Horny straight guys’ choices

You’re a heterosexual male, HIV-free, feeling horny tonight and in Singapore. Which partner presents the lowest chance of exposure to the HIV virus?

1. A casual (girl)friend you’ve known for a while

2. Your wife, or fiancée to whom you’re engaged to be married soon

3. Someone you’ve just met at a singles bar

4. A sex worker operating out of a licenced brothel

5. A freelance sex worker you picked up in a bar or on the street outside.

Let me help you by eliminating one of the five options. Aids activists reported at the 7th Singapore Aids Conference, held 4 December 2010, that based on cases of freelance sex workers surveyed, about 5 – 10 percent of them are HIV-positive.  Since you will think it is unlikely that all the other four categories have an HIV prevalence rate higher than 5 – 10 percent, I don’t think you will choose #5 as presenting the “lowest chance of exposure”.

* * * * *

During the last ten months, January – October 2010, there were 373 new cases of HIV discovered, and for the whole of the year, a total close to 2009’s 463 new cases is expected. Of the 373, heterosexual men made up about 60 percent, bisexual and homosexual men about 30 percent and women about 10 percent. Transmission among Singaporeans is predominantly via sex, unlike some neighbouring countries where injecting drug use also plays a significant role.

(I was rather annoyed with myself because I lost my pen fairly early during the conference proceedings. By the time the really interesting papers were presented there was no way I could jot down the figures I saw on slides. But maybe it’s for the better; too many figures here and my readers’ eyes will glaze over.)

There are interesting differences in the profiles of the three groups. The Heterosexual Men category tends to be older — with the largest number of new cases discovered among the 40+. Very few of them are discovered through screening; some three in four (if I recall correctly) are discovered when they see a doctor over a medical problem, and by then, they are already presenting with late-stage infection, i.e. Aids.

New cases among bisexual and homosexual men are more likely to have been discovered through voluntary screening, though the numbers are still relatively low. As a group, they are younger (most 20 – 39) and a little under half are discovered at late-stage. These three aspects of the group’s profile are inter-related.

Among females, they are also mostly older, and the large majority are married.

Health Minister Khaw Boon Wan’s chief message at the conference was to do more to promote early testing. “Our current challenge remains early identification of those who are infected,” he said in his keynote speech.  “More than half of our new cases are diagnosed when their infection has reached an advanced stage.”

Further on, he said, “We must step up our efforts on HIV testing,” and then announced all sorts of irrelevant measures — like increasing the number of anonymous testing sites — that do nothing to address the chief reason why people resist early testing.  I will go into more detail about this in my next article.

* * * * *

To me, one of the most interesting papers was that presented by Mark Chen, from Tan Tock Seng Hospital, and titled “The future of the HIV epidemic in Singapore — What models can and cannot tell us”, which took us laymen through the basic concepts and tools of mathematical modelling for epidemiology.

Taking into account factors such as transmissibility of the virus, prevalence rate, infectivity of partners and the number of partners a typical person has, he showed numerous graphs plotting the possible trajectory of the epidemic over time depending on assumptions made for these factors. Some of these assumptions, e.g. on transmissibility of the Human Immuno-deficiency Virus, and the prevalence rate of HIV-infection among brothel-based prostitutes in Singapore, are well supported by empirical findings; others, such as the number of sexual partners the typical Singaporean has, are poorly backed by data (available data for gay men better than for straight men). As he tweaked the assumptions, his graphs moved.

By comparing his models with the actual historical incidences of HIV, he could deduce which of his assumptions are more likely to be true, and then using these same assumptions, he tried projecting the epidemic into the future.

For heterosexuals, he found that among his models, the one that best fit the historical pattern involved a high rate of sexual liaisons with commercial sex workers in Thailand and Batam. None of the graphs that assumed a high usage of local brothel-based sex workers could reproduce the historical trend. Why? Because the HIV prevalence rate among brothel-based prostitutes in Singapore is zero. Yes, Zero. Nought. They cannot have been a key factor in the increasing rate of HIV infection among heterosexual men.

These men infected from abroad, or from freelance sex workers they met locally, then went on to infect their wives or casual (girl)friends.

(There was however one thing I noticed cross-referencing two different papers. A surprisingly high percentage of married men reported to contact tracers that they did not have sex with their wives, and this may account for the relatively lower prevalence of HIV among women in Singapore generally. As the epidemic progresses, the percentage of female infections rise — in Africa more women and than men suffer from HIV and Aids, for example —  but we seem to be a little behind on that curve.)

Mark Chen’s projections show a continuing upward trend if we assume heterosexual men’s habits of visiting prostitutes abroad and inconsistent use of condoms continue unchanged.

Even though empirical data was slightly better for gay men, thus helping him narrow his assumptions, the modelling exercise was more difficult. He found that the graph was most sensitive to condom use, but to fit the historical curve, he had to use a combination of two models at different times, one with a higher rate of condom use and another with lower condom use. Thus, he concluded that gay men’s behaviour changed twice. The first time was around 1990 when they became more conscientious about using condoms, with the result that the rise in HIV diagnoses among gay men  some 5 – 10 years later flattened somewhat. Then around 2000, he deduced that prevention fatigue set in and condom use fell. This caused an escalation in HIV cases over the last few years.

