By Raphael Meyer (Dec 2007)
Effective prevention ensures that everyone has access to the information, resources, and support needed to protect their health and general well-being. Prevention plays an important role in our health as individuals and as a society. It is an activity that should be encouraged on both a collective and an individual level.
Many comprehensive HIV/AIDS prevention strategies include “positive prevention” programmes. These programmes help people living with HIV/AIDS protect their sexual health, avoid new sexually transmitted infections, delay the progression of HIV/AIDS, and avoid passing their infection on to others. They are intended to reduce the negative/challenging effects of the illness and maximize quality of life.
Infectious Disease Act- Prevention or hindrance to Positive Prevention?
The fact is that prevention efforts had not been directed toward HIV-positive persons for fear of "pointing the finger" or blaming HIV-positive persons for the epidemic. In fact, AIDS is still stigmatized in the Singapore. HIV-positive persons have also feared laws criminalizing sexual risk behaviours and further prosecution of injection drug users (IDUs). In Singapore, under the Infectious Diseases Act (Chapter 137) section 23: (1) A person who knows that he has AIDS or HIV Infection shall not have sexual intercourse with another person unless, before the sexual intercourse takes place, the other person - (a) has been informed of the risk of contracting AIDS or HIV Infection from him; and (b) has voluntarily agreed to accept that risk. Any person who contravenes subsection (1) shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $10,000 or to imprisonment for a term not exceeding 2 years or to both.
So there is a genuine fear that the government might use the Infectious Disease act as they had done in the past when they jailed 5 HIV positive individuals for providing false information when they donated blood. They found out in turn that they were HIV positive through the blood donation but were jailed subsequently for falsifying information on the blood donation form.
In many countries, the intentional or reckless infection of a person with the human immunodeficiency virus (HIV) is considered to be illegal. People who do so can be charged with criminal transmission of HIV, murder, manslaughter attempted murder, or even assault. The biggest challenge is to link the infection with a person who has infected that person. But with DNA technology and detailed contact tracing, it can lead the finger to the culprit. It a matter of time when the courts in Singapore exercises their strong arm on this. This is not an effective prevention strategy. In fact, these coercive powers may cause a loss of trust and confidence by the gay community and discourage people with HIV from learning their HIV status voluntarily, thereby undermining prevention efforts. Further, these types of laws increase discrimination by suggesting that people with HIV are more irresponsible than others.
Do those living with HIV go out and purposely infect others?
It's one of the hardest things for sexually active gay men, especially those who feel validated by sex, to handle after they find out they are HIV positive. I think that to blame for the spread of HIV on the people who are already infected is not helpful. It’s incredibly psychologically challenging to live with both the social pressure of being gay and being seen as a walking infection especially in Singapore. Being gay is in itself illegal under section 377a of the penal code. However we have to accept that there are those who are knowingly running around indiscriminately infecting other men with HIV. These PWAs act irresponsibly because they are bitter over the situation they are in or have a hard time negotiating safe sex under the circumstances. Should we have compassion? What about compassion for the men he's infecting and his responsibility not to spread HIV? As for education, if this irresponsible guy is smart enough to use the Internet chat rooms to line up sex dates, he's smart enough to know it's wrong to give someone else HIV.
Sex and Drugs- What a cocktail!
Another major issue with the spread of HIV in the gay community is that many put themselves in situations where their judgment is impaired, for example by mixing sex with drugs and alcohol. Low self-esteem may fuel a need for drugs to have a good time. Party drugs often decrease inhibition, which some people may feel they need to participate in the club or sex scene. Even though the authorities in Singapore have largely been successful in suppressing activities related to the importation, trafficking and usage of illegal drugs, there are still those who are able to get their hands on small amounts of these drugs for personal use. The use of recreational drugs can impair the judgement of an individual during sex thus leading to unsafe behaviour. What they do not realise are the consequences they have to face should they be caught. Singapore has a very tough stand on drug consumption and trafficking. They can be jailed for years and even sentenced to death. If they are known to be HIV positive, and when they are sentenced to prison time, they are segregated in an area with only other HIV inmates. The stigma goes with them right into the prison and the time they have to spend in there.
Is it right to say HIV Positive individuals are causing the spread of HIV?
Most people who know they have HIV and understand how HIV is transmitted go to extraordinary lengths to make sure that they protect their sexual partners. Often there are enormous barriers to this in terms of possible stigma and rejection even violence and abuse. This leads to a great deal of fear and guilt, and people with HIV need support to address these barriers. There has not been much done for them to equip them with the necessary skills to adopt a life of a safer and more responsible behaviour. So what resources and programmes do we have here in Singapore targeting at HIV positive Men Having Sex with Men (MSM) and supporting them to lead a healthy and fulfilling life with HIV? Over the few years I have been involved with programmes for PWA’s (People living with HIV/AIDS) I have experimented on various health communication and prevention strategies targeted specifically to people living with HIV/AIDS, to recognize and empower the sexuality and sexual health of people living with HIV/AIDS and to promote risk/harm reduction behaviours and activities.
People working on prevention programs are starting to think about the role HIV-positive people might play in prevention. Where are positive people in prevention messages? Almost all prevention programs thus far have been aimed at people who are negative. Early prevention planners were reluctant to include HIV-positive people in prevention messages, at least partly out of concern about further increasing the stigma against people who are positive.
