Angry Doctor

Saturday, August 04, 2007

Take your rights? Don't mind if I do...

A rather serious topic to end the week on, but something we should all think about, I think...

(emphasis mine)

Aids stats point way to HIV tests
Health Minister 'seriously considering' opt-out scheme to stem tide

WITH recent statistics pointing to a worrying Aids trend here, the Government is thinking of extending the opt-out scheme to HIV-testing, too. So, if you are male, admitted to a hospital and have not opted out, then don't be surprised if you are asked to take an HIV test.

The Ministry of Health (MOH) is looking into an opt-out system for HIV testing as statistics show that one in 350 hospital patients is HIV-positive. A recent MOH study of more than 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.

Also, a record 357 Singapore residents were diagnosed with HIV last year, up 12.6 per cent from 317 cases in 2005. Of the new cases, about 91 per cent were males.

Since then, a voluntary welfare organisation has called for mandatory HIV testing for those in high-risk groups — which some have described as intrusive.

Health Minister Khaw Boon Wan said on Friday that while mandatory screening is good from a public health point of view, there are objections and difficulties in implementation.

"The minimum is, I think, we have an opt-out scheme," he said.

For example, it could be administered when a patient is admitted to the hospital as part of standard tests.

"So, you can opt out if you want to, but otherwise people would just take it as a routine exercise like taking high blood pressure (and blood sugar)," said Mr Khaw on the sidelines of a National Day Observance Ceremony at Tien Wah Press.

Mr Khaw added that he was "seriously considering" the move to routinely test adult males on an opt-out basis.

He said: "If you take this rate of 1 in 350. Every day, the public hospitals probably have about 5,000 in-patients ... so at this rate, that means there are about a dozen unknown HIV patients whom we have very close contact with every day.

"As healthcare workers, we have proper infection control — (we wear) double gloves and so on — but accidents do happen ... so it's a problem I cannot ignore."

Of the new HIV cases last year, 78 per cent were detected when they were tested for HIV while receiving other medical care. Only 13 per cent were detected as a result of voluntary HIV screening.

The MOH's opt-out screening for pregnant mothers, implemented in 2004, has been successful in saving babies, with just one case of mother-to-child transmission occurring, and that was because the mother refused her HIV test until very late in her pregnancy.

Less than 1 per cent of pregnant mothers had opted out of the scheme.

While HIV testing "makes a lot of sense", Mr Khaw admitted that a lot of planning would have to be put into the exercise, such as bumping up counselling services for those found to be HIV-positive.

Mr Andrew Tan, a 27-year-old engineer who is single, said: "I am okay with it as I don't think I'm at risk, but I think it may be uneasy for you if you know that you have engaged in risky behaviour (like unprotected sex)."

The chairman for the Government Parliamentary Committee on Health, Mdm Halimah Yacob, described the opt-out HIV testing as an idea worth exploring .

"If you test by selection saying that people are in higher risk groups then one can say that you're passing judgment on lifestyle, choices, et cetera," she said.

"But if it applies to everyone subject to their right to opt out ... then I think it's all right."

Mr Tan Thuan Seng, director of Focus on the Family, which had suggested mandatory HIV testing, said the MOH's move is in line with what it is proposing.

"I think once people get used to the idea that HIV testing will be routinely conducted, they will get used it and eventually most will not opt out," said Mr Tan.

angry doc was brought up in the era when the HIV test, far from being something mandatory or 'opt-out', was a test that required pre-test counseling, on the grounds that it was a serious infection with many implications, that there was no cure for it, and that it was a notifiable disease.

Things may have changed somewhat since then: there are now effective treatment for the disease (although not yet a cure), and testing can now be done anonymously.

Still, as he has mentioned in a previous post, angry doc is not convinced that the figure of 1 in 350, assuming it is representative, necessarily means that the general population is at a high risk of becoming infected with HIV.

Moreover, angry doc questions the reasons for making HIV testing an 'opt-out' test given in the article.

According to the MOH HIV Statistics page, the incidence of perinatal transmission was 1 or 2 per year from 2000 to 2003, rising to 4 cases in 2004 (the year 'opt-out' testing for pregnant women was implemented), 3 cases in 2005, and 2 cases in 2006.

As for the problem of protecting healthcare workers which we 'cannot ignored'? The Ministry's HIV Statistics page does not record any incidence. In any case, Universal Precaution applies for all patients - just because someone is not HIV-positive does not mean you don't need to wear gloves when handling his or her body fluids. Accidents do happen, except they haven't resulted in any patient-to-healthcare worker transmission locally, nor can we eliminate accidents totally even when we know if a patient is HIV-positive. In any case, post-exposure prophylaxis can and is given to healthcare workers involved.

The fact is, the majority of HIV patients are actually adult males who become infected through sexual contact.

