Fearful of getting Covid-19, HIV patients delay treatments, put their lives at greater risk

SINGAPORE — Unable to find a job after testing positive for acquired immunodeficiency syndrome (Aids), Singaporean Jeremy Tan (not his real name) left the country for good in 2009.

In his late 30s then, Mr Tan had the most advanced stage of an infection from the human immunodeficiency virus (HIV).

He was so demoralised by the discrimination he faced here that he did not return home even once during his decade-long stay in Thailand, where he eked out a living earning around S$3,000 to S$3,500 a month as a trader.

In an unexpected twist of events, a different deadly virus brought Mr Tan home for the first time in more than 10 years.

The 50-year-old declined to provide his real name for this interview due to the stigma attached to HIV.

When he returned to Singapore in May 2020, the Covid-19 pandemic had destroyed the small trading business he had built up overseas. He had also gone without proper HIV follow-up care for around six months and had put off seeing a cardiologist despite having chest pains.

In a Zoom interview with TODAY facilitated by non-government organisation Action for Aids (AFA), Mr Tan said that by the time he left Thailand, he had no income and his savings were running dry.

“As a foreigner living there, I wasn’t getting subsidies but I still needed treatment and medication.

“I had cut my medical appointments to the point where I was just self-medicating without seeing a doctor as you can get HIV medications over the counter there.”

While abroad, he was also worried that medication supply would run out.

“At the back of my mind, I knew I had to see a doctor. I wasn’t even getting treatment and no one knows how long more (the pandemic) would last. Also, the fear (of contracting Covid-19) was real, bearing in mind that I have low immunity,” he said.

DISRUPTIONS TO MEDICAL CARE

People living with HIV such as Mr Tan, or who are at risk of contracting HIV such as those leading a promiscuous lifestyle, have had their access to medical care halted or delayed during the Covid-19 pandemic. 

In a survey by biopharmaceutical company Gilead Sciences, it was found that almost half of the more than 1,200 respondents across 10 countries in the Asia-Pacific region reported a disruption in visits to hospitals or services to receive HIV care — whether for testing, preventive care or treatment.

They included 37 respondents from Singapore across three categories: People living with HIV, individuals at risk of contracting HIV, and HIV care prescribers who administer tests, treatments and medications to those in the first two categories.

In the Singapore group, about a third of people living with HIV reported either a decrease or complete halt to taking antiretroviral therapies.

The reasons given included travel restrictions, financial constraints and doctors not refilling prescriptions.

Some 73 per cent of people living with HIV reported concerns about accessing HIV medicines in the long term.

Almost nine in 10 (89 per cent) people at risk of HIV reported decreased frequency of taking HIV tests while more than six in 10 either delayed or stopped visits to the hospital.

Ms Sumita Banerjee, executive director of AFA, said that the data from the survey is significant because statistics from the health authorities here showed that almost half of the people diagnosed with HIV are in late stages of the infection.

“A delay in diagnosis not only affects treatment outcomes but also has implications on HIV transmission and control.

“The survey illustrates the need for health systems to innovate and act swiftly to address such disruptions in access to services,” she said.

The survey also found that the Covid-19 pandemic accelerated the adoption of telehealth for HIV care in Singapore, with 83 per cent of HIV care prescribers expecting an increase in such services in the future.

Telehealth may include telephone or video consultations, and refills of medications via deliveries.  

There are now more than 8,000 cases of HIV infections among Singapore residents.

A total of 220 new HIV cases were reported among Singapore citizens and permanent residents in the first 10 months of 2020, based on the Ministry of Health’s update on the HIV/Aids situation last month.

The ministry analysed 125 of the new cases and found that 54 per cent had late-stage HIV when they were diagnosed. This is an increase from the 49 per cent for the same period in 2019.

HARDER TO CONTROL REBOUND VIRUS

Dr Asok Kurup, an infectious diseases specialist practising at Mount Elizabeth Hospital, stressed that it is “absolutely imperative” that people with HIV continue to take their medicines as prescribed to keep the HIV virus suppressed and  to ensure their immune system stays strong.

“Stopping medications can lead to a rebound of the virus, making it more difficult to control the virus subsequently, potentially leading to drug resistance and having to use alternative costly agents or even limiting therapeutic options.

“A rebound of the virus can also lead to destruction of a key component of the immune system, rendering the patient to various opportunistic infections,” Dr Asok said.

