Commentary: HIV treatments have evolved, the law needs to catch up

SINGAPORE: Should it be a crime if your sexual partner does not inform you that he or she is living with HIV (human immunodeficiency virus)? Is HIV disclosure necessary always – even if the person has an “undetectable” status, meaning there is not enough of the virus in the body to pass it on during sex?

These questions have been in the spotlight recently, following reports that the Ministry of Health is reviewing the law on HIV disclosure, which was legislated in Singapore’s Infectious Diseases Act (IDA) in 1992.

Currently, section 23 of the IDA requires those living with HIV to inform their sexual partners beforehand of the risk of transmission, so that they can make an informed decision and take the necessary precautions. Those who fail to do so face a maximum jail term of 10 years and a fine of up to S$50,000.

To date, six people have been convicted for failing to disclose their HIV status to their sexual partners.

The possibility that such disclosures may no longer be legally required may not seem intuitive at first. Some may ask: Shouldn’t the law keep me safe from HIV?

The HIV scientific community and public health experts think the law may need updating. In its 2023 global update, the Joint United Nations Programme on HIV and AIDS said that punitive laws are more likely to drive people away from seeking HIV support and services. This is counterproductive to public health efforts.

REVIEWING THE LAW ON HIV DISCLOSURE

There is no evidence of increased risk should the disclosure law be amended or repealed for people who have been compliant with treatment and have maintained a stable undetectable viral load.

The science of HIV has progressed tremendously since the start of the epidemic in the 1980s. In the past decade alone, we have seen the rapid development of innovative HIV prevention methods beyond just the use of condoms. 

These include the use of medication to prevent infection after one’s exposure to HIV (post-exposure prophylaxis) and medication that can be taken daily or on-demand to prevent HIV infection before having sex (pre-exposure prophylaxis).

Last year, the World Health Organization (WHO) announced unequivocally that people living with HIV and who have an undetectable viral load cannot transmit HIV to others sexually. 

According to MOH, 94 per cent of Singapore residents living with HIV and undergoing treatment have an undetectable viral load.

HIV infection is measured through one’s HIV viral load, or more specifically, the number of copies of virus per millilitre (ml) of blood. Someone who has HIV and is not on treatment may have 50,000 copies/ml or higher, but being on treatment dramatically reduces this number towards zero. 

Evidence from the last three decades of research has shown that those with an undetectable viral load of less than 200 copies/ml cannot transmit HIV through sex.

How do we ensure that people are really “undetectable”? We can practically ascertain this through one’s regular viral load testing results. Through this approach, an HIV specialist can determine if an individual has achieved viral suppression through a series of blood tests.

Scientific evidence underpinning the non-transmissibility of HIV has also in their design accounted for “viral blips”. This is an uncommon event when the viral load of a patient who is on effective treatment goes from undetectable, to detectable (but still a suppressed viral load) at one point, and then back to undetectable again. Viral blips are not the same as treatment failure and may occur as a result of laboratory measurement issues or other ongoing infections such as a cold or flu.

REDUCING STIGMA

There are about 7,000 people living with HIV in Singapore currently, out of a total of 9,435 cases diagnosed since 1985. Most of the newly diagnosed HIV infections continue to be detected typically at a late stage.

Of the 188 new cases reported among residents in the first 10 months of last year, 58 per cent were detected during the course of medical care. Another 13 per cent were detected during screening programmes for people with sexually transmitted infections, hospital inpatients and those identified through contact tracing, while 18 per cent were detected through self-initiated screening.

Stigma still prevents many from getting access to HIV prevention methods, testing services, and treatment. It is worth considering if amending or repealing the law would help reduce HIV-related stigma, and therefore encourage testing for those who may have HIV or are at risk of HIV. 

Getting every person who has HIV tested and treated is important. In theory, once this happens, we should no longer see any new infections each year. Past studies in Singapore have indicated that the law fosters an attitude of “don’t know, don’t tell”; that is, the perception that not getting tested will allow one to avoid prosecution. 

Beyond public health and the scope of the IDA, what are some other important considerations? 

From a legal standpoint, some may worry about the lack of legislation that might protect them in cases where individuals may have placed them at actual risk of transmission. However, in such cases of malicious and intentional transmission, legal scholars have argued that existing criminal legislation beyond the Infectious Diseases Act may be used to prosecute offenders.

SEEING HIV AS A CHRONIC DISEASE, NOT A CRIME

As a private matter, disclosure of one’s HIV status remains a complex issue. Given the prevailing stigma, people living with HIV need to navigate potential risks of disclosure and how such information might be used against them, and on the other hand balance this with a desire for authentic relationships with others. 

Sexual partners of people living with HIV may also have a desire to better understand their risks. Nevertheless, sexual health should be a shared responsibility where precautions are undertaken by both parties. Thankfully, we have a range of tools in place such that everyone can empower themselves to stay safe from HIV, regardless of their partners’ status.

Scientific advances have transformed HIV infection from a progressive, typically fatal infection to a chronic disease with little to no transmission risk. Such advances have allowed people living with HIV who are on effective treatment to have similar life expectancies as the general population, give birth to HIV-negative children, and have meaningful relationships.

Nevertheless, stigma and a lack of access to prevention methods stand in the way of an HIV-free future. 

A community blueprint launched in 2019 by Action for AIDS Singapore sought to end HIV in Singapore by 2030. A review of our HIV disclosure law is a step in the right direction. 

Building a stigma-free future to end HIV also means that society must be ready to accept HIV as a preventable, chronic disease that can be managed easily through effective medication, and not a crime. 

It will take time for us to move beyond the narratives of terminal illness and death that shrouded the early years of the epidemic. But I believe we have the capacity to do this in Singapore, one step at a time.

Dr Rayner Tan is Assistant Professor at the NUS Saw Swee Hock School of Public Health.