Thank you for the privilege.

This editorial, by the retiring Editors Christopher Fairley and Roy Chan, tells the story of the founding of Sexual Health in 2004 and its journey. They express their gratitude for privilege they have enjoyed as Editors-in-Chief of the journal.

An optofluidic platform for interrogating chemosensory behavior and brainwide neural representation in larval zebrafish.

Studying chemosensory processing desires precise chemical cue presentation, behavioral response monitoring, and large-scale neuronal activity recording. Here we present Fish-on-Chips, a set of optofluidic tools for highly-controlled chemical delivery while simultaneously imaging behavioral outputs and whole-brain neuronal activities at cellular resolution in larval zebrafish. These include a fluidics-based swimming arena and an integrated microfluidics-light sheet fluorescence microscopy (µfluidics-LSFM) system, both of which utilize laminar fluid flows to achieve spatiotemporally precise chemical cue presentation. To demonstrate the strengths of the platform, we used the navigation arena to reveal binasal input-dependent behavioral strategies that larval zebrafish adopt to evade cadaverine, a death-associated odor. The µfluidics-LSFM system enables sequential presentation of odor stimuli to individual or both nasal cavities separated by only ~100 µm. This allowed us to uncover brainwide neural representations of cadaverine sensing and binasal input summation in the vertebrate model. Fish-on-Chips is readily generalizable and will empower the investigation of neural coding in the chemical senses.

Global monkeypox outbreak 2022: First case series in Singapore.

Monkeypox is a global health emergency. Prior to 2022, there were few reports of monkeypox outside of endemic countries, which were mostly travel-related. Since May 2022, an exponential increase in monkeypox infections in previously non-endemic countries has been reported. Unlike previous outbreaks of monkeypox, which were zoonotically transmitted and presented with generalised vesicular eruptions after prodromal symptoms, cases of the current outbreak feature significant travel and sexual history, and atypical localised genital eruptions with unpredictable onset relative to viral prodrome-like symptoms. We summarise the 15 Singapore cases reported to date as of August 2022, and highlight salient clinical clues that may aid physicians in narrowing the broad differential diagnosis of an acute vesicular genital eruption. Although research into vaccination and antiviral strategies is ongoing, monkeypox is currently conservatively managed. Clinical vigilance and a high index of suspicion are required to facilitate early detection and isolation of cases to contain transmission in Singapore.

Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial.

BACKGROUND: Gay, bisexual, and other men who have sex with men (GBMSM) are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBMSM are increasing worldwide, they remain suboptimal in a variety of settings. While many studies have attempted to evaluate the efficacy of a variety of community-based campaigns, including peer and reminder-based interventions on HIV/STI testing, however few have attempted to do so for a web drama series. OBJECTIVE: This study evaluates the effectiveness of a popular web drama video series developed by a community-based organization in Singapore for GBMSM on HIV and other STI testing behaviors. METHODS: The study is a pragmatic, randomized controlled trial to evaluate a popular web drama video series developed by a community-based organization in Singapore for GBMSM. A total of 300 HIV-negative, GBMSM men in Singapore aged 18 to 29 years old were recruited and block-randomized into the intervention (n=150) and control arms (n=150). Primary outcomes included changes in self-reported intention to test for, actual testing for, and regularity of testing for HIV, syphilis, chlamydia or gonorrhea, while secondary outcomes include changes in a variety of other knowledge-based and psychosocial measures at the end of the study period. RESULTS: Overall, 83.3% (125/150) of participants in the intervention arm completed the proof of completion survey, compared to 88.7% (133/150) in the control arm. We found improvements in self-reporting as a regular (at least yearly) tester for HIV (15.9% difference, 95% CI, 3.2% to 28.6%; P=.02), as well as chlamydia or gonorrhea (15.5% difference, 95% CI, 4.2% to 26.9%; P=.009), indicating that the intervention had positively impacted these outcomes compared to the control condition. We also found improvements in participants' intentions to test for HIV (16.6% difference, 95% CI, 4.3% to 28.9%; P=.009), syphilis (14.8% difference, 95% CI, 3.2% to 26.4%; P=.01), as well as chlamydia or gonorrhea (15.4% difference, 95% CI, 4.2% to 26.6%; P=.008), in the next 3 months, indicating that the intervention was effective in positively impacting intention for HIV and other STI testing among participants. CONCLUSIONS: There are clear benefits for promoting intentions to test regularly and prospectively on a broad scale through this intervention. This intervention also has potential to reach GBMSM who may not have access to conventional HIV and other STI prevention messaging, which have typically been implemented at sex-on-premises venues, bars, clubs, and in sexual health settings frequented by GBMSM. When coupled with community or population-wide structural interventions, the overall impact on testing will likely be significant. TRIAL REGISTRATION: ClinicalTrials.gov NCT04021953; https://clinicaltrials.gov/ct2/show/NCT04021953. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-033855.

