Session 1: Intersection of HIV and co-occurring conditions
Keynote 1: Integration of HIV, mental health and other co-occurring conditions
Dr Jeremy Ross, Director of Research, amfAR TREAT Asia |
Mental health and substance use disorders (MSDs) are prevalent among those living with HIV, and have substantial impact on their HIV, health and other outcomes. Resources for addressing MSDs are particularly limited in the Asia-Pacific region. Mental health, substance use disorders and non-communicable diseases also commonly co-occur. The integration of screening and treatment for MSDs within HIV clinical settings can address barriers and improve MSD screening and care coverage. However the integration of MSD screening and care in HIV clinical settings is limited in the region. Further leadership, funding, non-mental health specialist training, implementation research capacities and data to inform policies and programs are needed.
Introduction to the National HIV Programme: Primary Care Recommendations for People Living with HIV
Dr Choy Chiaw Yee, Consultant, NHIVP, NCID |
The advent of combination antiretroviral therapy (ART) has transformed HIV infection from a hitherto fatal illness into a chronic, but not yet curable disease. ART reduces the mortality attributed to HIV by 80% and reduces the risk of AIDS-related and non-AIDS related death by 50%. With increasing access to treatment, more people living with HIV infection are living longer and healthier lives. Consequently, there is a growing number of people aged 50 years and older living with HIV infection in the world today. Unfortunately, most healthcare systems globally are not adequately resourced or designed to address these issues. Care for older people living with HIV is often fragmented and not tailored to their unique needs and challenges. In light of these issues, the Primary Care Recommendations for People Living with HIV infection is created to aid infectious diseases physicians, geriatricians and primary care physicians in providing holistic care to older people living with HIV and identify gaps that can be further improved on.
Session 2A: Current HIV landscape in Singapore
The Road to 95-95-95: Update on Singapore HIV Care Cascade 2021
Dr Felicia Hong, Senior Assistant Director, Communicable Diseases, MOH |
In December 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) released the '90-90-90' target, or the three-part HIV treatment target, with the goals of 90% of all people living with HIV will know their HIV status, 90% of those diagnosed to be on HIV treatment and 90% of those treated achieving viral suppression by 2020. The targets were later updated in June 2021 to 95-95-95 to accelerate efforts towards ending the HIV/AIDS epidemic by 2025. This presentation will provide an update on Singapore's progress, based on 2021 cohort data, in achieving the new targets.
The role of molecular surveillance in the management of HIV and ART prescribing in Singapore
Dr Carmen Low, Senior Scientific Officer, NPHL, NCID
A/Prof Sophia Archuleta, Director, NHIVP, NCID |
HIV transmission continues to occur worldwide, despite expanded access to antiretroviral therapy. In the ongoing HIV epidemic, molecular biology approaches, such as PCR and whole genome sequencing, have become powerful tools for tracking circulating HIV strains, including those with transmitted drug resistances (TDR) to sustain antiretroviral therapy (ART) efficacy. The prevalence of transmitted drug resistance (TDR) is primarily linked to the ART prescription pattern in a country, the resistance barriers of the prescribed antiretroviral regimens and the frequency of virus load monitoring.
As the spread of HIV-1 infection is largely driven by individuals who have recently acquired the infection due to the high levels of virus during this phase, molecular surveillance of newly diagnosed HIV-infections is important to predict clinical resistance and guide the choice of individual treatments.
The National HIV Programme (NHIVP) developed the “Recommendations for the Use of ART in Adults Living with HIV in Singapore" in 2019, incorporating locally relevant TDR and other data, and providing guidance to physicians on ART prescription and monitoring for people living with HIV in Singapore. The guidelines target the specific needs and situation of each individual and aim to align ART prescribing practices among clinicians. The NHIVP's ART recommendations are reviewed and revised every two years and the updated guidelines are officially launched at every Singapore HIV Congress (SHC).
The 2023 update includes 1) Selection of ART, 2) Switching ART in the setting of virologic suppression, 3) Monitoring of PLHIV on treatment and 4) Prevention of mother-to-child transmission.
