World Aids Day is observed internationally on Dec 1 each year. A look at how two viruses - HIV and COVID-19 - coming 35 years apart in Singapore have changed the way we practise medicine and interact with one another.
by Wong Chen Seong For The Straits Times
This year marks 35 years since the first patient was diagnosed with HIV infection in Singapore in 1985. In the following years, the number of people living with HIV in Singapore has steadily increased, with a total of 8,618 people in Singapore having been diagnosed with the infection, of whom 2,097 have died, as of end-2019.
The number of new cases reported to the National HIV Registry yearly has also been on an upward trend, peaking at more than 400 new diagnoses annually in the mid-2010s, before falling in 2018.
A woman getting an HIV test in Mexico. HIV doctors in Singapore have had to find innovative ways to provide safe and effective care for their patients within the constraints imposed by COVID-19, says the writer. PHOTO: EPA-EFE
The year 2020, will, undoubtedly, go down in history as the year when the world was ravaged by a coronavirus now named the Severe Acute Respiratory Syndrome Coronavirus 2, or Sars-CoV-2, which causes Coronavirus Disease 2019 or COVID-19.
A pandemic on an unprecedented scale, COVID-19 first reached our shores on Jan 23. A concerted, whole-nation approach meant that Singapore managed to avoid the high mortality rates seen in other countries, while ensuring that society and the economy do not completely shut down.
HIV and Sars-CoV-2 have a number of interesting similarities. Both are RNA viruses, wherein their genetic codes are in the form of ribonucleic acid, as opposed to humans and other animals with deoxyribonucleic acid or DNA.
Both viruses emerged recently in human history, causing modern-day plagues; it is easy to forget that HIV and the Acquired Immunodeficiency Syndrome, or Aids, emerged in the 1980s. Due to their novel natures and the fact that they both caused severe disease and even death in large numbers of those infected, they were responsible for causing panic and disruptions to daily life.
However, there are also important distinctions between the two viruses and how they affect those infected. Sars-CoV-2 is much more infectious, being transmitted primarily through respiratory droplets. HIV, being a blood-borne virus, can be transmitted only through exposure to infected body fluids such as sexual secretions, blood and breast milk.
COVID-19 causes severe illness in about 20 per cent of those infected, and critical illness and death in up to 5 per cent, whereas untreated HIV infection and Aids are uniformly fatal. HIV was discovered to be the cause of Aids in 1983, years after the first cases of deaths due to severe immune compromise were reported in the United States in the late 1970s. The discovery won Francoise Barre-Sinoussi and Luc Montagnier the 2008 Nobel Prize in Physiology and Medicine.
To date, while there are highly effective anti-retroviral medications which can render people living with HIV healthy and effectively incapable of transmitting the virus to others, a cure and a vaccine for the disease still remain elusive.
In comparison, the mapping of the entire genome of Sars-CoV-2, as well as an understanding of its transmission, and several promising candidates for treatment and vaccine, have all been achieved in the short months since the first cluster of novel pneumonia was described in Wuhan, China, on Dec 31 last year.
The Fear Factor
In our approach towards Sars-CoV-2 and COVID-19 as a nation, and indeed as a human race, many lessons can be learned from our experience with HIV. In the early days of HIV, there was much fear surrounding its infectiousness, and the fact that it caused a seemingly unstoppable march towards progressive destruction of the immune system, resulting in death from opportunistic infections and cancers.
Fear and lack of knowledge of its spread and helplessness in the absence of a cure or treatment resulted in much stigma and discrimination which, unfortunately, still lingers today against those infected.
This fear of infection, or contagion, is also pervasive in the current pandemic, with numerous reports of people with COVID-19 - or even those suspected to be at risk of infection, like healthcare professionals and other front-line workers - being subjected to discriminatory behaviour, such as verbal or physical abuse and eviction from their homes.