Do Credit Momentum Policies Through the 15 to Finish Improve Academic Progression and Completion of Low-Income, First-Generation Students? Evidence from a College Promise Program.

Credit momentum policies, or performance-based financial aid policies, have become increasingly popular among policymakers seeking to improve degree completion rates. This paper examines Indiana's 30-credit-hour completion policy on first-time, full-time students who receive the Twenty-First Century Scholars (TFCS) Promise Program. Using administrative data from the Indiana University's University Institutional Research and Reporting, representing 7842 low-income students who enrolled shortly before the policy was implemented, I use a difference-in-differences framework to explore the heterogeneous treatment effects of a credit (academic) momentum policy that was supported by the Complete College America 15 to Finish initiative on the academic progression and completion of promise scholarship recipients at Indiana University Bloomington and Indiana University-Purdue University, Indianapolis, compared to non-TFCS Pell recipients from the Fall 2011 cohorts through the Fall 2014 cohorts. I find some evidence to suggest that credit momentum policies are associated with small increases in cumulative credits and grades but had no effect on degree completion status (Year 4 Graduation Status, Year 6 Graduation Status). I also find evidence that TFCS female and first-generation recipients responded positively to the policy change but find no evidence that the policy affects promise recipients differently by race/ethnicity. While consistent with prior work on credit momentum, these findings are among the first to explore the academic performance of college promise recipients. Together, these findings indicate that credit momentum policies may improve academic progression and completion for low-income, first-generation students who receive a promise scholarship. Implications for policy and research are discussed.

Effects of exercise on sleep, melatonin level, and behavioral functioning in children with autism.

LAY ABSTRACT: This study examined the impact of physical exercise on sleep and behavioral functioning in children (aged 8-12 years) with autism spectrum disorders. It also investigated whether exercise would alter endogenous melatonin level among the population. Participants were divided into two groups: exercise group (12-week, 30-min morning jogging intervention) and a control group (i.e. did not receive any physical exercise intervention during the study period). Significant improvements on sleep and behavioral functioning were found in the exercise group, but not in the control group Moreover, a significant increase in melatonin level was also shown in the exercise group. Findings of this study reconfirmed the sleep and behavioral benefits of exercise in children with autism spectrum disorder. Melatonin-mediated mechanism should be further explored to develop an effective treatment intervention.

Crafting a Community Blueprint towards ending HIV transmission and AIDS in Singapore by 2030.

In November 2019, Action for AIDS launched the Community Blueprint Towards Ending HIV and AIDS in Singapore by 2030, a key milestone in the country's HIV movement where a roadmap was developed with strategies to end HIV by 2030. Overall, 60 representatives from 30 community organisations and institutions were convened to plan and lead work on the Blueprint, which covers 10 themes. The Blueprint examines the current state of the epidemic and populations most affected by it: heterosexual males with multiple partners, men who have sex with men, sex workers, transgender persons, and persons who use drugs. It assesses existing programs, estimates gaps and recommends strategies and resources needed to close the gap. The second section of the Blueprint explores cross-cutting themes including: stigma and discrimination; strengthening the HIV community workforce; and scaling up pre-exposure prophylaxis. The Blueprint provides key recommendations and is being discussed with the Ministry of Health.

Chemsex among gay, bisexual, and other men who have sex with men in Singapore and the challenges ahead: A qualitative study.

