PrEP in Singapore

=Truvada=

Truvada is an antiretroviral drug combination of 300mg of tenofovir disoproxil fumarate and 200mg of emtricitabine formulated into tablets. It was approved for the pre-exposure prophylaxis of HIV infection (PrEP) in 2012 by the US Food and Drug Administration (FDA). Even though it has been available in Singapore since mid-2012, Truvada was reportedly offered only by a few clinics and given selectively, for instance, to the spouses and partners of infected people.

All that changed in late 2016 when Dr Dariusz Piotr Olszyna, a senior consultant at the National University Hospital's (NUH) Division of Infectious Diseases, said there was "overwhelming evidence and international guidelines which now recommend PrEP as an important tool in HIV prevention". Truvada has been shown to be 60-70% and, in some studies, up to 96% effective in preventing the transmission of HIV in gay men and other high-risk groups like sex workers, transgender women, intravenous drug users and HIV-negative partners in sero-discordant relationships. It was gradually and sporadically introduced in parts of Asia in the mid-2010s. While oral pre-exposure prophylaxis or PrEP is starting to transform HIV prevention in the United States, it has yet to be fully integrated into Asian programmes. Representatives from national AIDS programmes, health service providers and community groups from 18 Asian countries are currently exploring how to roll out PrEP in the region.

Many Singaporeans take Truvada to prevent HIV infection if they intend to have unprotected penile-vaginal or penile-anal sex or as an extra precaution in addition to using condoms. Truvada is also prescribed by doctors to individuals belonging to the high-risk groups mentioned above. One tablet of the drug should be taken daily without fail for at least seven days before sex to ensure adequately high steady-state levels in the bloodstream for effective protection against HIV infection. It may subsequently be consumed daily for life.

On-demand PrEP
Sexually active individuals who consider PrEP expensive may save on costs by performing what is called event-based PrEP or on-demand PrEP where 2 tablets of Truvada or its generic equivalent are taken 2 to 24 hours before anal sex, followed by 1 tablet 24 hours after sex, and another tablet 48 hours after sex. If having sex for an extended period of time, namely, potential exposure is sustained for more than a 24-hour period, 1 tablet is taken every 24 hours until the individual has 2 sex-free days. This dosage regimen has been proven to still be effective. However, a qualifying caveat is that on-demand PrEP has only been investigated in and recommended for cisgender men who have sex with men.

Patients also need to be followed up regularly. Doctors advise testing every three months for sexually-transmitted diseases and HIV as early detection and treatment of HIV offer a good chance of survival. If a patient is already HIV-positive but does not know it and commences PrEP, it is very dangerous. The infection may be inadequately treated and the virus could become resistant. As PrEP is available only via prescription, Singaporeans who request it will receive counselling as well. At NUH, patients get a comprehensive assessment of their HIV risk and individualised advice on how PrEP can help them in reducing the risk. The monitoring will continue for possible adverse effects. As Truvada may be toxic to the kidneys, renal function tests are done once every three to six months. 

Teno-Em


Teno-Em is a much cheaper, generic version of Truvada manufactured in Thailand by the Government Pharmaceutical Organization (GPO). It has the same composition as the original branded medication, namely, 300mg of tenofovir disoproxil fumarate and 200mg of emtricitabine.

Unlike most of the generic PrEP available worldwide, Teno-Em is the only PrEP formulation which is produced by a national government. PrEPSingapore.com is the sole authorised agent for the Thai GPO-manufactured Teno-Em for prescription orders. Its website allows Singaporeans to order directly from the Government Pharmaceutical Organization and to receive the medication at their homes at similar prices to Thai clinics, using Singapore prescriptions and partnering with various Singapore hospitals and clinics. It supports its service with refund and delivery guarantees. 

Ricovir-EM


Ricovir-EM is another generic version of Truvada with exactly the same composition, manufactured in India by Mylan pharmaceuticals. It is imported into Singapore by PrEP Online (see below) and sold at a very affordable price of SGD$30 per bottle of 30 tablets. 

Other generic drug combinations

 * Tavin-EM
 * Tafero EM
 * Tenvir-EM
 * Tenof EM

=Singapore hospitals and clinics=

On 29 November 2016, it was reported in TODAY newspaper that Truvada would be offered by Tan Tock Seng Hospital (TTSH) which sees more than one in two people living with HIV. Two other establishments - the Department of STI Control (DSC Clinic) at Kelantan Lane and the Be Prepared Clinic (BePrEP Clinic) at the NUH Medical Centre, National University Hospital (NUH) - also planned to offer PrEP,. TTSH decided to offer PrEP in early 2016 and hospital staff had been putting procedures in place to provide the service in a systematic and comprehensive manner. By November 2016, the hospital had prescribed PrEP to one patient, a middle-aged man who found out about the service through word-of-mouth. TTSH was in the midst of revising the cost of the medication and senior medical social worker Amanda Yap said the introduction of PrEP allowed the hospital to play a powerful preventive role, reaching out to people at risk. Dr. Tan Kok Kuan of Drs. Tan & Partners said an original Truvada tablet for PrEP cost about S$30 each, with additional costs for consultation and various tests.