We can see that stigma is born out of fear, and fear arises from a lack of knowledge or understanding. The fear of being stigmatised or discriminated against may also lead those most at risk of infection to avoid getting diagnosed and seeking medical attention when they most need it. This can have disastrous consequences both for themselves and those around them. It can lead to those infected developing more severe illness, as well as unknowingly infecting those they come in contact with, whether by not taking the appropriate protection during sex to prevent the transmission of HIV, or not wearing a mask and self-isolating to prevent the spread of Sars-CoV-2.
The stigma surrounding a disease can sometimes be more harmful and dangerous than the disease itself, and overcoming the challenges posed by the pandemic will require a concerted effort, based on compassion and rooted in science, as well as the involvement and participation of the entirety of society.
COVID-19 has had an indelible impact on many aspects of everyday life. It has also affected the lives of people living with HIV in numerous ways, not least of all in the way that care for their illness has been affected during this coronavirus pandemic.
People living with HIV require regular follow-up visits with their care providers in order to ensure that treatment continues to be effective, and that they enjoy good general health and well-being.
HIV care in Singapore remains centred in specialist hospitals and is provided primarily by infectious disease physicians, who are also part of the main vanguard providing COVID-19 care.
In addition, significant resources needed to be diverted to help cope with the COVID-19 response.
To add to this situation, little was known earlier in the year about whether people living with HIV were at greater risk of COVID-19 infection, severe COVID-19 or mortality, and hence a more conservative approach was employed. Efforts were made to reduce the risk of exposing them to the virus by reducing as much as possible the need for them to make hospital visits.
HIV physicians have had to find innovative ways to provide safe and effective care. We accomplished this in several ways. First, we adopted technological innovations such as telehealth, providing consultations for selected patients via secure video-conferencing, allowing us to address our patients' concerns without the need for them to be physically present in the clinic.
Second, we judiciously prolonged the duration between regular clinic visits for those patients with well-controlled HIV, while ensuring that all patients could contact the clinic in case of emergencies.
Third, we encouraged the use of home delivery of medications, further reducing the time patients have to spend in potentially crowded hospital pharmacies.
Finally, we avoided making changes to treatment regimens unless absolutely necessary to reduce the need for additional follow-up during this time. In so doing, we were able to keep on providing high-quality care for the patients.
These past months, our roles as HIV physicians have continued. Recently, a young man who had just received his diagnosis of HIV at a community clinic was referred to me.
He had been testing regularly for HIV, and at the time he tested positive, he was completely asymptomatic and felt well. He was seen at our specialist HIV clinic within a week of being referred, and after his consultation and a discussion with him, a decision was jointly made to start him on treatment once his laboratory test results were ready. He has been on medications for the past four months.
Despite the challenges of practising in a COVID-19 world, there was no delay in his HIV diagnosis or treatment, as early diagnosis and initiation of treatment are essential to ensure that people living with HIV are able to live healthy, happy lives.
Another patient had a different experience.
She has been living with HIV for the past 10 years, and has been under treatment for almost this entire time. Her viral load is undetectable, indicating not only that her HIV is under control and she is enjoying good health, but also that she is effectively unable to transmit the virus to others. As she is in her early 60s, we were concerned about her possible exposure to Sars-CoV-2 should she have to travel and visit the clinic.
So arrangements were made for me to see her via tele-consultation on a video call, during which I was able to ascertain that she was well and still taking her medications. She even showed me her new grandson during the call. I then arranged for her medications to be delivered to her home.
While circumstances have forced doctors to make changes to the way we practise, it has not reduced the warmth and sense of satisfaction all physicians feel when we see patients doing well.
COVID-19 and HIV are going to be part of our lives for many years to come. They have changed the way we practise medicine, interact with one another, and live our lives. Through it all, we will weather the storm by having compassion for one another, taking a scientifically-grounded approach, and, of course, having hope for better times ahead.
Dr Wong Chen Seong is consultant and deputy director at the National HIV Programme, National Centre for Infectious Diseases.
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