ZIKA IS AN STD!! – Battling the STD Stigma

The Zika virus gained notoriety in Brazil when it was blamed for causing a spate of birth defects known as microcephaly. Babies born with microcephaly had abnormally small heads and often also suffered concurrent problems with brain development. Some children born to Zika infected mothers had normal sized heads but their heads would fail to develop normally. These are obviously horrible consequences for both the mother and child. 


Zika is a virus that is spread by mosquitoes very much like Dengue. However, it was soon discovered that Zika was also sexually transmitted. And that consistent and correct use of condoms protected pregnant women from the Zika virus and consequently their unborn children to the devastating effects of Congenital Zika Syndrome.  

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But wait a minute? Does that mean Zika is an STD? Technically it seems to fit. STD is an acronym for Sexually Transmitted Disease. Zika is a disease that is sexually transmitted. But it is predominantly transmitted via the bite from an infected mosquito. So is it an STD? If Zika is an STD then is raises other uncomfortable questions like: if a person catches chickenpox from his/her partner because they had sex, is chickenpox then an STD too? Or even the common Flu, which is spread as an airborne virus, can also easily be caught via sexual intercourse. So the common Flu is an STD!


I’ve had this discussion many times with my patients when they have been diagnosed with an infection and they ask me “is it an STD?” Sometimes, this is rather easy to answer. If they have, for example, an infection of Gonorrhoea of the penis, one can be confident to say that they caught it from a sexual contact. But at times, things get murky. A good example is an infection with Ureaplasma Urealyticum. We know this tiny bacteria can be sexually transmitted. We also know that it can seem to appear out of nowhere in mutually monogamous couples. We also know that it can be just a commensal and not a disease causing pathogen. So when a patient with an infection of his urinary tract caused by Ureaplasma asks me “is this an STD?” I am unable to give a direct black and white answer. 


The same goes for what I would describe as the most feared STD by many, and that is HIV. For a fact, the commonest way that HIV is transmitted is via sexual contact. However, we also know for a fact that HIV can be transmitted by sharing needles, contaminated surgical instruments, transfusion of contaminated blood and transplant of contaminated organs. Albeit the last 2 hardly happens anymore due to increased awareness, better infection screening protocols and technology advancement. But let’s be honest, if and when we find out someone is infected with HIV, getting injured by surgical instruments is not likely the first reason to pop into our heads.


And therein lies the issue. Answering the question “is this an STD?” does not in any way contribute to the clinical management of the disease except perhaps for contact tracing. For partner protection, the same advice will be given if the disease can be transmitted sexually regardless of whether or not it is called an “STD”. The issue, I believe, is stigma. To be labelled as having an “STD” is to be labelled as a moral or sexual deviant. But should this really be the case? Infections are caused by microorganisms invading our bodies and using our resources to make more of themselves. Drawing on resources around them to reproduce is hardcoded into the genetic material of all living things, humans being the best and worst examples. Microorganisms do not care how they are transmitted or where they infect as long as the environment they are in supports their reproduction. Microorganisms do not care about our textbooks and whether or not we call them STDs.


Consequently, some infections although predominantly transmitted by sex, can also be transmitted by other means. And some that can easily be caught via sex, are for some reason not given the label “STD”. I do hope we can eventually drop this label and treat infections for what they are – infections. Treat the patient, prevent reinfection, protect partners. Labels are useless. 

Next read: WHAT IS ANTIBIOTIC RESISTANT GONORRHEA OR SUPER GONORRHEA?


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What is Antibiotic Resistant Gonorrhea or Super Gonorrhea?

Gonorrhea is a sexually-transmitted infection caused by the bacteria called Neisseria gonorrhoeae. 

Antibiotic-resistant Gonorrhea refers to strains of Gonorrhea that are not killed by antibiotics that were previously effective in killing off these bacteria. 

In the 1980s, penicillins and tetracyclines could kill off Gonorrhea. By the 1990s, these drugs were no longer effective and Fluoroquinolones were recommended as the first line treatment. By the 2000s, Fluoroquinolones resistance was commonplace and only one group of antibiotics remains as an effective treatment for Gonorrhea – Cephalosporins. By now, certain strains of Gonorrhea that are resistant to cephalosporins have already been detected and that is worrisome because if these medications become useless, we might face a situation where we cannot clear gonorrhea from a person’s body. 

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What drugs are super gonorrhea resistant to?

Super Gonorrhea is the colloquial term for strains of Gonorrhea that are extensively drug-resistant, with high-level resistance to the current recommended treatment for gonorrhea (ceftriaxone and azithromycin) including resistance to penicillin, sulphonamides, tetracycline, fluoroquinolones, macrolides.


What causes super gonorrhea? 

Super Gonorrhea is a problem that we have created. 

The unrestricted access, inappropriate selection and overuse of antibiotics over many decades has allowed the strains of gonorrhea to genetically mutate in such a way that they are no longer affected by these antibiotics. Extra genital infections in the rectum and throat may also play an important role in the development of resistant strains as gonorrhea can interact and exchange genetic material with other co-infections in these places.


How common is Super Gonorrhea?

Super Gonorrhea has been reported by several countries including France, Japan, Spain, the UK and Australia. The American CDC has not received any reports of verified clinical treatment failures to any cephalosporin in the United States to date. 


How does Gonorrhea spread?

Gonorrhea can be spread through sexual contact with the penis, vagina, mouth, or anus of an infected partner. Ejaculation does not have to occur for gonorrhea to be transmitted or acquired. Even if you have had gonorrhea in the past and was treated, you can still get reinfected again if you are exposed to it again. 


