Recommendations for the use of antiretroviral therapy in adults living with HIV in Singapore.

Since the advent of combination antiretroviral therapy (ART), the mortality attributable to HIV infection has been reduced by 80%. Newer antiretroviral agents are highly efficacious, have minimal side effects as compared to older drugs, and can be formulated as combination tablets, which reduces patients' pill burden. Despite these advances, 680,000 people died of AIDS-related illnesses worldwide in 2020. The National ART and Monitoring Recommendations by the National HIV Programme are created to guide physicians on the prescribing of ART based on the patients' needs. These recommendations are based on international guidelines and tailored to the local context and unique domestic considerations. It is hoped that with the publication of these recommendations, the care of people living with HIV can be enhanced, bringing us closer to the ending of HIV in our lifetime.

Exploring the role of trauma in underpinning sexualised drug use ('chemsex') among gay, bisexual and other men who have sex with men in Singapore.

BACKGROUND: Sexualised drug use (SDU) has been identified as a major risk factor for HIV, as well as other mental health comorbidities among gay, bisexual and other men who have sex with men (GBMSM). While multiple studies have been conducted on the topic, few have explored the role of trauma in underpinning experiences of SDU among substance use treatment-experienced GBMSM. This qualitative study investigates life histories of trauma, and proposes a framework to better situate the factors driving SDU among treatment-experienced GBMSM. METHODS: We conducted semi-structured in-depth interviews with 33 purposively-sampled GBMSM with a history of SDU, and seeking treatment for it in Singapore. Interview topics included participants' experiences and life histories of SDU, substance use, incarceration, trauma, as well as stories of resilience and ongoing recovery from SDU. Interviews were audio-recorded, transcribed, coded, and analysed using inductive thematic analysis, from which a trauma-informed framework was developed. RESULTS: Participants firstly articulated the positive and desired aspects of SDU, such as its utility in allowing them to achieve positive emotional states, sexual enhancement, and feelings of connectedness and intimacy. Participants also described how SDU, in contrast, was used as a coping mechanism to deal with emotional and situational 'precipitants', including dealing with loneliness and a low self-esteem, sexual shame and social anxiety, as well as general stressful situations. Participants also articulated how such precipitants were underpinned by experiences of trauma, including those relating to HIV-related stigma, racism, sexual violence, death and loss, neglect, as well as internalised homophobia. Next, participants illustrated how such trauma were in turn reinforced by several 'preconditions', including the accessibility of substances, emphasis on sexual capital, and lack of access to mainstream support structures in the gay male community, alongside general sociolegal barriers to accessing care. CONCLUSIONS: This study proposes the role of trauma and the preconditions underpinning them in motivating SDU among a sample of largely substance use treatment-experienced GBMSM in Singapore. Interventions that provide support for GBMSM seeking treatment for SDU should provide trauma-informed care to address the complex barriers to treatment effectiveness.

Perceptions of an HIV self-testing intervention and its potential role in addressing the barriers to HIV testing among at-risk heterosexual men: a qualitative analysis.

OBJECTIVES: Voluntary HIV testing rates are still low in several Asian countries including Singapore. HIV self-testing (HIVST) has the potential to increase testing, leading to earlier diagnosis and better prognosis. However, the views of at-risk individuals, especially heterosexual men (HSM), who are not coming forward for testing are still poorly understood. In this study, we examined the barriers and facilitators to and delivery preferences for HIVST in order to implement an effective intervention in Singapore. METHODS: From May 2017 to June 2018, 48 in-depth interviews were conducted with HSM aged 21-66 years and at risk of HIV infection. Participants were purposively sampled based on ethnicity, age and testing behaviour. Recruitment was done mainly at brothels and entertainment establishments in Singapore. Participants gave their views on HIV testing, factors affecting HIVST use and their preferred HIVST service delivery model. RESULTS: Most participants preferred HIVST over conventional testing for its convenience, privacy, anonymity and autonomy, but older men still preferred conventional testing. Low self-perceived risk, low awareness and self-efficacy for HIVST, and non-comprehensive test for other STIs were reported as barriers to HIVST. There were mixed opinions on kit preference. A blood-based kit was favoured for higher accuracy, while the oral-fluid-based kit was favoured for ease of use. Participants wanted a human touch for post-test counselling and linkage to care only if they self-tested positive. Traditional media, internet and social media, and venue-based outreach were potential advertising platforms mentioned. CONCLUSIONS: A locally acceptable and feasible HIVST intervention must address the barriers and facilitators of using HIVST in order to improve HIV testing rates among this at-risk population who might otherwise delay or fail to present for testing.

Potential interactions between the pathways to diagnosis of HIV and other STIs and HIV self-testing: insights from a qualitative study of gay, bisexual and other men who have sex with men in Singapore.