Session 2B: Advancing HIV prevention and treatment through implementation and socio-behavioural research
Keynote 2: Pay‑it‑forward to increase human papilloma virus (HPV) vaccine uptake compared to user‑paid vaccination: A community based randomized controlled trial in Chengdu, China
Dr Wu Dan, Professor, Nanjing Medical University |
Over 15% of global cervical cancer deaths occur in China but the HPV vaccination rates are low (<10%) among teenage girls. Barriers to vaccination included limited public funding and delayed use of HPV vaccines available in the market. Novel approaches are needed to address these issues. Pay-it-forward offers an individual a subsidized service and an opportunity to donate to support other people. A two-arm randomized control trial was conducted to assess the effectiveness of pay-it-forward against user-paid vaccination (control) in improving HPV vaccination among girls aged 15-18 years in China. Pay-it-forward participants would receive an educational pamphlet about HPV vaccination, a community-contributed subsidy (USD 47.70) to support the vaccination and an opportunity to donate to support others. Participants in the control arm received the educational pamphlet and could self-pay for vaccination. The primary outcome was uptake of the first-dose HPV vaccination ascertained by administrative records.
A total of 321 participants (via caregivers) were recruited and randomized to the control arm (n=160) and the pay-it-forward arm (n=161). 25.9% (83/321) received the first-dose HPV vaccine, 34.2% (55/161) in the pay-it-forward arm and 17.5% (28/160) in the standard-of-care arm, corresponding to a crude proportional difference of 16.7% (95% CI: 7.2-26.0). Among 55 girls in the pay-it-forward arm who received the vaccination, 70.90% donated and 67.3% wrote a postcard message to support future teenage girls. The financial cost per person vaccinated was $294.3 in the standard-of-care group and $230.5 in the pay-it-forward group, supporting the pro-social pay-it-forward strategy was effective and cost-saving in increasing HPV vaccination among teenage girls.
Warming the context: Situating qualitative methods in implementation sciences and research among key populations
Mr Daniel Ho, Clinical Psychologist, Independent Researcher |
Qualitative methods serve as essential tools for uncovering rich narratives and deeply rooted insights. Beyond stories that matter – the researcher builds trust, create empathy and engage reflexively with the topics and the participants. This talk draws on recent and community-based research to examine the necessity and strength of qualitative methods in revealing nuanced perspectives and bridging the gap around topics mired in stigma and often corresponding shame. This helps to better map lived experiences and drive more inclusive and effective interventions that addresses root causes and determinants of health behaviours.
Citizen-led qualitative research for HIV key populations: A framework for community-engaged implementation science Chong Shao Yuan, Associate Director (Research), RainbowAsia |
Introduction
HIV science has made significant progress but the dissemination and implementation of evidence-based interventions has been uneven, with marginalized and key populations being left behind. Discriminatory policies, medical mistrust, stigma, and a lack of resources remain key roadblocks. Citizen-led, community-engaged approaches hold promise in subverting power structures that reproduce such barriers in research and implementation, and allow us to leverage community resources to advance implementation sciences.
Methods
We draw on our experience of a collaborative research project between the National University of Singapore and RainbowAsia, a community-based organization addressing the needs of young gay, bisexual and queer (GBQ) men in Singapore and Malaysia. The study focused on stigma, resilience, relationships, sexual partnerships, and mental health among Singaporean GBQ men, and commenced in June 2022.
Results
Despite being a high-income country, research funding for HIV key populations in Singapore remains sparse, as local funders prioritize less politically sensitive topics while international funders typically focus funding on resource limited settings. A citizen-led approach was therefore implemented out of necessity and a desire by community members to translate research into evidence-based programs. We propose a citizen science framework comprising eight key phases, including (i) developing a research and implementation pipeline, (ii) stakeholder and resource mapping, (iii) delegation of expertise, (iv) creating plans for equity, (v) developing a research plan, (vi) generating evidence, (vii) dissemination and translation, and (viii) plans for sustainability and impact. Cross-cutting processes across all phases include the adoption of deliberative democratic processes, training and mentorship, and (re)negotiation of power and recognition for all stakeholders. A total of 44 in-depth interviews were completed, transcribed, and analyzed by a core research team and 25 volunteer research assistants. The entire study required crowdfunding USD1500.00 for participant reimbursements, but otherwise leveraged academic, community, and citizen resources to accomplish the study's outputs.
