As a family physician, I frequently assist patients with human immunodeficiency virus (HIV) and sexually-transmitted infection (STI) screening.
However, patients who step forward to carry out voluntary HIV and STI screening may be the minority.
Forty-year-old Melvin (not his real name) came for a clinic consultation. His friendly and cheerful demeanour were marred by a slight anxiety.
He was gay and in a monogamous relationship with a long-term partner. He had several previous partners from past relationships and the occasional casual fling.
However, he had never undergone any screening tests. The last time he had been tested for HIV was over 20 years ago, when he enlisted for National Service (compulsory military service for males in Singapore).
“The honest truth is I am embarrassed and also fearful of seeing a doctor to do these tests. “It took me a lot of courage to see you today,” said Melvin.
“I have always had this avoidance mentality towards HIV. I have always used condoms and I don’t think I have had many sex partners.
“It was my current partner who encouraged me to do the tests.”
Melvin did not take the results too well – he tested positive for HIV. It took some time for him to come to terms with it.
The silver lining was that Melvin was still in the early stages of the infection. He has since started on treatment and is doing regular follow-up monitoring of his condition.
The good news is that he will likely be able to keep the virus in check, and thus, maintain a healthy immune system.
Melvin’s case highlights a perennial problem in the fight against HIV.
Despite continuous efforts by health organisations to educate the public on HIV and the importance of regular screening, many people are still sitting on the fence.
It is estimated that 15% (one in seven) of people in the United States are presently living with HIV, but unaware that they have the infection.
In Singapore, the Health Ministry stated that only 14% of newly-reported HIV cases in 2018 were detected by voluntary screening.
Here are some of the common reasons that deter people from getting tested for HIV:
- I am scared of getting tested positive for HIV
Fear and anxiety are probably the biggest reasons why people avoid getting tested.
It is far better to get the testing over and done with.
If it is negative, it will bring much relief. If the result is unfortunately positive, it is timely to get support and treatment in order to stay healthy.
- If I test positive for HIV, people will find out
Medical clinics and testing centres endeavour to keep all patient records strictly confidential.
Under the Infectious Diseases Act in Singapore, a positive test for HIV is notifiable to the Health Ministry.
(Editor’s note: A positive HIV/AIDS case in Malaysia is also notifiable to the Health Ministry under the Infectious Disease Prevention and Control Act 1988.)
This is mainly for public health purposes, such as disease surveillance, monitoring the HIV infection situation, conducting contact tracing, and assessing disease prevention and management measures.
Healthcare professionals and the ministry do not inform the patient’s employer, insurance provider, or family and loved ones.
- I am afraid of being judged or being embarrassed
Healthcare professionals are trained to provide professional and non-judgmental consultation.
If you do not wish to visit your regular doctor, search online as there are plenty of alternative options that you can consider.
It is important to find a sexual health clinic or testing centre that you feel comfortable with.
- I trust my partner
If two HIV-negative people are in a monogamous relationship, then there is no risk of contracting HIV.
If one member strays from the relationship, then both parties could be at risk of HIV, especially if engaging in unprotected sex.
It is important to have open and honest communication with your partner.
If you or your partner has had sex with any casual partner, or if there is any doubt about your HIV status, get tested.
- I am not at risk of HIV
Even if you think that there is no chance that you have been exposed to HIV, as long as you are sexually active, do get HIV testing at least once a year, or more frequently if your behaviour puts you at higher risk.
Who should test
It is recommended by the US 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 routine healthcare.
However, if your behaviour 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.
If you answer ‘yes’ to any of the questions below, you should get an HIV test if you haven’t had one done recently:
- Are you a man who has had sex with another man?
- Have you had sex – anal or vaginal – with an HIV-positive partner?
- Have you had more than one sex partner?
- Have you injected drugs and shared needles or works (e.g. water or cotton) with others?
- Have you exchanged sex for drugs or money?
- Have you been diagnosed with, or sought treatment for, another STI?
- Have you been diagnosed with, or treated for, 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?
Types of tests
There are three types of HIV tests available:
- Nucleic Acid Test (NAT)
Also known as an 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 a negative NAT result.
Taking pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) may also reduce the accuracy of NAT.
A NAT is able to detect HIV in the blood as early as seven to 28 days after infection.
- 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 13 to 42 days after infection, and is most accurate after 28 days of infection.
- Antibody test
This is also known as a third-generation test.
The antibody test is able to detect HIV in the blood in approximately 97% of people within 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.
Just turn up
In the clinic setting, all the tests are typically performed using blood samples.
Laboratory testing can be performed for all three types of HIV tests, whereby blood is drawn from a vein and collected in a tube.
Rapid testing is only available for the fourth-generation test and the antibody test, whereby a few drops of blood are obtained via finger prick, and the results can be ready in 20 minutes.
The rapid HIV antibody test can also be performed using oral fluids collected from the mouth and gums with a swab stick. Similarly, the results are ready in 20 minutes.
Regardless of the test you choose, the process is simple and fuss-free, and no prior preparation is required – all you need to do is show up at the clinic.
Pre- and post-test counselling is always conducted professionally and non-judgementally.
If your healthcare provider uses a fourth-generation antigen/antibody test, you should get tested again 45 days after your most recent exposure.
For other tests, you should test again at least 90 days after your most recent exposure to tell for sure if you have HIV.
If your last HIV test was negative, you can only be sure you are still negative if you have not had a potential HIV exposure since then.
If you are sexually active, continue to take actions to prevent HIV, like using condoms the right way every time you have sex and taking PrEP if you are at high risk.
Dr Edwin Ong is a physician in Singapore. For more information, email firstname.lastname@example.org. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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