Singapore, being a developed country, is not given the concession by major international pharmaceutical companies of officially being able to sell cheaper, generic versions of Truvada and other antiretroviral drugs before the patents and exclusivity granted to the original versions have expired. This is unlike the case in developing countries such as Thailand or India, where local pharmaceutical companies have been licensed to manufacture generics, even before the drug patents have expired, on compassionate grounds because of their large prevalence of HIV infection and the lower per capita income.

Original, branded versions of Truvada are now available at the larger government hospital pharmacies at the National University Hospital (NUH), Singapore General Hospital (SGH), the Communicable Disease Centre (CDC), Tan Tock Seng Hospital (TTSH) and the Department of STI Control (DSC) and have also been available at certain GP (general practitioner) clinics like the 6 branches of Drs. Tan & Partners (namely, Drs. Tan & Partners, Drs. Tan and Partners at Bencoolen, Drs. Tan & Partners at Scotts, Drs. Tan and Partners at Katong, Drs. Tan and Partners at Novena, Drs. Tan and Partners at Somerset) since 2014 and Dr. Chua at Cambridge Clinic. The cost of Truvada at these establishments is about SGD$900 for one month's supply, before GST. The medication may be obtained on the very first visit after a HIV test which can be completed within 15 minutes.

Medisave cannot be used to pay for PrEP and the cost of the drugs is not subsidised by the Singapore government.

Other GP clinics offering PrEP:
 * Prudence Family Clinic:
 * DB Medical:

=Buyers clubs=

Much cheaper generic versions (less than one-tenth the price of the branded original) may be obtained through buyers clubs modelled after Dallas Buyers Club, as portrayed in the movie. There are several of these clubs in Singapore. One of them was organised by Rev. Yap Kim Hao of the Free Community Church which has a closeted cell group of HIV-positive churchgoers. A separate club (+65 97531592) which supplies generic antiretroviral drugs to people living with HIV is headed by a volunteer who sells generics at one of the cheapest prices available - one month's supply of generic Truvada costs SGD$70 (plus an additional SGD$50 for shipping and handling charges) as compared to over SGD$900 for the branded version sold at clinics. The price of one pill of Truvada is 30 Singapore dollars, equivalent to about SGD$55 in the UK, SGD$50 in the USA and SGD$35 in Canada. The cost of the generic version in Thailand is SGD$1 and just over SGD$2 after being imported into Singapore via the buyers clubs.

The Ministry of Health and Health Sciences Authority tacitly allow these buyers clubs to source for generic antiretroviral medication from overseas and have them shipped to the Action for AIDS (AfA) headquarters along Kelantan Lane, just opposite the Department of STI Control (DSC). From these stocks, representatives of the clubs can then procure the drugs for sale to individual buyers. AfA may be contacted via their hotline at: 6254 0212.

=Bangkok=

Some Singaporeans also travel to Bangkok, Thailand to buy Teno-Em, the generic version of Truvada, and to be followed up by the STI specialists there once every three months. Many catch a flight on Friday evening and return to Singapore by Sunday night. Places where generic antiretrovirals may be obtained include Bumrungrad Hospital (most expensive of all the options), the Christian Bangkok Hospital and the Thai Red Cross AIDS Research Center. The latter is colloquially referred to as the "snake farm" or "Sa Pa Ka Chad" in Thai. It is located along Angreedunang Road, at the junction opposite Surawong Road. The Thai Red Cross is reputed to offer the cheapest prices. However, one has to factor in the cost of airfare, accommodation, food and local transport.

One physician who prescribes and sells generic antiretrovirals is Dr. Natthakhet of Sathorn International Clinic, telephone/fax: +66 (0) 20093877, e-mail: sic56216@hotmail.com. He used to work at the Thai Red Cross. Opening hours are from 5pm to 8pm on weekdays and 8:00am to around 6:00pm or 7:00pm on weekends. Many Singaporeans who are wary of the large crowds at the Thai Red Cross consult him.

The price of a bottle of original Truvada in Thailand is over SGD$100 whereas the generic Teno-Em costs less than half of that.

Bangkok clinics catering to English speakers
While most Singaporeans are familiar with Pulse Clinic, it is not the only clinic in Bangkok that patients can get PrEP from.