BACKGROUND: Sexualised substance use, or 'chemsex' has been shown to be a major factor driving the syndemic of HIV/AIDS in communities of gay, bisexual, and other men who have sex with men (GBMSM) around the world. However, there is a paucity of research on chemsex among GBMSM in Singapore due to punitive drug laws and the criminalisation of sexual behaviour between men. This qualitative descriptive study is the first to explore perceptions towards, motivators to engaging in, and the barriers to addressing the harms associated with chemsex among GBMSM in Singapore. METHODS: We conducted 30 semi-structured in-depth interviews with self-identifying GBMSM between the ages of 18-39 in Singapore following a purposive sampling strategy. Interview topics included participants' perceptions of drug use among GBMSM in Singapore, perceptions towards chemsex, reasons for drug use and chemsex, and recommendations to address the harms associated with chemsex in Singapore. Interviews were audio-recorded, transcribed, coded, and analysed using thematic analysis. RESULTS: Participants reported that it was common to encounter chemsex among GBMSM in Singapore as it could be easily accessed or initiated using social networking phone apps. Enhancement and prolongation of sexual experiences, fear of rejection from sexual partners and peers, and its use as a means of coping with societal rejection were three main reasons cited for engaging in chemsex. The impact of punitive drug laws on disclosure and stigmatisation of GBMSM who use drugs were reported to be key barriers towards addressing chemsex. Participants suggested using gay-specific commercial venues as avenues for awareness and educational campaigns, and social media to reach out to younger GBMSM. CONCLUSIONS: This study highlights the complexities behind chemsex use among GBMSM in Singapore, and the range of individual to institutional factors to be addressed. We recommend that community-based organisations and policy-makers find ways to destigmatise discussion of chemsex and provide safe spaces to seek help for drug use.

Optimization of protein extraction and two-dimensional gel electrophoresis profiles for the identification of Cordyceps sinensis and other similar species.

Given that Chinese materia medica (CMM) is expensive and rare, people take tremendous risk to adulterate and falsify Cordyceps sinensis with counterfeit species with similar morphological features. It is thus essential to develop new methods to identify the authenticity of Cordyceps sinensis. It is hypothesized in this study that Cordyceps sinensis possesses certain protein biomarkers distinct from its counterfeits, which can be identified by proteomic technologies for authentication purposes. This is the first study that aims to optimize the conditions for extracting proteins from Cordyceps sinensis, a hybrid of fungal-animal CMM, and to compare the two-dimensional gel electrophoresis (2-DE) profiles between different Cordyceps species. Two different protein extraction buffer systems, namely, phenol/sodium dodecyl sulfate (SDS) buffer or lysis buffer, were evaluated, where the preparation using lysis buffer yielded better protein content. The results also showed that extraction with lysis buffer without pre- or post-washing of samples was the most effective protocol, with over 220% of protein yield and 819 protein spots detected on a 2-DE gel. Moreover, the results demonstrated that Cordyceps sinensis possesses protein biomarkers distinct from its counterfeits, and these biomarkers are not source- or origin-dependent, strongly supporting the feasibility of using identified biomarkers as indicators for authentication of Cordyceps species. The findings of this study warrant further investigations on the structural identification of protein biomarkers of Cordyceps species.

Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore.

BACKGROUND: There is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention. METHODS: In-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation. RESULTS: We estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group. CONCLUSIONS: The qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02780986 . Registered 23 May 2016 (retrospectively registered).

An Abstinence and Safer Sex Intervention for Adolescents Attending the Public Sexually Transmitted Infection Clinic in Singapore.

PURPOSE: The objective of this study was to evaluate the efficacy of a behavioral intervention in increasing secondary abstinence and safer sex among heterosexually active adolescents aged 16-19 years. METHODS: This was a randomized controlled trial conducted at the only national sexually transmitted infection clinic in Singapore. The intervention focused on information giving, motivation, and skills building to abstain or practice safer sex. The outcome measures were self-reported secondary abstinence, consistent condom use, and keeping to one partner in the past 6 months over a 12-month period. We recruited 688 adolescents, with 337 participants receiving intervention and 351 receiving standard care (control). RESULTS: At the 12-month follow-up, 187 (56%) intervention participants and 189 (54%) control participants were retained. Over the 12-month period, the intervention had a significant effect on secondary abstinence in adolescent boys (42% vs. 27%, adjusted risk ratio [aRR] 1.80, 95% confidence interval [CI] 1.29-2.34) but not in adolescent girls (21% vs. 24%, aRR 1.10, 95% CI .68-1.66). Consistent condom use was higher among intervention adolescent girls than control adolescent girls (40% vs. 20%, aRR 2.01, 95% CI 1.32-2.82), but this effect was not evident in adolescent boys (51% vs. 43%, aRR 1.27, 95% CI .78-1.88). Intervention effect on keeping to one partner was evident in both adolescent boys (76% vs. 45%, aRR 1.35, 95% CI 1.06-1.50) and adolescent girls (79% vs. 65%, aRR 1.20, 95% CI 1.02-1.23). CONCLUSIONS: An intervention targeting adolescents in a clinical care setting did achieve an increase in secondary abstinence in adolescent boys, consistent condom use in adolescent girls, and keeping to one partner in both genders at 1-year assessment.