What are the symptoms of super gonorrhea?

The symptoms of super gonorrhea are the same as regular gonorrhea. Gonorrhea can infect different areas of the body. Most symptoms present within 1-2 weeks after exposure.

In males, the most commonly infected site is the genitourinary system. It can present with symptoms such as pain on passing urine, penile discharge, swelling at the tip of the penis and scrotal pain and swelling.

In females, the most commonly infected site is also the genitourinary system and and present with symptoms such as vaginal discharge, pain on passing urine, intermenstrual bleeding, painful intercourse, and mild lower abdominal pain

Gonorrhea can also infect other areas of the body such as the rectum, causing rectal pain, itching, discharge, or tenesmus. If gonorrhea infects the throat, you can get a persistent sore throat. Gonorrhea can also infect the eyes, causing conjunctivitis which may present with eye pain, discharge, and redness. If gonorrhea spreads by blood to the rest of the body including the brain, heart, bone, joints, skin and liver, this is termed Disseminated gonococcal infection (DGI). While rare, DGI can be deadly and have long term complications. 


Does Gonorrhea always have symptoms?

Gonorrhea can have little to no symptoms at all in some people. That is the reason why it is so important to screen for STIs with every sexual encounter. 

A study has reported that more than 80% of people (both males and females) with Gonorrhea can have no symptoms. Do not wait for symptoms to appear before you screen for STIs. Do it regularly with every new sexual encounter. 

Also read: Rapid STD Test for Chlamydia and Gonorrhoea PCR


What are other STDs that do not display symptoms and have serious complications if left untreated?

All STIs can have no symptoms at all. Because people do not experience any symptoms, they think that they do not have an STI and thus the spread of STIs continues. Other STIs we regularly test for include other urinary STIs such as Chlamydia, Ureaplasma urealyticum, Mycoplasma hominis and Trichomonas. What we can test for in the blood are STIs such as HIV, Syphilis, Herpes and Hepatitis B and C.


What happens if gonorrhea is treated effectively?

If gonorrhea is treated effectively (with the proper antibiotics), your symptoms should clear up, and subsequent follow up tests to test for clearance should come back as negative for gonorrhea.


What are the complications of Gonorrhea?

In females, untreated gonorrhea may lead to pelvic inflammatory disease (PID). This is an infection of the fallopian tubes, uterus, and cervix. If left untreated, PID may cause permanent damage to the reproductive tract, which may lead to infertility. It may also lead to long-term pelvic pain.

Males with untreated gonorrhea may develop a condition called epididymitis. This condition is characterized by inflammation of the tubes near the testicles that carry semen. It can also lead to infertility. 

DGI is another complication of gonorrhea as well. 


What happens if you have drug resistant gonorrhea? Can I get rid of Antibiotic Resistant Gonorrhea?

If you have drug resistant gonorrhea, your doctor may opt to treat you with antibiotics that hopefully are effective against this strain of gonorrhea. Antibiotic sensitivity testing for that strain should be done. If it is truly multi-drug resistant, a referral to an infectious diseases specialist is appropriate, and they may have to treat you with antibiotics that are reserved for the worst kinds of infections. 


How do you reduce your risk of contracting these STIs?

Abstinence is the only way to reduce your risk to zero.

If you are sexually active, use barrier protection such as condoms, the right way. You can also speak to your partner to get tested for STIs before engaging in sexual activity.  A mutually monogamous relationship also carries a lower risk of STIs than having multiple sexual partners.

If you are sexually active with multiple sexual partners, get yourself tested regularly and treated. The presence of one STI can increase your risk of contracting another one more easily. Most STIs can easily be detected through swabs, urine or blood tests at your doctors. These are rather pain free and minimally invasive, so there should be no fear to get tested!

There are some STIs that are preventable through vaccinations. Vaccines are available against certain strains of HPV that may cause warts, cervical, anal and penile cancer. Effective vaccines against Hepatitis B are available as well.

Also read: What is HPV (Human Papilloma Virus)?


How do I find out if I have been infected with Super Gonorrhea?

Gonorrhea is often diagnosed using a PCR test. This test can give results very fast and determine if a person is infected with Gonorrhea or not. However, this test cannot differentiate between regular Gonorrhea and Super Gonorrhea.

For that, a test called Gonorrhea Culture and Sensitivity has to be conducted. This test takes a longer time as the Gonorrhea bacteria has to be grown on a plate and tested against various antibiotics. This test is also less sensitive as for various reasons, sometimes the Gonorrhea bacteria cannot grow.

Also read: What Is Rapid Chlamydia & Gonorrhea PCR STD Testing?

If you think you may have been exposed to Super Gonorrhea, you have to see your Doctor immediately. DTAP clinics focus on STD screening and STD treatment. We offer rapid PCR testing for Gonorrhea (next day results) as well as culture tests to detect multi-drug resistant (Super) Gonorrhea. 

Speak to your doctor if you have any questions regarding Gonorrhea or other STDs.