Will an 'opt-out' testing system reduce the rate of new infection amongst this group of patients? Probably, if we give them access to counseling, education, and affordable treatment.

Will it reduce the rate of perinatal transmission and transmission to healthcare workers in the course of their work? Well, these groups of people constitute less than 1% of the new infection cases each year, so even if you eliminate them altogether, you will barely put a dent in the total HIV infection rate.

So why use them as the justification for implementing an 'opt-out' system? Well, because if we are going to give up our rights, we would rather be told that we are doing it to protect babies and doctors, and not men who catch HIV from gay or paid sex, wouldn't we?

(Added: See insanepoly's take on this subject here)



  • That is a new way of taking more money out of everyone, by asuming that everyone is infected unless proven otherwise. Just like our laws have changed to assuming that once one is charged in court one is guilty unless proven otherwise.

    What is becoming of our ministers and what is happening to their brains?

    Always finding the easy way out at the expense of the powerless and hapless citizens?

    By Anonymous Sickened, At August 05, 2007 2:05 am  

  • I disagree with the comments posted. It is well known among those on the ground that 'universal precautions' translate into 'just do the usual' in a busy hospital. Needle stick injuries are recorded in the incident report book (although many are not because of the hassle of reporting a 'minor cut from a non-infectious case') but not everyone is given anti-retroviral prophylaxis. If it is known that the patient concerned is HIV positive, there will be definitely greater care involved to reduce needle-stick injuries during handling. Of course it is not possible to prevent all HIV transmission as some cases may be in the window period, but it will definitely cut down the risk.

    Secondly and more importantly, knowing that a patient is HIV-positive will change the management and avoid wasting large sums of money doing needless investigations. It also provides valuable epidemiological data for making healthcare policies.

    I say 'yes'..test all patients for HIV unless they opt out.

    By Anonymous Anonymous, At August 05, 2007 2:28 pm  

  • The KTM is not sure he understands your position on this matter. Are you against opt-out testing or are you just unhappy with the official reasons for the move?

    If you are against opt-out testing, perhaps you can explain why? The KTM is of the opinion that it is good for us to know if there are HIV-positive people within the healthcare system and it is not a matter of infringement of privacy.

    Exactly what can be done with that information, the KTM doesn't know 'cos he's not a healthcare professional, but from a systemic perspective, having more information most definitely doesn't hurt.

    Also, there may be blur people who dunno that they got infected and who wouldn't ordinarily go for AIDS tests. Early detection would most definitely be good for such people 'cos they can get treated earlier.

    By Blogger kwayteowman, At August 05, 2007 5:14 pm  

  • KTM,

    I am not against 'opt out' testing, but I am not yet convinced I should be for it either.

    There are several questions we need to answer first.

    How representative is the figure of 1 in 350, and if it is representative, how big a risk does it represent to the population at large?

    To implement an 'opt out' system represents an investment in manpower and money, so the other question is: will an 'opt out' scheme for all adult male hospital patients make a real difference to the HIV prevalence in Singapore?

    How does the projected total cost of doing all those screening HIV tests plus confirmatory tests compare to what it will cost to give free or subsidised treatment for those already known to have HIV?

    Those are the questions related to cost-effectiveness of the scheme. There are also ethical issues, but as I mentioned in the earlier post I am open to some civil liberties being suspended for public health reasons provided that such a scheme will give real, concrete benefits to the public, and that the reasons behind the decision are sound and not based on hysteria and misrepresentation of facts.

    Certainly to use the protection of babies (4 or fewer cases per year) and healthcare workers (zero case documented so far) as a reason to go on to argue that 'opt out' testing can make a difference in a disease with more than 300 new cases a year is a bit of a stretch.

    By Blogger angry doc, At August 05, 2007 5:52 pm  

  • There is no reason to screen people without risk. It is a waste of money and resources on virgin boys with no sexual contact? People dont' get HIV wihtout a reason. We might as well make opt out scheme for Hep B as well if that is the case. Just because people might not be truthful does not mean we should waste our resources like that. I think the government is over reacting. Plus why just the man? Why not women also? Singapore data probably shows higher infection in the MSM population but it doesn't mean that it will not spill over to women. It would probably a good inidicator for monitoring the progression if they really do it.


    By Anonymous Anonymous, At August 06, 2007 12:36 pm  

  • Another thing i've wondered about is the number of new cases relative to the numbers tested in the past year. It is also not that alarming if you were to note that as with more awareness people tend to be more willing to go for testing. That may be the real reason behind the jump rather than there being more "new" infected cases. And if that is so, the steps taken to address the problem as mentioned would not be enough. You'd have to get the entire population HIV tested and compare the numbers every year. Well that's if you want a more scientific way of looking at things.

    And yes, why not women as well?

    By Blogger Dawne, At August 06, 2007 2:27 pm  

  • dawne,

    Yes, the figures need to be seen in context, and against the rising population in the country.