Efficacy of multicomponent culturally tailored HIV/ STI prevention interventions targeting foreign female entertainment workers: a quasi-experimental trial.

OBJECTIVES: We assessed the efficacy of a multicomponent culturally tailored HIV/STI prevention intervention programme on consistent condom use and STI incidence among foreign Thai and Vietnamese female entertainment workers (FEWs) in Singapore. METHODS: We conducted a quasi-experimental pretest and post-test intervention trial with a comparison group. We recruited 220 participants (115 Vietnamese and 105 Thai) for the comparison group, followed by the intervention group (same number) from the same sites which were purposively selected after a 3-month interval period. Both groups completed a self-administered anonymous questionnaire and STI testing for cervical gonorrhoea and Chlamydia, as well as pharyngeal gonorrhoea at baseline and 6-week follow-up. The peer-led intervention consisted of behavioural (HIV/STI education and condom negotiation skills), biomedical (STI screening and treatment services) and structural components (access to free condoms). We used the mixed effects Poisson regression model accounting for clustering by establishment venue to compute the adjusted risk ratio (aRR) of the outcomes at follow-up. RESULTS: At follow-up, the intervention group was more likely than the comparison group to report consistent condom use for vaginal sex with paid (aRR 1.77; 95% CI 1.71 to 1.83) and casual (aRR 1.81; 95% CI 1.71 to 1.91) partners. For consistent condom use for oral sex, this was aRR 1.50; 95% CI 1.23 to 1.82 with paid and aRR 1.54; 95% CI 1.22 to 1.95 with casual partners. STI incidence at follow-up was significantly lower in the intervention (6.8 per 100 FEWs) than the comparison (14.8 per 100 FEWs) group (aRR 0.42; 95% CI 0.32 to 0.55). CONCLUSIONS: This trial was effective in promoting consistent condom use for vaginal and oral sex as well as reducing STI incidence among the foreign Thai and Vietnamese FEWs in Singapore. The feasibility of scaling up the interventions to all entertainment establishments in Singapore should be assessed.

Clinical characteristics and management of patients with rosacea in a tertiary dermatology center in Singapore from 2009 to 2013.

INTRODUCTION: Rosacea is a common chronic facial skin disease. A multiethnic society such as Singapore provides an opportunity to evaluate the demographic characteristics and their impact on clinical outcome in rosacea. AIMS: The aim of this study was to evaluate characteristics and outcome of rosacea in a multiracial population in Singapore. METHODS: Records of all rosacea patients between January 2009 and December 2013 were retrospectively retrieved from the electronic medical records (EMR). Descriptive analysis was performed to understand the characteristics of patients with rosacea. Multivariate logistic regression was used to evaluate the associations between the various variables and types of rosacea as well as the clinical outcome. RESULTS: A total of 1340 patients were identified. The mean age at presentation was 42.8 years with a female predominance (65%). Most of the patients had erythematotelangiectatic rosacea (ETR) (56.3%) followed by papulopustular rosacea (PPR) (37%). With multinomial logistic regression, controlling for age, gender, and known triggers, Indians and Caucasians were more likely to have PPR compared to ETR (OR: 3.4, P = 0.01 and OR: 2.1, P = 0.01 respectively). Patients who had phymatous rosacea are also more likely to be older males (OR: 3.82 95% CI 1.64-8.92, P = 0.002). CONCLUSION: The epidemiology and outcome of rosacea among local patients were studied. Rosacea is more common among certain racial groups such as Chinese, Caucasian, and other races. The clinical subtypes also seem to be related to races of certain skin colors and might be related to varied natural intrinsic responses to the sun among different racial groups.

Randomized controlled trial of abstinence and safer sex intervention for adolescents in Singapore: 6-month follow-up.

We assessed the efficacy of an individual-based behavioral intervention on sexually transmitted infections' (STI) risk-reduction behaviors in Singapore. A randomized controlled trial of a behavioral intervention compared to usual care was conducted on sexually active heterosexual adolescents aged 16-19 years attending the only public STI clinic. The intervention included two on-site skills-based sessions targeting individual, relational and environmental influences on sexual behaviors, followed by online support. Participants were assessed at baseline and 6-month follow-up. Primary outcomes were self-reported abstinence, number of partners and consistent condom use for vaginal sex. We recruited 337 adolescents to the intervention and 351 to usual care (controls). Fifty-nine percent of intervention participants and 53% of controls completed follow-up. Young men [adjusted risk ratio (RR) 2.03; 95% CI, 1.25-3.30], but not young women, in the intervention were more likely than controls to report secondary abstinence. More non-abstinent young women in the intervention than controls kept to one partner (adjusted RR, 1.25; 95% CI, 1.04-1.50) compared to no differences in young men. There was no intervention effect on consistent condom use in both genders. Skill-based intervention can promote abstinence in young men and keeping to one partner in young women in a clinic setting.