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People Living With HIV In Singapore

The alarm chimes to life. As the incessant ringing crescendos the clock face starts to flash an LED blue. Mr. J stretches a slim arm out from under the blankets and pushes down on the snooze button. It was 6:00am on another nice balmy morning in Singapore. Because it was approaching the year end it was a cool 24°C. Jumping out of bed, Mr. J prepares for his morning run on the Park Connector, a network of roads and paths linking the various parks and gardens in Singapore.
A quick shower follows his run and he slips into his shite cotton shirt and blue cotton pants, all ready for a 20 minutes ride on the MRT to Raffles Place and his office in the financial hub of Singapore. After a hard day’s work a 10 minute walk takes him to Fullerton One where he enjoys a well earned dinner and drinks with his friends while the sun sets behind the Marina Bay Sands integrated resort. Another most typical day for a typical Singaporean in Singapore. Except for one difference. Mr. J is one of the almost 7000 people living with HIV in Singapore. 
I set up our first clinic at Robertson Walk in 2005 and in 2008 was awarded the mandate to conduct anonymous HIV tests. Mr. J saw me in 2009. He was recently married. His wife had to spend a few days out of town and he saw no harm in engaging the services of a sex worker. He did not use a condom. As the positive line slowly materialized on the test strip, I turned to Mr. J and said “It looks like the test is positive.”
He screamed and he screamed. He could not stop screaming. He grabbed the pillow on my examination couch and screamed into that. Even in the state he was in, he was considerate enough not to scare the other patients in the waiting room. He finally picked up his phone and called his brother. Soon after, his mother and his brother arrived. They spoke and they cried. I told him it was going to be OK but I knew nothing I said was getting through. A few days later Mr. J came back to the clinic, this time with his wife. She tested negative. She had forgiven him and they were going to have a family together. He would be strong, he would take his medicines and he would live what I promised was a long healthy and meaningful life. 


Since 2008 our clinic at Robertson Walk has conducted more than thirty thousand anonymous HIV tests. We have given good news most of the time and bad news more often than we would like. We have diagnosed people from all walks of life, all orientations, all genders, all vocations and a huge variety of nationalities with HIV. It is a virus that does not discriminate. Some took the news with stoic calm, some crumbled mentally, emotionally and physically. We tell everyone the same thing: it is going to be OK. HIV is not a death sentence. HIV is a chronic disease. It is no different from diabetes. You just have to take a single pill a day. You just have to see the doctor a couple of times a year. It is not so bad. It is not so bad. It is not so bad. It is going to be OK. We have held hands, wiped tears and held people together as they mended. 
After the initial shock comes acceptance and the relatively mundane work of getting the virus under control. We walk with them every step of the way from their first blood tests to their first pills. We link them up with emotional support services, we counsel them on their medical finances and step by step, piece by piece their lives reassemble and are made whole again.


On the 1st of April 2015, Singapore lifted its travel ban on people living with HIV. We opened our arms to all in the region who wished for our brand of care. We started seeing people living with HIV come from Malaysia, Vietnam, Indonesia and many other countries in the region. We provided the best care we knew how and watched like a proud parent as their viral loads dropped and the CD4 counts rose. 
2 to 3 out of every 1000 people in Singapore is living with HIV. Did you walk past a thousand people today? On the bus, on the train, in the mall, at your office? Then you have walked past a few people living with HIV. They are no different from anyone else. In fact, I often tell my patients that the people living with HIV I know are frequently in much better shape. Perhaps they appreciate their health more. It is also a myth that once a person is diagnosed with HIV in Singapore the authorities will come flying in and inform his family and his employer and every time he goes past immigration the officers will look at their screens and give him a dirty knowing look.
None of these happens. In fact, laws in Singapore protect the anonymity of people living with HIV and punish people who share someone’s status unnecessarily. Another myth is that HIV treatment in Singapore is unaffordable costing thousands of dollars a month. There are now many schemes in place to make treatment extremely affordable. What still needs a lot of work is the stigma and discrimination. That is why almost every person living with HIV in Singapore keeps their status a secret. That is also why we salute Mr. Avin Tan who went public with his HIV status and now works tirelessly to help others.


The theme of this year’s World AIDS Day is “Communities make the difference. Communities are the lifeblood of an effective AIDS response and an important pillar of support.” Because HIV/AIDS is not “their problem”, it is our problem. Less stigma means a lower barrier to testing which leads to earlier diagnosis and decreasing the risk to others. Less discrimination means more willingness to seek help and treatment which leads to earlier viral load control and less contagion. More support means people living with HIV staying on treatment and remaining physically, mentally and emotionally healthy and contributing to society.


READ: WORLD AIDS DAY PRESS STATEMENT

My Facebook just got updated. There’s a picture of Mr. J with his wife and 2 lovely twin daughters at the Singapore Barrage. They look like they are flying kites or at least trying to. His girls must be 6 years old by now. 6 years since I tested both of them to be negative for HIV. They look like a really happy family. A typical Singaporean family.
Speak to your doctor if you have any questions regarding HIV, Anonymous HIV Testing, HIV Screening and HIV Treatment & Management.