Conclusion
Our case study illustrates a microcosm of how research evidence can not only be generated, but disseminated and translated by citizens and communities into evidence-based programmes at the community level. Our framework integrates citizen science, community engagement, and implementation sciences and can provide a roadmap for sustainable collaborative research between academic, community, and citizen stakeholders.
Session 3A: Improving health through multi-disciplinary management
Management of metabolic conditions in People Living with HIV infection – Role of primary care physicians
A/Prof Rinkoo Dalan, Senior Consultant, Endocrinology, TTSH |
Common metabolic conditions that are more common in people living with HIV Infection include Diabetes Mellitus, Dyslipidemia, and Osteoporosis. The screening guidelines and approach towards management of these conditions from the Primary Care Perspective will be discussed through interactive case discussions.
Multi-disciplinary care for people living with HIV
Dr Ho Lai Peng, Senior Principal Medical Social Worker, NCID
Ms Joy Yong, Principal Clinical Pharmacist, NUH
Ms Cheng Hong, Advanced Practice Nurse, NCID |
In the evolving landscape of HIV care, a multidisciplinary approach has emerged as a pivotal strategy to address the complex needs of individuals living with HIV. This presentation explores the multifaceted dimensions of multidisciplinary care, with a particular emphasis on the unique roles played by social work services, pharmacy, and nursing in ensuring the well-being of those affected by HIV, and highlights the synergistic collaboration among these disciplines, where social workers, pharmacists, and nurses work in tandem to provide holistic care that goes beyond medical treatment.
The social aspect of care is essential for addressing the psychosocial and emotional needs of HIV patients. It involves providing counselling for people living with HIV, their families and partners; peer support through support groups, and advocating changes through stigma reduction initiatives to foster an environment of acceptance and equal opportunities. Social services not only enhance psychosocial well-being but also promote treatment adherence and overall health outcomes.
Pharmacy services are integral to managing HIV by ensuring access to antiretroviral therapy and optimizing medication regimens. Pharmacists play a crucial role in drug-drug interaction assessments, dose adjustments, and patient education, thereby contributing to improved medication adherence and reduced drug-related complications.
Nursing care represents the heart of HIV care. Nurses' role in the care and management of people living with HIV has evolved over the years. With increasing proportion of people aging with HIV, multi-morbidity has become the norm among people living with HIV. HIV trained nurses play a crucial role in managing chronic metabolic syndromes, age - related conditions and optimizing care for people aging with HIV. They bridge the gap between patients and healthcare providers, ensuring that individuals receive timely and compassionate care. Moreover, nurses often serve as educators, empowering patients to self-manage their condition effectively across different care settings.
Session 3B: Integrating HIV care and prevention services with primary care
PrEP updates and HIV prevention in primary care
Dr Lee Pei Hua, Associate Consultant, NCID |
Pre-Exposure Prophylaxis (PrEP) has emerged as a game-changing intervention in the global fight against HIV/AIDS. PrEP national guidelines play a pivotal role in shaping the implementation, accessibility, and efficacy of PrEP programs. The presentation will emphasise the importance of PrEP, monitoring while on PrEP and highlight on healthcare provider education in ensuring the effective implementation of PrEP guidelines, as well as valuable insights into the latest PrEP updates and their critical role in shaping the future of HIV prevention.
Latent TB Screening and Management for People Living with HIV
Dr Tay Jun Yang, Consultant, NTBP, NCID |
The risk of developing active TB disease is up to 30 times higher in people living with HIV compared to those without HIV. Globally, TB remains a leading cause of death in people living with HIV, despite TB being both preventable and treatable. In this session, we will examine screening of latent TB infection – why we should screen, when and how to screen; and discuss the management and preventive treatment of latent TB infection in people living with HIV.
