Angry Doctor

Friday, July 20, 2007

Take my rights... please!‎

angry doc is once again amazed by how fear of a perceived threat can cause us to trade our dignity for the illusion of security...

Have docs test for HIV without patients' consent

I READ with concern the article, 'Most with Aids virus don't know they have it' (ST, July 18). It is disturbing to learn that there is a significant number of HIV-infected people who have not yet been diagnosed.

These people endanger themselves, their sexual partners, families and possibly health-care workers. As they are undiagnosed, they may not get the right medical treatment. This affects their health and lives.

Early diagnosis and treatment of HIV can save lives and reduce the possibility of misdiagnosis. This will benefit the infected individuals and society as a whole.

Though there is currently no mandatory testing, doctors should be able to conduct HIV tests on patients, without the need to get their prior consent.

There should be screening and diagnosis points built into our medical system. For instance, patients undergoing operations, including eye operations, can have their blood tested automatically as part of the treatment process.

Patients displaying symptoms of HIV infection should also have their blood tested during medical treatment, without the need to seek their consent.

More can be done to educate people, especially the ones with at-risk behaviour, about the need to undergo blood tests.

In this way, HIV infection can be diagnosed and treated earlier. It can also reduce the spread of HIV and the increase in Aids cases.

Edmund Lim Wee Kiat

The cause of Mr Lim's concern can be found in this news article (emphasis mine):

Should Aids testing be mandatory?
Tan Hui Leng

AMID startling statistics that one in 350 hospital patients are HIV-positive, at least one voluntary welfare organisation here has called for mandatory testing of high-risk groups, in what some have described as a highly controversial and intrusive move.

The group — Focus on the Family — said it would be submitting a proposal, drafted together with doctors, to the Ministry of Health (MOH) soon.

High-risk groups, such as men who visit sex workers and sexually-active gay men, should go for compulsory testing, said its director, Mr Tan Thuan Seng.

"We should not allow people who choose high-risk lifestyles to avoid testing and thereby subject innocents in their households and medical workers to unfair risks of infection," said Mr Tan.

"These undiagnosed infected are walking time-bombs as they have the potential to knowingly or unknowingly infect others."

On Tuesday, it was revealed that a recent MOH study of over 3,000 anonymous blood samples collected in hospitals showed that 0.28 per cent of those who thought they were free of the disease were in fact HIV-positive.

This was followed by the news that the MOH is investigating the case of a man suspected of spreading the virus knowingly.

However, MPs and Aids volunteers Today spoke to were concerned about how the identification of such HIV-positive carriers is intrusive and stigmatises those affected.

"In implementing it, it's hard to not intrude into the privacy and rights of individuals," said chairman of the Aids Business Alliance, Mr Zulkifli Baharuddin.

Mr Benedict Jacob-Thambiah, an Action for Aids volunteer and the programme director of Heat Consultants, which provides HIV education at the workplace, agreed.

"Mandatory testing of any group only serves to stigmatise, isolate and deepen discrimination. It is not something I would advocate as I do not think any Singaporean should be subject to something that is patently wrong. It does no one any good," he said.

Since December 2004, pregnant women have been subjected to opt-out HIV tests as part of standard antenatal screening here. Only one case of mother-to-child transmission has occurred, and that was because the mother refused her HIV test until very late in her pregnancy, according to the MOH.

Last year, Singapore experienced a record high of 357 new HIV-positive cases.

Making testing compulsory — even for small high-risk groups — could pose some implementation problems, said deputy chairman of the Government Parliamentary Committee for Health, Dr Lam Pin Min.

"It's hard to identify persons in the high-risk groups unless they declare it themselves," he said. "It also makes it very difficult to draw a line on whether you visit sex workers or are sexually liberal or promiscuous.

"So, if you make it a law to self-declare, does it mean that you're breaking the law if you're in one category or the other?"

Those Today spoke to were all in favour of better public education, particularly as the HIV/Aids situation here is not seen as dire.

"I don't think the situation has come to the point where there is a real epidemic that requires an intrusion into private lives," said Aids Business Alliance chairman Zulkifli. "We always try to persuade and cajole people, and, in most cases, they respond."

Compulsory testing, vaccination, and quarantine for infectious diseases are not new. Society accepts that the risk of certain diseases (like measles, tuberculosis, and SARS) spreading to the population justifies the suspension of individual liberties. angry doc, having been brought up in that environment, has no problems with that. The question, to his mind, is then this: is the risk of a HIV epidemic high enough to justify compulsory testing?

Whether we test universally or only individuals identified as 'high risk' (presumably meaning everyone else but ourselves?) is another matter which we will perhaps discuss another day.

Now the 1 in 350 figure is likely skewed and may not be representative of the population at large, but let's work with it since it is obviously the figure that has gotten everyone worried.

HIV is speard primarily through bodily fluids during sexual intercourse, introduction of infected blood into the body via transfusion or needle, or from an infected mother to a baby.

Let's look at sexual contact, which is the main mode of transmission for HIV here.

The probability of transmission per coital act for a man having intercourse with an infected woman is estimated to be 0.0013 in this study*. In other words, the risk of a man catching HIV from a woman not known to be HIV-positive from a single episode of intercourse, using a prevalance of 1 in 350, is in the region of 1 in 270,000.

But of course, you can argue that one single sexual encounter with an infected partner is enough to give a person HIV, in which case it doesn't really matter whether the figure you are looking at is 1 in 270,000, 1 in 350, or even 1 in 2 (either you get it, or you don't).

The fact is, the risk of a person catching HIV is not just a function of the prevalance of infection in the population, but also a function of risk-behaviour. Compared to diseases like SARS, we as individuals do have a much high degree of control over the risk of HIV-infection we are exposed to without having to impose compulsory testing (and presumably compulsory something-else afterwards).

After all, you can't catch HIV just because someone coughed at you.

* - angry doc had earlier used a figure of 1 in 200,000 in his caluclation, but on further reading he found that this calculation included the prevalance of HIV in the community. As noted in the study he has linked to, the transmission probability per act ranged from 0.0001 to 0.0020 in other studies. angry doc apologises for the error.



  • considering that HIV/AIDS sufferers are way more likely to get all sorts of complications that keep them in hospitals, i daresay 1/350 way overestimates the population prevalence

    i more or less agree with what the letter writer said, but i guess it's the topic that sparked the furore

    of course, if someone is getting recurrent and unusual infections, it only makes sense to test him/her for HIV

    damn you, misleading journalists!

    By Blogger KC, At July 20, 2007 9:09 pm  

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