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性传播感染 (STDs)

大家好,今天黄医生想谈的是性传播感染也有些人称之为性病。

性传播感染是由病毒,细菌和其他微生物引起的,如果你与携带这些感染的人发生性关系,你可以捕获它们。

性病症状可分为泌尿系统症状,皮肤症状和一般症状,可在性生活后3天开始出现,也可能需要数周至数月。有些人受到感染但从未出现任何症状。

性病治疗取决于您所拥有的性传播感染的类型。一些可以通过抗生素治疗,一些如疱疹和艾滋病毒是必须管理的终身感染。人类乳頭瘤狀病毒 (HPV) 和肝炎等性传播疾病可通过疫苗预防


请记住,只要你发生性行为,你就可以患有性病。如果不及时治疗,大多数性传播感染会导致严重的并发症。

如有必要,请去看医生进行定期筛查和治疗。和他谈谈接种肝炎和HPV疫苗。


如果您怀疑自己有任何高风险的艾滋病毒感染,请告诉我们的医生。

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艾滋病 (HIV) 的症状与治疗方法

大家好,今天黄医生谈谈艾滋病感染的症状。

HIV症状取决于个体和疾病阶段。

在最初感染后的前2-4周内,患者可能会出现流感样症状, 他们称之为“有史以来最严重的流感”。


这被称为急性逆转录病毒综合征。症状包括发烧,腺体肿胀,喉咙痛,皮疹,疲劳,身体疼痛和头痛。

艾滋病毒症状可持续数天至数周。请记住,这些症状可见于其他常见疾病,您不应仅仅因为体验过它而认为您患有艾滋病毒。还要注意许多早期HIV感染者没有症状。


在HIV感染的早期阶段之后,该疾病进入临床潜伏期,其中病毒在体内发展,但没有看到症状。如果您正在接受艾滋病治疗,那么病毒通常会受到控制,您可能会遇到可能持续数十年的无症状期。如果您感染了艾滋病病毒并且没有接受治疗,那么它将进展为艾滋病。您可能会出现严重的症状,包括体重迅速减轻,反复发烧,大量盗汗,极度疲倦,腺体肿胀,腹泻,口腔溃疡,肺部感染和神经系统疾病。

即使您遇到上述症状,除非您接受检测,否则无法确认HIV。


如果你担心自己有可能跟性(爱)产生接触或正在经历类似状况,请到我们的诊所进行相关咨询和诊测。

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HIV / AIDS: The Differences & Myths Surrounding Them

HIV & AIDS in Singapore

There were 434 reported cases of HIV infection among Singapore residents in 2017. Of these cases, 94% were male and 6% were female, and 71% were between 20 to 49 years old. Among ethnic groups, 69% were Chinese, 19% were Malay, 6% were Indian and 6% from other ethnicities.
Sexual intercourse remains the main mode of HIV transmission, accounting for 96% of all cases. Heterosexual transmission accounted for 36%, while 51% were from homosexual transmission and 10% from bisexual transmission.  The number of new HIV cases among Singapore residents has remained consistent at about 450 per year since 2008. These are the latest statistics published by the Government Technology Agency of Singapore, which analyzes data provided by the Ministry of Health.
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What’s the difference between the two? 

HIV is a virus that causes weakening of the body’s immune system. It does so by destroying white blood cells that protect against bacteria, viruses and other harmful pathogens. Without these white blood cells, the body is will no longer be able to defend itself effectively against such infections.
AIDS refers to a spectrum of potentially life-threatening conditions that are caused by the virus, and is the end stage of HIV infection.


How does HIV progress to AIDS? 

HIV infection undergoes 3 stages. The first stage (Acute Stage) may present with flu-like symptoms, fever and a rash. The second stage (Latent Stage) may present with lymph node swelling, but most patients may not have any symptoms at all. The second stage can last anywhere from a few years to over 20 years. Thus, many HIV-infected patients, especially during this stage, may not even know that they have contracted HIV. Last but not least, the third stage is the presentation of AIDS. 
Without adequate treatment, up to 50% of HIV-infected patients develop AIDS within 10 years. Elevated levels of HIV affect the patient’s immune system and prevent it from functioning properly, eventually leading to AIDS. This may result in the individual being more prone to infections. Patients may develop symptoms such as prolonged fever, tiredness, swollen lymph nodes, weight loss and night sweats. Various virus-induced cancers, and opportunistic infections such as tuberculosis and recurrent pneumonia may occur, and these are the leading causes of death worldwide in patients with AIDS.


Who should test for HIV?

Everyone! It is recommended by the United States Centre for Disease Control and Prevention (CDC) that everyone between the ages of 13 to 64 should undergo HIV testing at least once as part of your routine healthcare. However, if your behaviour still puts you at risk even after getting tested, you should consider getting tested again at some point later on. People who engage in higher risk activity should get tested regularly.


Are you at risk?

If you answer “yes” to any of the questions below, you should get a HIV test if not done recently.

  • Are you a man who has had sex with another man?
  • Have you had sex – anal or vaginal – with a HIV-positive partner?
  • have you had more than one sex partner?
  • have you injected drugs and shared needles or works (for example, water or cotton) with others?
  • Have you exchanged sex for drugs or money?
  • Have you been diagnosed with, or sought treatment for, another sexually transmitted disease?
  • Have you been diagnosed with or treated hepatitis or tuberculosis?
  • Have you had sex with someone who could answer yes to any of the above questions or someone whose sexual history you don’t know?

What are some of the HIV tests available?