The intersection of frailty, ageing and HIV
Dr Justin Chew, Consultant, Geriatric Medicine, TTSH |
The increasing prevalence of frailty and geriatric syndromes in the ageing population, especially among those living with HIV, underscores a pressing clinical and public health concern. This presentation will delve into the multifaceted issue of frailty, laying out its implications and significance, particularly for the ageing of people living with HIV. Challenges specific to people living with HIV, such as screening, diagnosis, and effective management of frailty and geriatric syndromes in this vulnerable population, will be thoroughly explored. The discussion also encompasses various care models that have been developed specifically for this demographic, and will examine the existing gaps in the current understanding and potential directions for future research in the intersection of frailty, ageing, and HIV.
Session 4: Empowering communities – Innovative strategies for HIV prevention, treatment and support
Keynote 4: Chemsex among GBMSM in Taiwan: from Harm Reduction to Recovery
Dr Stephane Ku, Attending Physician, Division of Infectious Diseases, Department of Medicine, Taipei City Hospital Renai Branch |
Chemsex, or sexualised drug use to facilitate or enhance sexual experience, has become prevalent among a small yet substantial proportion of gay and bisexual men who have sex with men in Asia-Pacific region as well as around the world in the past decade. Although many different kinds of substance have been associated with sex, crystal methamphetamine and GHB/GBL are the most commonly reported Chemsex drugs, which cause very different symptoms and potential harms with acute intoxication and dependence disorder. Interventions to facilitate abstaining from drug use, to treat drug use disorders and manage detoxification, and to simply reduce physical, psychological and social harms have been developed for individuals with problematic Chemsex. While the standard treatment for crystal methamphetamine dependence relies on cognitive-behavioral therapy such as Matrix Model, several pharmaceutical agents like mirtazapine, naltrexone and bupropion, administered alongside with conventional interventions, have also been shown some effects in clinical trials. Harm reduction strategies focus on drugs per se, HIV, and other STIs at the timing before, during, and after Chemsex session have been proposed. These interventions delivered with integrated sexual health services by LGBT-friendly clinics and community-led NGOs have been shown great acceptance and increased utilization. However, there have been few, robust data published regarding harm reduction strategies specific to Chemsex, and evidence-based harm reduction interventions are needed be evaluated in terms of effectiveness, cost-effectiveness and process in the further research.
NHIVP HIV testing recommendations and HIV Self-Testing Pilot Programme implementation
Ms Lavinia Lin, Assistant Manager, NHIVP, NCID
Fikri Alkhatib, Manager, AfA
Sally Low, Assistant Manager, NHIVP, NCID |
In recognition of the morbidity and mortality associated with HIV, the UNAIDS has strived to combat the HIV epidemic, setting ambitious 95-95-95 targets to be achieved by 2030. These targets aim for 95% of all people living with HIV to be aware of their diagnosis, 95% of those diagnosed with HIV to receive sustained ARV, and 95% of those receiving ARV to achieve viral suppression. However, Singapore faces challenges in meeting the first 95 target, as a significant proportion of newly diagnosed cases each year are identified at a late stage of infection. Only a small proportion were detected through programmatic HIV screening or self-initiated testing.
To increase HIV testing uptake and promote earlier detection, the National HIV Programme (NHIVP) has developed recommendations for HIV testing. These recommendations offer guidance to all physicians serving the adult population in Singapore, covering specific considerations such as who to screen, and what to do pre and post HIV testing. In order to further enhance the range of available testing options and encourage self-testing, the HIV Self-Testing (HIVST) pilot programme was conceptualised in 2019 and officially launched in 2022. HIV self-test kits are available for purchase at Department of STI Control (DSC) Clinic and Action for AIDS Singapore (AfA). The pilot programme has expanded its scope since the implementation over the past year, with valuable lessons learned to be considered and adapted for a wider national rollout in the future.
HIV Destigmatisation and Online Outreach marketing efforts from FY21 to FY23
Ms Sylvia Chin, Assistant Director, Marketing (Preventive Health), HPB (Corporate Marketing) |
HPB takes on the educational role in the National HIV Prevention & Control Strategy for Singapore, running HIV prevention marketing campaigns targeting the general population as well as those at higher risk of infection, with a call-to-action for voluntary HIV testing so as to receive early treatment if tested positive.
As the 3-year HIV Destigmatisation Campaign (FY19-FY21) has come to an end, addressing self-perceived risk of HIV infection and closing the testing gap are the focus areas of the next phase in FY22-FY23 to reduce the spread of HIV.
