV infection nearly doubled from 226 to 422.

A survey done in 2007 indicated that 3.1% or one out of every 33 of the MSM community were HIV-positive. This was one of the lowest prevalence rates in Asia, dwarfed by numbers gathered in similar studies in Taiwan (8%) and Bangkok, Thailand (28.3%)

However, there was an enormous amount of stigma associated with being positive, with no employers or educational institutions publicly coming out to defend the rights of positive people to work alongside others in Singapore.

At the end 2009, a total of 4404 cases of HIV/AIDS had been diagnosed, out of which 3956 (89.8%) were males, and 448 (10.2%) were females. This translated to a HIV notification rate of 12 per 100,000 persons in 2009.

2010s[]

2012[]

In 2012, another 469 Singapore residents were newly reported with HIV infection[1]. About 93% of the new cases were males and 7% were females. This brought the total number of HIV-infected Singapore residents to 5,775 as at the end of 2012. 2,814 persons were asymptomatic carriers, 1,379 had or had had AIDS-related illnesses and 1,582 had died.

Sexual transmission remained the main mode of HIV transmission among Singapore residents. Of the 469 cases reported in 2012, 457 cases acquired the infection through the sexual route, with heterosexual transmission accounting for 47% of infections, homosexual transmission 45% and bisexual transmission 6%. Intravenous drug use (2 cases) accounted for 0.4% of infections.

Nearly 90% of all new cases reported in 2012 were between 20 to 59 years of age. Almost half were between 30 and 49 years of age.

Approximately 64% of all new reported cases were single, 25% were married and 9% were divorced or separated. 68% of the males were single, compared to only 22% among the females.

In 2012, 48% of the new cases already had late-stage HIV infection at the time of diagnosis.

45% of the new cases in 2012 were diagnosed during medical care, while another 34% were detected as a result of routine programmatic HIV screening. 14% were detected as a result of voluntary HIV screening. When differentiated by sexual transmission, a higher proportion of homosexuals/bisexuals had their HIV infection detected via voluntary screening compared to heterosexuals (25% vs. 4%).

2013[]

In 2013, 454 new cases of HIV infection were reported among Singapore residents. This brought the total number of HIV infected Singapore residents to 6,229 as of end 2013, of whom 1,671 had died[2].

Sexual transmission remained the main mode of HIV transmission among Singapore residents. Of the 454 cases reported in 2013, 428 cases acquired the infection through the sexual route, with heterosexual transmission accounting for 40% of infections, homosexual transmission 46% and bisexual transmission 8%. Intravenous drug use (4 cases) accounted for 1% of infections.

Almost half of the new cases reported in 2013 were between 30 and 49 years of age.

About 94% of the new cases were males. Approximately 66% of all new reported cases were single, 23% were married and 9% were divorced or separated. 68% of the males were single, compared to 31% among the females.

In 2013, 41% of the new cases already had late-stage HIV infection when they were diagnosed.

About 46% of the new cases in 2013 had their HIV infection detected when testing was performed in the course of medical care provision. Another 25% were detected during routine programmatic HIV screening while another 20% were detected as a result of voluntary HIV screening. The rest were detected as through other types of screenings. When differentiated by sexual transmission, a higher proportion of homosexuals/bisexuals (30%) had their HIV infection detected via voluntary screening compared to heterosexuals.

2019[]

At the end of 2019, a total number of 8,618 Singapore residents had been infected with HIV of whom 2,097 had died. The number of new cases reported to the National HIV Registry yearly had been on an upward trend, peaking at more than 400 new diagnoses annually in the mid-2010s, before falling in 2018[3].