Since the start of the pandemic, he has encountered at least one patient who died from complications arising from HIV-related infection.

The male patient from a neighbouring country had been undergoing HIV treatment in Singapore for some years. However, he ran out of medicines during the pandemic, resulting in him taking alternative medications that was unhelpful to his HIV infection.

Dr Asok said that some of his Singapore patients were also initially scared to follow up on treatment due to a fear of contracting Covid-19.

Those from low-income groups or from overseas are also less likely to follow up on their HIV treatments during the pandemic.

Dr Asok said that he adopted telehealth services during the pandemic, which included providing delivery of medication when patients needed refills.

“As the science around Covid-19 evolved, it became clear that people living with HIV were not a significant vulnerable risk group per se, so it became easier to get some patients back.”

The United States’ Centers for Disease Control and Prevention stated that people with HIV on effective treatment have similar risk for Covid-19 as those who do not have HIV.

The risk for people with HIV getting very sick from Covid-19 is greatest in those with a low CD4 cell count (which shows how robust the immune system is) and who are not on effective HIV treatment.

When CD4 cell count is lower than 200 per mm3, the person is vulnerable to opportunistic infections.

WHY HE LEFT SINGAPORE

Mr Tan found out about his late-stage HIV status after experiencing a bout of fever and persistent rashes. Recently divorced at the time of the diagnosis, he was leading what he dubbed a partying lifestyle, drinking and smoking too much, and having casual sex without using protection. 

“My ex-wife is cleared (of HIV). I don’t know who I got it from. The diagnosis came as a shock as I never thought it would happen to me,” he said.

Mr Tan’s mother and siblings are supportive and understanding, but it is not the same outside of his family. 

“Unlike my family who are not judgemental and still love me no matter what, there is still a lot of stigma attached to HIV in Singapore society,” he said.

Mr Tan, who worked in the advertising and media industry when he was diagnosed, was offered jobs at several companies. But these job offers were retracted after his HIV status was revealed during pre-employment medical screening.

Some of his long-time friends avoided him.

“I was very disillusioned with Singapore at that point in time after all the rejection. I felt very stigmatised,” he said.

HEART PROBLEMS

Having lived overseas for so long, Mr Tan said that he is still trying to adjust to life in Singapore.

“I feel like a total stranger in my own country.”

However, he believes that his decision to return in May saved his life.

He was found to have severely blocked heart arteries, one of which had a 97 per cent blockage, after being admitted to the emergency department for chest pains.

“If I were still in Thailand, I would probably have died there. I wouldn’t have gone to the emergency department, thinking that the pain might go away. As a foreigner there, medical treatments are not subsidised at all,” Mr Tan said.

People infected with HIV have a higher risk of developing cardiovascular disease compared to those without the infection. Dr Asok said that it is thus important for them to have regular follow-up treatments and tests.

Follow-up checks and medications for HIV should also be directed and supervised by a clinician, he added. 

Mr Tan has since undergone treatment for his cardiovascular ailments and is getting proper HIV care here.

Now living with his mother and getting by on some freelance work, he is uncertain if he would go back to Thailand with the pandemic still ongoing.

He hopes to be able to find work here soon even though he knows that it will be tough and many people’s livelihoods have been affected by the Covid-19 crisis.

“I’m also hoping the stigma here won’t be as bad as it was 10 years ago. (I don’t) want to be alone over there in Thailand. Even if I go back there, I’m not sure if the type of work I was doing would be sustainable.”

For people living with HIV, Mr Tan urges them not to discontinue their medications and to stick to their medical check-ups.

COVID-19 VACCINE FOR HIV PATIENTS

With the Covid-19 pandemic showing no signs of slowing down, Dr Asok said that people living with HIV should “stay put, not be gung-ho, not travel unless really required, and to stick with the science”.

On the Covid-19 vaccine, he said that it is indicated for people living with HIV as long as their immune system as measured by the CD4 cell count test is more than 200, and their healthcare provider advises them accordingly.

“People living with HIV on stable antiretroviral therapy may have similar outcomes to those without HIV when it comes to Covid-19, but the data (on deaths) is conflicting and much more remains to be truly understood.

“People with HIV may also be predisposed to cardiovascular risks, which may render them at higher risk for Covid-19-related complications,” Dr Asok said.