    Problem is there does not seem to be a source where one can obtain the raw data and figures, and there is no independent organisation with access to those information that will assess the validity of the data and the way they are used to justify certain policies.

    By Blogger angry doc, At August 06, 2007 5:24 pm  

  • The interesting question now is, if they are not looking at the big picture, what is the reason behind it. Is it pure shortsightedness or some secret agenda...

    By Blogger Dawne, At August 06, 2007 10:41 pm  

  • Angry Doctor is right. 'Affordable medication' should be available. At the prescribed cost of ~SGD 1200/pm. Is this affordable to most people?

    Having identified as HIV +ve does not mean a DEATH sentence. In fact, several people go back to work, and support the country economically. And several earn 5 figures per month.

    Look around you the next time you in a public area. Who is and who isn't HIV +ve. The answer is you can't tell.

    HIV can be described as diabetes mellitus II (well almost). A chronic illness, with no cure, but that can be controlled by medications.

    The data for 1/350 (in 3000 samples of blood). How many of them were known HIV patients? How many NEW cases of HIV will you pick up because of this exercise? That is the most pertinent question.If the ~8 cases were all patients from CDC...your data has had no added value.

    So what if the diagnosis of HIV is made? Will a HIV infected individual simply start practising safe sex? There are several HIV +ve sexual predators out there who have the incredulous thought that having sex with virgins will cure them of HIV. What a load of HOGWASH! Perhaps they have HIV dementia!

    For the practising doctors. Post exposure prophylaxis is given according to the risk of transmission. Hence not everybody is given. There are guidelines in place.

    On the statement "If it is known that the patient concerned is HIV positive, there will be definitely greater care involved..." More often than NOT, a HCW becomes so paranoid that he / she ends up making more mistakes, especially the new HOs!

    Does the diagnosis of lymphoma + HIV means that the patient gets investigated less? NO! The patient is still entitled to chemotherapy + HAART with good results! ie Money will still be spent! PERIOD!

    This scheme does not help prevent transmission to babies. There is already in existence an excellent case identification scheme where there is an OPT-OUT option for HIV testing for mothers in Singapore. Sign-up rate is virtually 100%. What are you hoping to prevent? More importantly, the volunteer groups have done the RIGHT THING, by NEVER EVER DENYING a HIV+ve mother HIV TREATMENT during the pregnancy.

    By Anonymous Concerned Singaporean, At August 06, 2007 11:56 pm  

  • Affordable medication? The anti-retroviral drugs are patented and that explains the high costs. It is not appropriate to take funding away from other patients for a condition that is incurable. Everyone knows there is another option: HIV patients should cross over to Thailand to buy such drugs. Singapore cannot follow Thailand down the compulsory licensing route as it will hurt our pharmaceutical industry. That would not be in the national interests.

    By Anonymous Anonymous, At August 08, 2007 2:47 pm  

  • "It is not appropriate to take funding away from other patients for a condition that is incurable."

    I'm pretty sure my patients with asthma, diabetes, chronic hepatitis B, and terminal cancer will disagree with that statement.

    By Blogger angry doc, At August 08, 2007 3:16 pm  

  • I really like your blog. Thank you for thinking about things and articulating many insightful comments which have been very useful for me in deciphering all these extraordinary things I have read in the newspapers recently.

    My take on compulsory HIV testing is that there certainly is the issue of cost-effectiveness, as you point out, and the fact that there are other more transmissible diseases like Hep B which healthcare workers (if that is indeed the argument) are at risk of catching... more importantly, in my humble opinion, the problem lies with the fact that high-risk individuals remain unconvinced of the importance of HIV testing, and that they will receive sufficient support thereafter.

    Perhaps a better incentive, instead of passing the imperial diktat that everyone needs to be tested, would be raising public awareness about the fact that there are confidential services available and that many people with HIV do go on to lead normal lives.

    Regarding the minister's other suggestion of insurance companies 'paying-per-performance' based on patients' 'performance indicators' you are absolutely right that this is a scheme that has been implemented in the UK for a few years now. I am not aware if public health studies have already been conducted to measure the impact of this on the population's health, but I personally think that there is definitely some benefit from it (besides the GPs' giant pay-packets) although the primary healthcare in Singapore is perhaps in need of some restructuring.

    By Blogger Rachel, At August 08, 2007 4:40 pm  

  • "How does the projected total cost of doing all those screening HIV tests plus confirmatory tests compare to what it will cost to give free or subsidised treatment for those already known to have HIV?"

    Tax payers do not want their money spent on helping those who supposedly lead a 'sinful' lifestyle, but are willing to spend more to witch hunt these people. I say that because large scale hiv testing achieves nothing, either for helping those diagnosed with hiv, nor prevention of future cases.

    You have to question the govt's troubleshooting intelligence.

    By Anonymous Anonymous, At August 10, 2007 7:22 pm  

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