2020s[]

2020[]

Incidence[]

From January 2020 to October 2020, a total of 220 newly diagnosed cases of HIV were reported[4]. Of the cases:

90% were male
37% were 20-39 years and 42% were 40-59 years
54% had late-stage HIV infection[2] at diagnosis. This was higher than the proportion of 49% for the same period in 2019.
Sexual intercourse remained the main mode of transmission, accounting for 96% of the 125 cases. Homosexual transmission was the mode of transmission for 46% of all cases, while 40% were from heterosexual transmission and 10% were from bisexual transmission.
About 58% of the newly reported cases were detected by HIV tests done in the course of medical care. Another 22% were detected during routine programmatic HIV screening while 15% were detected through self-initiated HIV screening. The rest were detected through other types of screening. A higher proportion of homosexuals/bisexuals (21%) had their HIV infection detected via self-initiated HIV screening compared to heterosexuals (8%).

The incidence of HIV for the whole of 2020 dropped to below 300 for the first time in 17 years. The last time case numbers remained below 300 was in 2003, when there were 242 cases. HIV infections had been rising steadily since the first cases were reported in the mid-1980s, hovering between 300 and 500 per year from 2004 to 2017. Since 2012, however, when there were 469 new cases, there had been a general downward trend in the number of new patients with HIV infections.

Effect of Covid-19 pandemic[]

Doctors attributed the marked reduction in new HIV cases in 2020 to safe distancing measures due to the Covid-19 pandemic, and the circuit breaker from April 2020 to June 2020[5]. “Fear of Covid-19 caused people to minimise social interactions and basically stay home. Gatherings and night life were all affected,” said Dr Colleen Thomas, medical director of the Saint Jude Centre of Internal Medicine at Mount Elizabeth Novena Specialist Centre. Infectious diseases specialist Dr Leong Hoe Nam from Mount Elizabeth Novena Hospital said: “With restricted mobility and less meet-ups, the chances of sexual encounters in non-monogamous relationships were reduced.” But he also noted that some people may have been infected with HIV who did not get tested because of the pandemic, and would not be reflected in the figures. “There might have been reduced testing this year due to Covid-19. People may have postponed the HIV testing as they were frightened of coming forward to see the doctor or going to hospitals,” said Leong.

Sumita Banerjee, executive director of Action for Aids said a "much lower" number of people came for testing at its anonymous testing site in 2020, compared with previous years, due to Covid-19. Rayner Tan, a doctoral candidate at the Saw Swee Hock School of Public Health who had been conducting research in HIV and sexually transmitted infections, noted the steeper drops in yearly cases after 2017, attributing it to the rollout of PrEP in late 2016. Since 2018, yearly cases had hovered in the low 300 range, down drastically from 434 cases in 2017. “Research underpinned both the efficacy of PrEP, as well as its acceptability and higher uptake among homosexual and bisexual men,” reported Tan. “If we are able to scale up access to HIV PrEP, our modelling studies at the school suggest that it is possible to eliminate the onward transmission of HIV as early as 2030."

16 HIV drugs subsidised by Government[]

In a move widely lauded by activists, the Ministry of Health added 16 antiretroviral drugs used for the treatment of HIV, including Truvada and Edurant, to its list of subsidised drugs with effect from 1 September 2020, making them much more affordable for thousands of Singaporeans[6]. The 16 drugs were also added to the Medication Assistance Fund which allowed patients who could not afford them to draw from it to help pay the cost. All subsidised patients who purchased any of the 16 drugs would henceforth receive 50% or 75% worth of subsidies, depending on patient's means test status. Previously, people living with HIV could only receive help from the Medication Assistance Fund on a case by case basis.

2021[]

On Wednesday, 2021, the Ministry of Health reported that Singapore detected 198 new cases of HIV infection among citizens and permanent residents in the first 10 months of the year, a fall of 10% year-on-year[7]. The lower figure could be related to the impact of the Covid-19 pandemic.

In an analysis of the 119 cases which were reported in the first six months of the year, the majority of the infections (93%) were in men. 48% of the cases were those aged between 20 and 39 years while 33% of the cases were among those who were aged between 40 and 59. 60% of these 119 cases had late-stage HIV infection at the time of diagnosis, which was 6% higher compared to the same period the previous year. Sexual intercourse remained the main mode of transmission and accounted for 94% of the cases in the first half of the year.