There are four types of HIV tests available.
1. Nuclecic Acid Test (NAT) 
Also know as a HIV viral load test, this test looks for the actual virus in the blood. If the result is positive, the test will also show the amount of virus present in the blood. NAT is very expensive and thus not routinely used to screen individuals unless they recently had a high-risk or possible exposure and there are early symptoms of HIV infection. NAT is usually considered accurate during the early stages of infection. However, it is best to get an antibody or antigen/ antibody test at the same time to help in the interpretation of negative NAT result. Taking pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) may also reduce the accuracy of NAT.
NAT is able to detect HIV in the blood as early as 1 to 4 weeks (7 to 28 days) after infection.
2. Antigen/ Antibody Test
Also known as a fourth-generation or combination test, this test looks for both HIV antibodies and antigens. Antibodies are produced by the immune system when one is exposed to bacteria or viruses like HIV. Antigens are foreign substances that cause the immune system to activate. In early HIV infection, an antigen called p24 is produced even before antibodies develop.
The fourth generation test is able to detect HIV in the blood 2 to 6 weeks (13 to 42 days) after infection, and is most accurate after a 28-day window period.
3. Antibody test
This is also known as a third-generation test. As mentioned before, antibodies are produced by the immune system upon exposure to bacteria or viruses like HIV.
The antibody test is able to detect HIV in the blood approximately 97% of people within 3 to 12 weeks (21 to 84 days) of infection. If a positive HIV result is obtained from any type of antibody test, a follow up test is required to confirm the result.
4. HIV Pro-Viral DNA Test

The HIV Pro-Viral DNA test can be used in specific situations where there are challenges to getting an accurate HIV diagnosis with other available HIV tests including HIV Antibody tests (3rd Generation HIV test), HIV Antibody and Antigen tests (4th Generation HIV test) as well as HIV RNA PCR test.

It is especially useful in the following situations:

  1. Diagnosing HIV in newborns born to HIV +ve mothers
  2. Elite controllers with undetectable HIV viral load despite not being on anti-retroviral treatment
  3. Individual with sero-negative HIV infections i.e. People who get infected with HIV but do not develop anti-HIV antibodies : see FALSE NEGATIVE HIV ELISA TEST

It can be used for situations where the diagnosis of HIV is challenging. It has a lower false positive rate compared to the HIV RNA PCR test when used for diagnosis and it can be done 10 days post exposure.


Can you share the 4 most common myths about HIV? 

1. HIV is a death sentence. 

This may have been the case several decades ago, where without prompt and adequate HIV treatment, the infection progresses and causes the immune system to weaken, leading to AIDS. However, thanks to advances in modern medicine, most HIV-infected patients today are still able to lead healthy, productive lives and may never develop AIDS.

2. HIV can spread by kissing, sharing of food or close contact. 

It is extremely unlikely to contract HIV via these methods as HIV is not spread by saliva. However, if the person you are in contact with has mouth sores/ulcers, bleeding gums or open wounds then there is a possible risk. HIV is spread by 3 main routes: sexual contact, significant exposure to infected body fluids such as semen, blood, vaginal secretions or breast milk, and lastly, mother-to-child transmission. 

3. HIV can spread through mosquito bites. 

This is completely untrue as the virus cannot survive and replicate within the mosquito’s body.

4. There is no need to use a condom during sexual contact if both partners already have HIV. 

Different strains of HIV exist. If two HIV-infected partners are carrying different strains of HIV, having unprotected sexual intercourse may result in the exchange of these strains, leading to re-infection. Treatment in this situation becomes more difficult as the new HIV strain may be more resistant to the current treatment, or cause the current treatment to become ineffective.


What are the 4 things (facts) we should all know about HIV that we probably don’t know already?

  1. Under the Infectious Diseases Act, it is an offence for people who know that they are infected with HIV or AIDS in Singapore to not inform their sexual partners of their HIV status before engaging in sexual intercourse.
  2. For those who are worried but too afraid to undergo HIV screening, there are 10 clinics in Singapore that offer Anonymous HIV Testing (AHT). AHT is made available so as to encourage more individuals who suspect that they are at risk to go for early HIV screening. There is no requirement to provide any form of personal particulars, even if the test comes back positive.
  3. Persons who plan to engage in high-risk sexual behaviour can reduce their risk of HIV infection by taking Pre-Exposure Prophylaxis (PrEP). This is an oral medication that, when taken correctly, can reduce the risk of HIV transmission through sex by over 90%. Persons who did not take PrEP prior to engaging in high-risk sexual behaviour are eligible for Post-Exposure Prophylaxis (PEP). This is a one month course of oral medications that must be started within 72 hours of the sexual exposure, the earlier the better.
  4. The current tagline in HIV is Undetectable = Untransmittable (U=U). In recent years, there is overwhelming clinical evidence proving that people living with HIV who achieve and maintain an undetectable HIV viral load by adhering to their treatment cannot sexually transmit the virus to uninfected partners. Several large studies had been conducted over a course of 10 years between 2007 to 2016, involving thousands of heterosexual and homosexual couples. In these studies, there was not a single case of HIV transmission from a virally suppressed person to their uninfected partner. This is life changing for people living with HIV. In addition to being able to choose to have sex without a condom, this news allows them to approach existing or new relationships with a sense of liberation. 

Speak to our doctors for professional advice or if you wish to find out more information on HIV and AIDS.
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World AIDS Day 2019 Press Statement

World AIDS Day is a day to remember all those who have lost their lives to the illness. At the end of 2018, it is estimated that 32 million lives were lost worldwide to the disease. WHO had previously set the 90-90-90 target for countries in the world to achieve by 2020, 90% of those living with HIV will know their status, 90% of those who are positive are on ART treatment and 90% of those who are on treatment have undetectable levels of the virus. Let us take stock of what we have been able to achieve thus far.