* * * * *

In Singapore’s licenced brothels,  a “100-percent condom use” policy is implemented, with the result that even women who do sex as a living have a zero percent infection rate. Even married women are not at zero-prevalence, and certainly not casual sex partners (friends or singles-bar pick-ups).   This means the answer to the question at the top of the article is #4 — I wonder how many readers got it right. It also proves to you how effective is this simple precaution of using a condom.

Yet, among both straight and gay men, the failure to use condoms consistently is the chief reason why the disease continues to spread.

The June 2010 issue of The Act, Action for Aids’ magazine, reported the group’s finding from a 2006 survey that of the gay men who engaged in anal sex during the last 6 months prior to a survey, “48.9% [reported] consistent condom use with regular partners and 67.2% with casual partners”. This is not good enough. Mathematical models indicate that we need at least 80 percent use to halt the spread of the disease in the community and 100 percent use to protect yourself personally. (I don’t know what the condom use figures are for straight men.)

Part of the reason for less than satisfactory condom-use levels is recklessness and impulsiveness, but also, part of it is poor public education, especially among the less educated and youth.

The same issue of The Act reported that:

[Martin] Chio highlights a serious concern regarding the number of young MSM being diagnosed, indicating that education, awareness and prevention programmes have not been effective in reaching out to this group. His 2007 dissertation highlights a lack of knowledge and awareness of STIs/HIV, at the time of sexual debut: “subjects had limited awareness, knowledge and exposure to STIs/HIV education”.

An alarming statistic from [Brenton] Wong’s informal survey of newly infected MSM is that 86% of newly diagnosed HIV positive MSM claimed they were not provided information on AIDS/STIs during their school days.

Note: MSM stands of ‘men who have sex with men’ and STI ‘sexually-transmitted infections’.

Blinkered moralism continues to stand in the way. At the conference, Paul Ananth Tambyah highlighted yet another example of this. See the 1 December 2010 news story at right.

A bar is trying to do its part to raise awareness but immediately coming out of the woodwork are these creepy-crawlies — how did they manage to style themselves “health counsellors” when talking to the media? — for whom combatting what they (and they alone) consider “immorality” is way, way more important than saving lives.

At the centre of this news story is just one bar, but the truly atrocious thing about Singapore is that this kind of stupidity reigns supreme at the Ministry of Education.

4 Responses to “Horny straight guys’ choices”


  1. 1 boozie 7 December 2010 at 08:31

    Think the difference here is besides the rules of ‘engagement’ in the local brothels, the service providers are subjected to half yearly medical checkups to ensure they are not carrying any STDs. Good article, admire you courage to write about such issues which helps to keep ur readership abreast of such developments.

  2. 2 yuen 7 December 2010 at 09:23

    like the discussion about income inequality, you have to consider cost and weigh it against risk: going to a licensed brothel is more expensive than buying a few drinks for a girl at a singles bar, but chance of catching something (not just aids) is lower;

    getting sex from wife is in one sense free, in another sense very expensive; it is hard to be quantitative…

  3. 3 KiWeTO 8 December 2010 at 00:58

    Seems like at the end of the day,

    the best tool to reduce infection risk is a piece of latex.

    Not that latex=100%safety; perhaps the question prevention-campaigners need to figure out is how to convince the greater public to use latex.

    But, since it’s pretty hard to portray the act of searching for latex on any made-for-tv-(in-singapore-and-elsewhere) show, how do we best change average joe’s perception that groping for latex is a showstopper?

    Porn stars don’t do it (or at least, don’t portray the act of grabbing latex much.)

    What can we dream up to change mindsets positively on (instead of negatively warning joe public about the risks of NOT)using latex?

    E.o.M.

  4. 4 thornofplenty 8 December 2010 at 13:58

    The story from TNP makes me very sad. It is hard to find much data about what behaviors strongly suggest a person’s likelihood to engage in safer sex activity, but having a person with a condom is probably more likely to use one than a person who isn’t. Just as a person who runs around with condoms is probably more likely to have a personal policy about safer sex.

    Speaking as someone who used to design an intervention program for cruising areas, it is also a mistake to assume that non-condom use= no precautions taken. For instance, some clients we worked had no casual anal sex and would not allow cum in their mouths, which in the scheme of things presents lower risk.

    Part of the point is that people create rules for themselves and take precautions that might not always be scientifically sound, but we found that it was important in working with clients to strike a balance between encouraging a person to think of ways to reduce harm and getting them to stay safe in prescribed ways, which can be very disempowering and had some clients report made them not think about and prepare for safer sex.

    On a separate note, please refer to them as condoms and barrier methods, not latex, the material doesn’t work for everyone and there are options like cling wrap (in place of dental dams), polyurethane condoms and nitryl gloves that are as safe.


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