Homosexual transmission was the mode of transmission for 55% of all cases, while 35% were from heterosexual transmission and 4% from bisexual transmission. The majority of the newly reported cases (57%) were detected by HIV tests which were performed in the course of medical care typically at a late stage of HIV infection. Another 15% of the cases were detected during routine programmatic HIV screening which included screening programmes for people with sexually transmitted infections, hospital inpatients as well as those who were identified through contact tracing. A further 21% of the cases were detected through self-initiated HIV screening while the remaining 7% had been detected through other forms of screening. A higher proportion of people who identified as homosexual or bisexual (30%) had their infection detected via self-initiated HIV screening compared to heterosexuals (10%).

2024[]

Parliament amends Infectious Diseases Act so that PLHIV no longer need to inform sex partners of risk if undetectable viral load maintained[]

On Thursday, 7 March 2024, after a discussion which saw pertinent questions being fielded by Workers' Party MP He Ting Ru and PAP MP Louis Ng, Parliament unanimously passed an amendment to Section 23(1) of the Infectious Diseases Act so that people living with the human immunodeficiency virus (PLHIV) would no longer be required to inform their partner of the risk of contracting HIV infection before sexual activity if the individual had maintained “an undetectable viral load for a certain period of time” preceding the sexual activity.

Senior Parliamentary Secretary for Health, Rahayu Mahzam, announced that a PLHIV was presumed to have zero risk of transmitting the infection if “certain conditions” had been met.

First, the PLHIV must have maintained a stable undetectable HIV viral load “consistently below 200 copies per ml of blood, for at least six months, based on test results from a recognised laboratory”.
Second, their most recent undetectable viral load test result should be nine months or less before the sexual activity in question.
And third, they must have adhered to medical treatment for HIV infection up to the time of the sexual activity.

The HIV disclosure amendment aligned with medical advancements and Singapore’s public health objective to curb transmission by “shifting greater responsibility to individuals” to get tested and treated for HIV in order to achieve and maintain a stable undetectable viral load. More details would be set out in subsidiary legislation to allow for “timely and responsive adjustments” should medical science change in the future.

Prior to the amendment, Section 23(1) required a person living with HIV to inform their partner of the risk of contracting HIV infection before sexual activity took place. Doctors regularly informed patients of this legal obligation at the point of HIV diagnosis. The previous requirement accorded “choice and protection” to the partner who could then decide whether to engage in sexual activity and to take precautions if so, such as through the use of condoms, thereby reducing the risk of spreading HIV.

Rahayu reminded the House that “irresponsible behaviour” that could lead to the transmission of HIV remained an offence in Singapore, and appropriate enforcement action would be taken as required. As such, Section 23(2) of the Infectious Diseases Act would remain. This legislation required people who did not know they had HIV but who had reason to believe they may carry the virus to inform their sexual partners of the risk of infection.

That legal obligation would continue to deter irresponsible behaviour, “including from those who attempt to hide behind the ignorance of their HIV status”, she said. However, while there were safeguards in place, it was also important for HIV legislation to be “aligned with medical advancements in HIV treatment, in order to encourage early detection and treatment of HIV”, Rahayu explained. Even though HIV remained incurable, medical advancements in HIV treatment meant that a PLHIV and maintained a stable undetectable viral load over time, as a result of consistent adherence to their treatment, “cannot transmit HIV to their sexual partner”, she said. “The sexual partner therefore is not at risk of contracting HIV from these individuals.”

Responding to MP Louis Ng’s (PAP-Nee Soon) queries about how the Health Ministry defines “undetectable viral load”, Rahayu emphasised that the criteria for the maintenance of an undetectable viral load were “rigorously determined” based on the latest scientific evidence and clinical knowledge, after consultation with HIV and infectious diseases experts.