Factors associated with consistent condom use and STIs among foreign female entertainment workers: results from a cross-sectional survey in Singapore.

OBJECTIVES: We assessed the prevalence of consistent condom use and laboratory-confirmed STIs among foreign female entertainment workers (FEWs) who engaged in paid or casual sex in Singapore and the factors associated with these characteristics. METHODS: A cross-sectional survey, using time-location sampling, was conducted on 220 FEWs (115 Vietnamese and 105 Thai) in 2015. For multivariable analysis, we used a mixed-effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratios (aPRs) of factors associated with consistent condom use and STI positivity, respectively. RESULTS: Consistent condom use with paid or casual partners in the past month was 39.6% and 36.2% for vaginal and oral sex, respectively. The prevalence of STI (cervical chlamydia, cervical gonorrhoea or pharyngeal gonorrhoea) positivity was 13.6%. In multivariable analysis, consistent condom use for both vaginal and oral sex increased with high self-perceived risk of getting STI/HIV (vaginal: aPR 2.09; 95% CI 1.26 to 3.46; oral: aPR 2.41; 95% CI 1.23 to 4.69) and condom negotiation (vaginal: aPR 3.74; 95% CI 2.07 to 6.75; oral: aPR 2.81; 95% CI 1.51 to 5.26). STI positivity decreased with consistent condom use for vaginal sex (aPR 0.22; 95% CI 0.07 to 0.75) and increased with number of sexual partners (aPR 1.43; 95% CI 1.07 to 1.92). CONCLUSION: In addition to advocating for policy decisions to provide a safer work environment, behavioural interventions on condom negotiation skills and condom use and biomedical interventions on STI/HIV testing and treatment interventions are needed among the FEWs in Singapore. TRIAL REGISTRATION NUMBER: NCT02780986; pre-results.

What are the factors associated with human immunodeficiency virus/sexually transmitted infection screening behaviour among heterosexual men patronising entertainment establishments who engaged in casual or paid sex? - Results from a cross-sectional survey in an Asian urban setting.

BACKGROUND: Late presentation of human immunodeficiency virus (HIV) is associated with heterosexual transmission, particularly among heterosexual men in Asia. Although data on HIV/sexually transmitted infection (STI) testing behaviour is increasing, information is still lacking among heterosexual men who receive far lesser attention and are generally invisible in HIV/ STI prevention, particularly in the Asian urban setting. The aim of this study was to assess the prevalence of HIV/STI testing among heterosexual men patronising entertainment establishments (EEs) who engaged in casual or paid sex in Singapore, and the factors associated with this behaviour. METHODS: This was a cross-sectional survey involving 604 participants using time location sampling between March and May 2015. For multivariable analysis, we used a mixed effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratio (aPR) for the association of various factors with HIV/STI testing. RESULTS: Among 604 at-risk participants, only 163 (27.0%) had gone for HIV or STI testing in the past 6 months. Of this, 83.4% of them specifically underwent HIV testing. In multivariable analysis, HIV/STI testing increased with being non-Chinese (aPR 1.50; 95% CI: 1.08-2.06), having engaged in anal sex with casual or paid partner in the past 6 months (aPR 1.80; 95% CI: 1.27-2.57), number of partners in the past 6 months (aPR 1.03; 95% CI: 1.01-1.05) and HIV knowledge score (aPR 1.11; 95% CI: 1.05-1.16). Among those who reported non-consistent condom use with casual or paid partner, almost half of them (47.9%) perceived that they were at low risk for HIV/STI. Sigmatisation and discrimination was another common barrier for non-testing. CONCLUSIONS: Despite being at risk of HIV/STI, the low prevalence of testing coupled with a high prevalence of risky sexual behaviour among this group of heterosexual men in Singapore calls for a need for HIV/STI prevention interventions in the EE setting. Other than promoting testing and safer sex, the interventions should address the discordance between perceived risk and actual sexual behaviour, in addition to the stigma and discrimination associated with testing for this group.