Since then Singapore has risen to the challenge to achieve those goals.
 Singapore has done well with 2 of the goals – 89% of those who are positive are on ART treatment and 94% of those who are on treatment achieved undetectable viral loads. However, much has to be done to improve on getting those living with HIV to know their status as only about 72% are aware they are positive for HIV.
Thus we need to encourage more people who are at risk of HIV infection to get tested. At Dr Tan and Partners we have been strong advocates of screening of HIV and STIs for at risk persons and provide a non-judgmental and LGBT-friendly environment to discuss your concerns. This is to help to protect their families and their loved ones. It is not uncommon for people that I see in my practice to tell me one of the reasons why they are reluctant to get tested is because they are afraid of what will happen if their families or their loved ones find out.
The other common concern is that they will lose their jobs. Finally there are still many misconceptions about how HIV is transmitted. I have patients who are concerned that because they share food with their families they can transmit HIV to their family which is of course not true. HIV is NOT transmitted via casual contact like sharing of food and drinks or shaking hands.


Of note in Singapore as of 2018, of all those who were tested positive more LGBTs are stepping up to get voluntary testing for HIV (20%) compared to heterosexuals (9%). Also importantly, in all newly diagnosed HIV persons in Singapore both homosexuals (42%) and heterosexuals (43%) contribute equally to number of cases. What this shows is that contrary to what some believe, HIV is NOT a homosexual disease but it is a disease that affects all sexual orientation.
Finally, there is strong evidence from large studies involving thousands of sero-discordant couples (that is one partner is HIV positive and the other partner is HIV negative) who have sexual acts between 2007-2016 showed that there was not a single case of HIV transmission to the HIV negative partner if the HIV positive treated partner has undetectable levels of HIV virus. This highlights the importance of treatment of HIV, that treatment of HIV can be successful in achieving undetectable levels of virus and that transmission of HIV is effectively blocked when levels of the virus is undetectable.


We are proud that our Doctors at DTAP have been actively involved in the fight against the HIV epidemic. Our Anonymous HIV Testing site at Robertson Walk has provided a safe space for thousands of people seeking confidential HIV testing since 2005. Our Doctors were the lead and co-lead authors of the Community Workforce section in the Blueprint to end HIV transmission and AIDS in Singapore by 2030. Our Doctors were also part of the Singapore HIV PrEP Taskforce and helped write the first ever local Singapore guidelines for the clinical management of HIV PrEP.
We will continue this fight until we see a world free of stigma, free of discrimination and hopefully free of HIV.


Dr. Julian Ng

Dr Julian Ng has 10 years of medical practice experience. He currently serves as the Chief Medical Officer of the DTAP Group of clinics in Singapore, Malaysia and Vietnam. He is also a member of the Singapore Men’s Health Society. His special interests are in the field Andrology, especially sexual health. He is currently practising at Dr Tan and Partners (DTAP) clinic at Novena Medical Centre.

Cytomegalovirus (CMV): Risks, Symptoms & Treatment

What is Cytomegalovirus?

Cytomegalovirus (CMV) is an extremely common virus which is part of the herpesvirus family. There are various different strains of CMV. CMV infection seldom causes any symptoms in healthy individuals. Infected individuals carry the virus lifelong but it remains suppressed by the immune system in healthy individuals and they have no long term health complications. 
However, CMV can cause symptoms and potentially dangerous, even life-threatening illness and complications in individuals with weakened immune systems, such as infants whose immune systems are not fully developed, or individuals on immunosuppressive or chemotherapy and individuals with poorly controlled HIV. 


How common is CMV?

According to the US Centers for Diseases Control and Prevention, almost one third of children will be infected by CMV by age 5, and more than half of adults will have been infected by the time they reach age 40. 


How is CMV spread?

CMV is transmitted through body fluids like blood, semen, vaginal fluids, saliva, urine and breast milk. 
Transmission can occur when infected bodily fluid comes into contact with someone’s mucosa e.g. the eyes, lining of the mouth, or through sexual contact. An infected individual can transmit the virus during periods of activation- when it is not adequately suppressed by one’s immune system. Other modes of transmission include vertical transmission from mother to infant before or during birth, or through breastfeeding. One can also acquire CMV through blood transfusions or organ transplants. 


What are the symptoms and possible complications of CMV?

In most healthy individuals, CMV may not cause any symptoms at all. However, during the initial infection, some individuals may experience symptoms of fever, fatigue, myalgia (muscle ache), swollen lymph nodes and a sore throat. These symptoms are very similar to that of infectious mononucleosis or glandular fever. In healthy individuals, reactivation of the virus very rarely occurs as the immune system keeps it in check. 
In immunocompromised individuals, CMV can affect and cause symptoms involving various organs including the eye, liver (hepatitis), and the gastrointestinal tract (esophagus, stomach, intestines). 
CMV infection during pregnancy can lead to severe consequences for the unborn infant – infants who are infected during pregnancy (known as congenital CMV) may have problems affecting various organs including the brain, ears, liver, and lungs (see below for more on congenital CMV). 


What is congenital CMV? 

Congenital CMV occurs when CMV is transmitted from a pregnant mother to her unborn foetus during pregnancy. This can occur if a pregnant woman has a primary (new) CMV infection, or is reinfected with a new strain of CMV, or if she suffers a reactivation of a preexisting CMV infection. The risk of severe complications is highest if infection occurs during the first trimester of pregnancy.
Some of the effects of congenital CMV infection are apparent at birth. This includes possible jaundice, hepatosplenomegaly (enlargement of the liver and spleen), inflammation of the eye retina (retinitis), seizures, microcephaly (small head) and low birth weight. 
Some complications can be long term/life-long, including hearing and vision loss, intellectual disability and seizures. 


Who is at risk of CMV?

CMV can cause serious health problems in susceptible individuals: 
1) Infants who are infected during pregnancy (congenital CMV)
2) Infants born premature or with very low birth weight
3) Immunocompromised individuals e.g. organ transplant recipients or individuals with HIV. 