From 2015 to 2023, seven people were convicted for failing to inform their sexual partners of the risk of getting HIV infection. Among them, four had undetectable viral loads at the time of their offence, she added. Singapore was not the first or only country to amend its disclosure law, she also noted. Other jurisdictions, such as Sweden, Taiwan and the United States, had removed the disclosure requirement for people living with HIV with no risk of transmitting the virus. Rahayu also emphasised that MOH was “not relaxing public health safeguards against HIV transmission” with the proposed amendments. Rather, the ministry was encouraging infected persons to come forward to be tested and treated, thereby better protecting their sexual partners.

Data and charts[]

Discussion[]

Females make up less than 10% of HIV infections in Singapore today. One wonders why this proportion is still relatively small compared to males, if the majority of infected males are heterosexuals. There are a number of possible reasons - firstly, most of the infected males are single, and may not have had steady partners in Singapore, contracting their infections overseas. Secondly it may be that many infected females have not been detected as it is likely that females do not consider themselves to be at risk of HIV infection, since they often do not have multiple partners, and therefore have not sought HIV testing.

On 13 January 2022, The Daily Ketchup Podcast uploaded a video entitled "Why is HIV Still Taboo In Singapore? | TDK #61" in which Dr. Wong Chen Seong was interviewed to its YouTube channel[8]:

References[]

Ministry of Health, "Update on the HIV/AIDS situation in Singapore 2014"[9],[10].
Ministry of Health, "Update on the HIV/AIDS situation in Singapore 2013"[11].
Ministry of Health, "Update of the HIV/AIDS situation in Singapore 2012"[12].
Jeannie SH Tey, Li Wei Ang, Joanne Tay, Jeffery L Cutter, Lyn James, Suok Kai Chew, Kee Tai Goh, Annals of the Academy of Medicine, Singapore, Vol. 41 No. 5 "Determinants of Late-Stage HIV Disease at Diagnosis in Singapore, 1996 to 2009", May 2012[13].
Roy Chan, Editorial in Issue 21 of The Act, "AIDS in Singapore: Is the worst over?".
Naidu Ratnala Thulaja, "National AIDS Control Programme", Singapore Infopedia, National Library Board [14].
"AIDS/HIV News Archive: SINGAPORE", Utopia [15].
Clara Chong, "Drugs used for HIV treatment now subsidised by MOH", The Straits Times, 6 September 2020[16].
Shabana Begum, "New HIV cases this year likely to dip below 300 for first time since 2003", The Straits Times, 1 December 2020[17].
https://www.moh.gov.sg/news-highlights/details/update-on-the-hiv-aids-situation-in-singapore-2020-(december-2020)/
https://www.ricemedia.co/hiv-non-disclosure-laws-in-singapore/
https://www.todayonline.com/singapore/singapore-detects-198-hiv-cases-first-10-months-2021-down-10-year-year
https://www.todayonline.com/singapore/countering-hiv-stigma-scientific-facts-and-personal-stories-one-post-time
https://www.youtube.com/playlist?list=PLeGBnz7_4hnqE03ChBlWwi4eRG5djdCo-
https://theindependent.sg/malaysian-jailed-3-5-months-in-singapore-after-concealing-hiv-status-during-blood-donation/
https://www.straitstimes.com/singapore/fewer-people-here-getting-diagnosed-with-hiv
https://theindependent.sg/hiv-individuals-seek-more-legal-protection-in-workplace/
https://www.channelnewsasia.com/commentary/singapore-hiv-review-disclosure-law-chronic-disease-perception-stigma-4032526
https://www.channelnewsasia.com/singapore/hiv-disclosure-undetectable-viral-loads-inform-partner-sexual-activity-moh-4177896
https://www.straitstimes.com/singapore/health/new-hiv-infections-in-first-10-months-of-2023-up-by-10-but-2022-infection-rate-lowest-in-26-years
https://www.straitstimes.com/singapore/with-early-and-effective-treatment-people-with-hiv-live-no-differently-from-others
https://www.straitstimes.com/singapore/85-of-people-living-with-hiv-know-their-status-aim-is-to-reach-95-by-2025-moh

Acknowledgements[]

This article was written by Roy Tan.

HIV/AIDS in Singapore

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