OBJECTIVES: This study draws on qualitative insights on the barriers and facilitators to HIV testing, as well as perceptions of HIV self-testing (HIVST), to propose a framework to understand not only the benefits but also potential knock-on implications of introducing HIVST in the context of other STI testing. METHODS: We conducted semistructured, in-depth interviews with 30 gay, bisexual and other men who have sex with men aged 18 and 39 years old in Singapore. Interview topics included barriers and facilitators to HIV and other STI testing, as well as perceptions of HIVST. Interviews were audio-recorded, transcribed, coded and analysed using thematic analysis. RESULTS: For HIV testing, participants cited the perceived risk of acquiring, susceptibility to and symptoms of HIV as internal motivators, while social influence and accessibility of HIV testing services were external motivators. For STI testing, perceived symptoms and partner notification of STI were reported as internal and external motivators, respectively. Availability of bundle tests, starting a new relationship and instances of mandatory testing motivated both simultaneous HIV and other STI testing. The fear of a positive diagnosis and lack of confidentiality were cited as internal and external barriers to HIV testing, respectively, while low perceived severity of other STI and the cost of STI tests were cited as internal and external barriers to other STI testing, respectively. We identified pathways to HIV and other STI testing and discussed how the introduction of HIVST may reduce opportunities for other STI testing. CONCLUSIONS: The findings of this study suggest that introducing HIVST might weaken linkages to other STI testing if alternative strategies of promoting other STI testing are not simultaneously implemented. We recommend that future interventions address both the risks of HIV and other STI simultaneously, and that structural interventions promoting HIV and other STI preventions be balanced accordingly.

"I have HIV but I'm not the HIV" - the experiences of heterosexual Chinese men living with HIV in Singapore.

As HIV is widely acknowledged as a stigmatized chronic condition which impacts the self, it is important to study the experiences of people living with HIV in relation to their selves and identities. According to extant literature on HIV and identity, the incorporation of an HIV identity is essential to adapting to the diagnosis. However, most of the participants in this study reject HIV as an identity. Using qualitative in-depth interviews, this paper explores the experiences of twelve heterosexual Chinese men living with HIV in Singapore. This paper is anchored by identity concepts from identity theory to examine the impact of HIV on self and identities and how various identities are reworked in the face of a stigmatized chronic medical condition. Thematic analysis shows varying impact of HIV on self, the role of normative identities and the location of HIV in their lives. The findings shed light on the importance of normative identities and the manner in which participants locate HIV in their lives.

How HIV patients construct liveable identities in a shame based culture: the case of Singapore.

This article interrogates the mainstream healthcare narrative that frames human immunodeficiency virus (HIV) as a chronic disease, and triangulates it with the lived experiences of people with HIV in Singapore. It also examines how HIV patients reconstruct their identities after the diagnosis of HIV. Four HIV patients (two males and two females) were interviewed in depth by an experienced medical social worker. Findings revealed that even as the illness trajectory of HIV has shifted from a terminal condition to a chronic one, living with HIV continues to be fraught with difficulty as society, especially in the Asian context, perceives HIV with much fear and disapproval. The participants had an overwhelming sense of shame when they were initially diagnosed with HIV and they had to reconstruct a liveable identity by containing the shroud of shame, reinforcing their normative identities and constructing new ones. These strategies help them to keep their shame at bay. This paper also unpacks nuanced insights of shame experienced by Chinese HIV patients in an Asian city dominated by Confucian values.

Empathy – The Essentials in Counselling People with HIV

The landscape of HIV has changed from an incurable disease to be more like a chronic disease as the result of advances in medications; the lifespan of People Living with HIV (PLHIV) has also lengthened, HIV defining diseases are delayed, and many of the complications of HIV prevented with adherence to medications. The stigma and discrimination of HIV remain however. PLHIV need to cope with emotional issues of guilt, shame, and self-blame; social issues of rejection, termination of employment, fear and bad social experiences. The paradigm shift from negative regard of PLHIV to that of empathy, which is a deliberate and conscious attitude to relate to PLHIV as fellow travellers in life, to be able to feel with them rather than against them, has therapeutic effects. Empathy has its processes of active listening, responding with appropriately chosen words to describe feelings of the patients, and reflecting the desire to understand more about the patient’s emotions and social turmoil. The benefit of empathy in counseling are the ability to connect with the patient, to build trust from the patient being counseled, and a more objective perspective of being able to see the patient from his/her perspective rather than from the therapist’s perspective. More importantly empathy is a positive response to emotional and social issues experienced by the patient compared to platitudes like “You will be alright; or “don’t worry”, which negate and minimise the opportunity to have a catharsis.