CMV and HIV

Not all individuals with HIV are at risk of CMV disease. Only individuals with a low CD4 (T cell – a form of immune cell) count are at risk. This usually occurs only if they are not on, or have failed to respond to antiretroviral therapy. Either re-infection with a new strain of CMV, or reactivation of an existing CMV infection can result in symptoms. 
The most common manifestation is CMV retinitis – inflammation of the retina of the eye, resulting in visual disturbances or visual loss. CMV can also cause inflammation of the esophagus (esophagitis), resulting in symptoms like pain on swallowing, and inflammation of the colon (colitis), causing diarrhoea, abdominal pain and weight loss. 
In rarer cases, CMV can affect the brain and nerves, causing symptoms like dementia, confusion, numbness and weakness. 


How does one test for CMV?

In symptomatic adults, antibody blood tests can be used to diagnose CMV infection. Other special tests may be necessary to determine organ involvement if there are symptoms to suggest this.
For infants with CMV, a urine or saliva sample is usually used to test for infection. Testing for congenital CMV has to be done within 3 weeks after birth. 


What is the treatment for CMV infection?

Healthy individuals with no symptoms do not require any treatment for CMV. However, in immunocompromised individuals who develop symptoms or in cases of congenital CMV infection, anti-viral medications can be used to treat and suppress the virus. In individuals with HIV, adherence to antiretroviral therapy and maintaining good CD4 counts is crucial. Treatment with anti-virals against CMV is not recommended unless there is evidence of CMV disease affecting an organ (end-organ disease). 
Speak to our doctors to find out more about Cytomegalovirus (CMV) and it’s available testing or treatment options.
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Common Causes Of Bumps & White Spots On Penis & Foreskin

This situation may be familiar to many men: while taking a shower one day, you happen to notice some white spots on your foreskin. You do a double take as you lean down to inspect your manhood. What could it be? How long have they been there? The questions are aplenty as you instinctively reach for your smartphone to begin a Google search.

There are many conditions that can cause white spots to develop on the penis and foreskin. Some men may be born with them, while others may develop them as a result of poor hygiene practices or sexually transmitted infections (STIs). It is important to know what the white spots are due to, as not all conditions require treatment. Listed below are some common causes of white spots on the foreskin and penis.


Pearly Penile Papules

Pearly penile papules (PPP) are small, dome-shaped or projection-like bumps that are located just below the head of the penis, usually arranged in a neat row. They can be white, flesh-coloured, yellow or translucent in colour. They do not cause any pain or itch. PPP is considered as a normal variant of the male penile anatomy, and are harmless bumps. It is not cancerous and there is no cancer risk. It is not a sexually transmitted infection and is not contagious. It is common and can occur in up to 38% of young men up to age 25.

PPP can be left alone and does not require treatment. However, for men who find them unsightly, they can be removed. Treatment options include laser therapy, cryotherapy and electrosurgery. 

READ: What are Pearly Penile Papules?


Fordyce Spots

Also known as Fordyce glands, these are harmless, small white or yellow bumps that are found on the foreskin. They are basically enlarged sebaceous glands, and can occur alone or in clusters. They do not cause any pain or itch. Fordyce spots can also commonly occur on the edges of your lips or on the inside of your cheeks.

Just like PPP, Fordyce spots are not cancerous and infectious, and also does not require treatment. Similarly, they can be removed if men find them unsightly. Treatment options include topical retinoid cream, oral isotretinoin, laser therapy and electrosurgery. 


Tyson’s Glands

Also known as preputial glands, Tyson’s glands are modified sebaceous glands that are found on the inner surface of the foreskin. They occur in pairs and are located on either side of the frenulum. These glands are also present on the hood of the clitoris in females. Tyson’s glands are normal structures and do not require treatment.  


Skin Tags

Skin tags are small, soft, flesh-coloured growths on the skin. They usually have a stalk and hang off the skin, and can vary in size from a few millimetres up to several centimetres. They tend not to grow on the penis itself, but rather, around the groin and scrotum. They often grow in areas where the skin folds and rubs against itself, and as such they are often also found on the neck, armpits, eyelids and under the breast. They affect men and women equally. Obesity, diabetes and pregnancy can increase the chances of occurrence.

Skin tags are benign tumours of the skin and do not require treatment. Occasionally, they may fall off on their own. People often wish to get them removed for aesthetic reasons, or if the skin tags are large and get in the way. Treatment options include cryosurgery, electrosurgery, ligation and excision.  

READ: Skin


Balanitis

Balanitis is inflammation of the foreskin and head of the penis. Spots can appear on the penile head or foreskin, and can be white or reddish. Other symptoms include redness, pain, itching, discharge, swelling and difficulty with retraction of the foreskin, and sometimes pain when passing urine. 

Balanitis can affect as many as 1 in 10 males, and can occur at any age. It is more likely to occur in uncircumcised men. The most common cause of Balanitis is a bacteria or fungal infection, or a combination of both. This can result from inadequate personal hygiene and/or phimosis (tight foreskin). There are non-infectious causes for balanitis as well. Risk factors for recurrent balanitis include diabetes, HIV and other sexually transmitted infections. 

To investigate balanitis, your doctor may perform swab tests to identify the responsible organism. Treatment involves topical and/or oral anti-fungal and antibiotics. The long term solution to balanitis is a circumcision.

READ: Causes, symptoms and treatment of Balanitis.