Positive MSM are left with a host of social issues they need to deal with. When is the best time to disclose to a partner? How do you handle rejection if you disclose? Who is entitled to know what facts about your life? How do you deal with the isolation from the larger community if you’re open about your HIV status? How much of the burden of protection ought to fall on people living with HIV, and how much on people who are (or believe themselves to be) HIV-negative? Medical issues, too, must be considered. When do you start medication? What combination do you take? How do you decrease the disease progression and deal with side effect from the medication?
How do all of these issues interact to contribute to their decisions about sexual safety?
One of the most effective HIV support programs are the ones that have been designed by peers based on knowledge derived from their life experience as someone who is also HIV positive; this signifies ownership. Prevention programs for positive persons should be designed by positive persons.
These types of peer-driven action programs are starting to emerge in a Singapore starting with the MSM positive community and spearheaded by Action for AIDS (AfA). They include a range of activities, such as workshops on living with HIV, safer sex, staying healthy, and disclosure. The goals of the programmes include developing HIV-positive role models. Club Genesis (CG), a support group for MSM in Singapore and a part of AfA, has been developing programs especially targeted to positive MSM.
So far over 60 HIV-positive people attend the CG’s programmes which range from weekly cell group meetings, monthly gatherings to discuss current HIV issues and medical updates, buddies programme, to workshops dealing with range of issues affecting positive people.
Disclosure of HIV serostatus has been difficult for most PWAs. In Singapore, there is still much stigma surrounding the issues relating to MSM and even more so the subject of HIV infection. Disclosure of HIV positive status has its own set of risks. PWAs fear being cast as social pariahs accused of illegal behaviour. Gay sex addiction has been one of the factors contributing to the continued spread of HIV. There is a need to focus on education with regards to sex addiction and intimacy.
At cell meetings, members are counselled to identify and change sexual behaviours that increase their risk of transmitting HIV or contracting additional infections. They discuss the difficulties of maintaining safer behaviours to prevent HIV transmission. These discussions are usually lively and compelling, marked with the sharing of experiences.
The members speak on love, rejection, trust, depression, desire, discrimination, passion, death, loss, stigma, and the way these issues affect safer sex behaviour. PWAs have few opportunities to express their deepest concerns and the complex situations they must deal with; cell meetings provide a channel for PWAs to voice their concerns. One focus of prevention strategies is to ensure that PWAs discuss their problems among themselves and even to HIV-negative people. A survey was carried out to compare their behaviour before participation; those who attended the counselling sessions reported having fewer sex partners and their concerns shifted from psychological concerns to more tangible concerns on their health.
Another strategy is that CG has been encouraging HIV positive individuals to use personal story-telling as a health promotion strategy for people with HIV and with healthcare workers. Participants in at a recent Health Promotion Board HIV awareness for business leaders in December 2006, reported that the HIV positive speaker who shared his story was the most effective educational intervention for connecting theory of HIV to reality. Moreover the speaker himself reported an increased sense of well-being related to the therapeutic function of sharing his story and the sense of their ability to create positive changes in the lives of other people with HIV, and in community perception of HIV.
UNAIDS (Sept. 1999) has developed a ‘pyramid of involvement’ by people with HIV to show how the GIPA principle (Greater involvement of People living with or affected by HIV/AIDS) is applied at all levels, from being target audiences for activities aimed at people with HIV, to contributors, speakers, implementers, experts and ultimately decision-makers. The involvement of people with HIV is key in helping to realise an approach to HIV/AIDS that follows the prevention-care continuum.
PWAs are living longer today, insofar as there is proper medical care and medication. The rates of new HIV infection appear to be rising. Now is the time that PWAs should be looking for support to be included in prevention planning, for our own benefit and the benefit of all those who are not yet infected as more governments around the world are striving to tackle the increasing challenge of HIV/AIDS.
Resources
Bradford G, Campbell W. (2002) Selling safer sex to PWAs. Living+. The British Columbia Persons With AIDS Society. (September / October 2002 issue)
Collins C, Morin SF, Shriver MD, Coates TJ. (2000) Designing primary prevention for people living with HIV. AIDS Policy Research Center & Center for AIDS Prevention Studies, Policy Monograph Series.
GNP+. (2001) Celebrating our lives: 10th International Conference for people with HIVA post-conference report.
GNP+. (undated).Positive development: setting up self-help groups and advocating for change. A manual for people living with HIV/AIDS.
International HIV/AIDS Alliance. (2000)Technical review: prevention with people with HIV. Prevention at the Frontiers of the HIV/AIDS Epidemic, Concept Paper Annex 4
International HIV/AIDS Alliance. (2003) Prevention Strategies for People with HIV/AIDS. Draft Background Paper
Infectious Diseases Act (Chapter 137)
http://app.nea.gov.sg/cms/htdocs/category_sub.asp?cid=213
International HIV/AIDS Alliance. (2002) Handbook on access to HIV/AIDS-related treatment: a collection of information, tools and resources for NGOs, CBOs and people with HIV groups.
NAM. Living with HIV, guide to HIV Positive People. 2006. (aidsmap.co.uk)
NAM. Living with HIV. (2006) HIV, Stigma &You (aidsmap.co.uk)
Rotheram-Borus, M.J. (2001)Efficacy of a preventive intervention for youths living with HIV. American Journal of Public Health
Schiltz M and Sandfort T. (2000) HIV-positive people, risk and sexual behaviour. Social Science and Medicine
Terrence Higgins Trust. Viral load and infectiousness: issues for people with HIV. Briefing Sheet, Sept 2002.
UNAIDS. Protocol for the identification of discrimination against people living with HIV.
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