Of Foolish fools and unchanging facts.


Singapore Med J. 2011 Dec;52(12):860-3.

Acute HIV infection in Singapore: predominance of men who have sex with men.


Department of General Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. wongchenseong@gmail.com



The incidence of human immunodeficiency virus (HIV) infection in Singapore is on the rise. We aimed to study the clinical epidemiology of acute HIV infection in Singapore.


All patients that fulfilled the criteria for definite and probable acute HIV infection were prospectively identified from January 1, 2003 to June 30, 2006. Demographic, clinical and laboratory data were recorded.


A total of 16 out of 34 patients had definite acute HIV infection, and 68 percent of the entire cohort comprised men who have sex with men (MSM). Ten percent of the patients were co-infected with hepatitis B and C viruses, while 27 percent were infected with syphilis. Signs and symptoms were nonspecific, with fever, rash and diarrhoea being the three most common symptoms. Only 35 percent of the patients required hospitalisation.


Men who have sex with men account for the majority of patients with acute HIV infections in Singapore, many of them also being co-infected with syphilis. Safer sex campaign among MSM should be implemented or intensified.




Sodomy Laws and the Emperor’s New Clothes

“How well Your Majesty’s new clothes look. Aren’t they becoming!” He heard on all sides, “That pattern, so perfect! Those colors, so suitable! It is a magnificent outfit.”

Then the minister of public processions announced: “Your Majesty’s canopy is waiting outside.”

“Well, I’m supposed to be ready,” the Emperor said, and turned again for one last look in the mirror. “It is a remarkable fit, isn’t it?” He seemed to regard his costume with the greatest interest.

The noblemen who were to carry his train stooped low and reached for the floor as if they were picking up his mantle. Then they pretended to lift and hold it high. They didn’t dare admit they had nothing to hold.

So off went the Emperor in procession under his splendid canopy. Everyone in the streets and the windows said, “Oh, how fine are the Emperor’s new clothes! Don’t they fit him to perfection? And see his long train!” Nobody would confess that he couldn’t see anything, for that would prove him either unfit for his position, or a fool. No costume the Emperor had worn before was ever such a complete success.

Virtually everyone should be familiar with Hans Christian Andersen’s The Emperor’s New Clothes, a childhood tale so easily understood for its simple message.

Or really?


The World Health Organization (WHO) has often criticised sodomy laws as a barrier to treatment for HIV (Human immunodeficiency virus) in men who have sex with men (MSM). In a document titled, “Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people“, the WHO writes:

Criminalization, and legal and policy barriers play a key role in the vulnerability of MSM and transgender people to HIV. More than 75 countries currently criminalize same-gender sexual activity. And transgender people lack legal recognition in most countries. These legal conditions force MSM and transgender people to risk criminal sanctions if they want to discuss their level of sexual risk with a service provider. They also give police the authority to harass organizations that provide services to these populations.

The WHO has urged governments to repeal their sodomy laws as a result.

With Singapore’s sodomy law, section 377A of the Penal Code (Cap. 224, 2008 Rev. Ed. Sing.), subject to legal challenge, it is perhaps worth examining the question: Does repeal of sodomy laws help combat HIV?

Recent studies from the Centers for Disease Control and Prevention (CDC) in the United States show otherwise.

Sodomy Laws and HIV

It is a widely known fact that MSM are at a disproportionately high risk of HIV infection. The CDC estimates that though MSM represent approximately 4 percent of the male population in the United States, male-to-male sex accounted for more than three-fourths (78 percent) of new HIV infections among men and nearly two-thirds (63 percent) of all new infections in 2010. The same applies for Singapore. As observed by Wong, et al., in “Acute HIV infection in Singapore: predominance of men who have sex with men” (2011) 52(12) Sing. Med. J. 860, “Men who have sex with men account for the majority of patients with acute HIV infections in Singapore, many of them also being co-infected with syphilis.”

The number of MSM diagnosed with HIV in the United States had been increasing in the years leading up to 2003, the year when the Supreme Court declared sodomy laws unconstitutional in the case of Lawrence v. Texas. According to CDC statistics, the number of MSM diagnosed with HIV had increased from 13,112 in 2000 to 14,532 in 2003 in a study of 32 US states and the Virgin Islands. The number is about a thousand higher per year if MSM with injection drug use are included.

However, the number of HIV cases among MSM has not decreased as a result. On the contrary, a factsheet released by CDC showed that, in the United States, the number of new HIV cases among MSM was 26,700 in 2008, and increased to 29,800 in 2010. Between those years, various states had legalised same-sex marriage.

Following the repeal of sodomy laws throughout the United States, and growing social and legal acceptance of homosexuality, HIV infections among MSM has still been on the increase. This essentially confirms what was observed in a 2011 report by Wolitski RJ and Fenton KA:

The sexual health of gay, bisexual, and other men who have sex with men (MSM) in the United States is not getting better despite considerable social, political and human rights advances. Instead of improving, HIV and sexually transmitted infections (STIs) remain disproportionately high among MSM and have been increasing for almost two decades. The disproportionate and worsening burden of HIV and other STIs among MSM requires an urgent re-assessment of what we have been doing as a nation to reduce these infections, how we have been doing it, and the scale of our efforts…

Statistics from countries like Canada, the United Kingdom and Australia corroborate these observations.

Access to medical care?
What about the impact on access to medical care in the event of HIV infection?

I would hesitate to conclude on this point without further, concrete data. However, some experts in Singapore seem to suggest that access is not hindered. In “Acute HIV infection in Singapore: predominance of men who have sex with men“, the authors suggested that the doubling in proportion of detected HIV infection among MSM from 19 percent in 2001 to 37 percent in 2007 could be due to detection bias, namely, that “MSM are more aware of HIV risk and seek medical attention when they become sick”.

Conclusion: “But he hasn’t got anything on…”

The repeal of sodomy laws does not reduce the incidence of HIV infection among MSM. Instead, statistics indicate that the number of HIV infections among MSM continues to increase alongside growing social and legal acceptance of homosexuality, and not in spite of it.

In their article, Wong and the other authors warn that the high incidence of HIV infection among MSM may indicate a “new epidemic” and warrant “urgent public health interventions”. Public health intervention is undoubtedly necessary, but there is little reason to believe that the repeal of section 377A is part of that solution.

In The Emperor’s New Clothes, the Emperor continues his parade while the town unwittingly praises his “new clothes”, until a little child speaks up…

“But he hasn’t got anything on,” a little child said.
“Did you ever hear such innocent prattle?” said its father. And one person whispered to another what the child had said, “He hasn’t anything on. A child says he hasn’t anything on.”
“But he hasn’t got anything on!” the whole town cried out at last.
The Emperor shivered, for he suspected they were right. But he thought, “This procession has got to go on.” So he walked more proudly than ever, as his noblemen held high the train that wasn’t there at all…
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