Pimples

Pimples develop as a result of the pores of our skin being blocked by dead skin cells, sebum and other debris. The sebaceous gland continues to produce sebum and build up under the blockage, allowing bacteria to grow in the area, resulting in inflammation, infection and pain. They can occur anywhere on the body, including the penis.

Pimples can be left alone and usually resolve on their own without treatment. It is important to resist the urge to pop the pimples as this may lead to superimposed infection, scarring and hyperpigmentation. However, they may end up self erupting and discharge small amounts of pus. Treatments for pimples include topical over-the-counter creams such as benzoyl peroxide, antibiotic creams and, if more severe, oral antibiotics.

READ: Skin


Folliculitis

Folliculitis is an inflammation or infection of the hair follicles. It can occur anywhere on the body, including the penis, where it is frequently seen at the shaft or base of the penis, or the pubic area. Folliculitis tends to result from shaving, waxing or chafing of the hair follicles. The damage to the hair follicles allows bacteria to enter. Sometimes, ingrown hairs can also occur from hair removal treatments, eventually leading to folliculitis as well. Folliculitis can be painful and/or itchy. Treatment options include topical and/or oral antibiotics. 

READ: Common causes of penile itching and pubic itching


Genital Warts

Genital warts are caused by the Human Papillomavirus (HPV). HPV is the most common sexually transmitted infection and can be spread via vaginal, oral or anal sex. They appear as flesh-coloured growths over the genitals that can cluster and resemble a cauliflower. Most of the time they do not have any symptoms but can sometimes itch. Bleeding can also occur during sexual intercourse. 

READ: Causes, symptoms and treatment for Genital Warts
READ: How to get rid of Genital Warts

Left alone, the warts can remain the same or increase in size and number. They will disappear once the body has shed the virus completely, typically over a course of 1 to 2 years. Treatment options include topical medications such as imiquimod, cryotherapy and electrosurgery. Vaccines are available to help prevent HPV infection, consider getting a HPV vaccination. 

READ: HPV Vaccination For Men
READ: Rapid HPV Testing

Genital Herpes

Genital herpes is caused by the Herpes Simplex Virus (HSV) and is a sexually transmitted infection. Itching of the penis is usually the first symptom, and can occur in other areas such as the scrotum, groin, buttocks and anus. Shortly after, tiny clusters of painful blisters develop, which can then rupture and form shallow ulcers with crusts. Other symptoms include painful urination, enlarged groin lymph nodes, fever and body aches. The virus can lie dormant in the body for years without causing any symptoms, therefore some people may not even be aware that they are infected. 

Genital herpes can be diagnosed via swab testing of the lesions. When there are no symptoms, no treatment is required. Flares can be treated with oral and topical antiviral medications. There is unfortunately no cure for genital herpes, as the virus will permanently remain in the body.

READ: Rapid Herpes Testing

Molluscum Contagiosum

This is a benign infection of the skin caused by the Molluscum Contagiosum virus, resulting in painless, small, shiny pearl-shaped lesions. They can happen anywhere on the body as a result of physical contact, but when they occur on the genital area, it is usually as a result of sexual contact. The virus is thus spread via sexual contact, or even to another part of the person’s own body, from scratching the lesions and touching another part of the body. They can appear alone, or in clusters. They usually do not cause any symptoms, but can sometimes itch. 

Left alone, the lesions will eventually disappear once the body has shed the virus completely, typically over a course of several months to a year. Treatment options include topical medications such as salicylic acid, cryotherapy, laser therapy and curettage.

READ: Everything you need to know about Molluscum Contagiosum

In conclusion, do not panic if you notice white spots on your penis, as not all white spots require treatment.  Speak to your doctor for advice on white spots or bumps and request for an examination. 

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Condyloma Lata vs Condyloma Acuminata

Condyloma

Condyloma refers to wart-like skin growths – usually in the genital, anal, or oral regions but occasionally found in other areas of the body – that are caused by a sexually transmitted infection. The most common type is known as genital warts and is termed condyloma acuminata.

These are caused by an infection with Human Papilloma Virus (HPV), the same group of viruses that can lead to cervical cancer as well as other oral and anogenital cancers. The prevalence of genital warts in the general population is estimated to be around 3-5%, making it the most common STD globally. See: 

Read: Rapid HPV Testing (Next Day Results)
Read:
Anal Pap Smear


Condyloma Acuminata On The Penis

When condyloma acuminata are detected, we must always look for and differentiate these lesions from condyloma lata, which are caused by secondary syphilis infection. These two types of condyloma can appear extremely similar and are easily mistaken for the other.

They may also both be present as a co-infection, seeing as they share common risk factors. It is essential that syphilis infection is considered and tested for when condyloma lesions are found, so that rapid diagnosis, treatment, and partner tracing can be performed. 

Condyloma lata

Condyloma lata of secondary syphilis tend to be slightly larger and more moist than common genital warts, and may even ulcerate in later stages. They are usually found in the anogenital or oral regions, but can also be found sometimes on the palms or soles of the feet. Other signs of syphilis may be a diffuse body rash or a classic painless sore or chancre (seen in earlier stages of primary syphilis).

Both types of condyloma are mainly transmitted through penetrative anal or vaginal sex, as well as oral sex (fellatio and cunnilungus). However, as they can be spread with direct contact with mucosa and/or broken skin, there have even been cases of transmission through mutual masturbation.

If you or your partner noticed any suspicious skin lesions, please visit our doctors for a full consultation and assessment. 

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