There are several clinics scattered across the city that offer PrEP, some of which cater to English-speaking visitors and expats. (The reader can find out more in this guide specially prepared by Dear Straight People: https://dearstraightpeople.com/2019/11/30/prep-guide-bangkok/ )







Chula MD Pharmacy
A prescription for a bottle of Teno-Em, containing 30 tablets of the generic version of Truvada, can be filled for about SGD$30 without the need for haggling at Chula MD Pharmacy (also known as Chula Bhesaj Drug Store), located about 5 minutes' walk from Saladaeng BTS. Its address is 942/25 Rama IV Road, Bang Rak, Bangkok 10500. Opening hours are from Mondays to Saturdays from 8:00am to 8:30pm. Telephone number: +66 2 233 5105. Chula's prices are amongst the cheapest as other pharmacies may charge as much as SGD$50 to $65 per bottle.



(Leftmost photo and pricing information credit: Otto Fong.) 

=Johor Bahru=

Caring Pharmacy
Caring Pharmacy in Malaysia also stocks antiretroviral drugs. The branch in Johor Bahru is located at G-104, G floor, R&F Mall, Mercu 1, Jalan Tanjung Puteri 1, R&F Tanjung Puteri 83000, Johor Bahru. Telephone number: 07-267 3725. It opens every day of the week from 10:00am to 10:00pm.



Dr. Singaraveloo of Johor Specialist Hospital, 39 B Jalan Abdul Samad, telephone number: 02-07 225 3000 ext. 4854 is a physician who sees HIV-related problems.

Klinik STI JB
Klinik STI JB offers PrEP and PEP services for Malaysians. It is located at Jalan Mahmoodiah, Johor Bahru. All tests for STIs and PrEP monitoring are done by the clinic, subsidised by Malaysia's Ministry Of Health. Patients only have to pay for the cost of the drugs. Non-Malaysians have to fork out the full payment for the consultations, tests and medication. Individuals requiring more information may telephone the clinic at +60 192371956 or visit their Facebook page: https://www.facebook.com/klinikstijb



=Online suppliers=

PrEP Singapore, PrEP Online, PrEP GLOBAL and Dynamix International are more reliable and assuring alternatives to procuring medication from unaffiliated, independent suppliers who advertise themselves on Grindr and who may charge as much as SGD$75 per bottle of generic drugs from unverifiable sources.

PrEP Singapore
With the establishment of prepsingapore.com, an organisation which works with Singapore hospitals/clinics and Thailand's Government Pharmaceutical Organization in collaboration with Thai clinics to provide prescription generic medication at affordable prices, and sent to Singapore in accordance with regulations governing the importation of drugs for personal use, it is no longer necessary to travel to Bangkok for cost savings. The site supplies Truvada from Thailand at a third of the prices in Singapore. The Truvada generics are now available cheaply at around SGD65 for one month's supply and delivered to homes legitimately as prescription medication through prepsingapore.com. PrEP Singapore began from successful partnerships with Taiwanese hospitals providing generic Truvada via doctors from Thai clinics and directly from pharmaceutical manufacturers to protect the privacy and safety of their patients. It offers the full suite of customer assurance including customs declaration, refunds and service guarantees, and partners with Singapore sexual health clinics to provide similar prescription-based models.

PrEP Online
PrEP Online was started by a group of PrEP users based in Europe and Asia who believe that access to PrEP should be made more convenient and affordable for people who need it all around the world. The group works with HIV and LGBT-related organisations around the world to provide up-to-date information on PrEP, and sources for PrEP directly from manufacturers to bring it to the community at the lowest prices.

PrEP GLOBAL
PrEP GLOBAL (also known as PrEP Worldwide) is a Singapore-based company that offers PrEP at affordable prices with free shipping. Orders usually arrive within 3 days. If customers use the code "STEVEN", they can get an additional 10% off. The code "STEVEN" is only applicable for orders of $115 and above so it is good to use the code to get a 3-month supply. It offers Ricovir-EM (30 tablets per pack) from $50 onwards and Tenvir-EM (30 tablets per pack) also from $50 onwards.

Dynamix International
Dynamix International is an import-export company established in Singapore in 2009. It delivers PrEP to a customer within 2 weeks. The products it offers are: 
 * Tavin-EM at $57 per bottle (Price Buster offer)
 * Ricovir-EM at $92 per bottle
 * Tafero EM (generic Descovy) at $62 to $106.00 per bottle
 * Tenvir-EM at $84.00 per bottle

Pulse Clinic Online
https://www.pulse-clinic.com/buypreponline/

To save its Singaporean clients the hassle and expense of travelling to Thailand, the Bangkok-based Pulse Clinic began offering PrEP for sale online in the late 2010s. However, buyers must have the original prescription with the date and doctor's signature and Singapore Medical Council registration number (MCR no.), or the official report from a laboratory sent to its email address beforehand.

Up to three months of PrEP medication can be legally imported into Singapore for personal use. This includes:
 * Truvada by Gilead (TDF/FTC; Tenofovir disoproxil fumarate/Emtricitabine (2',3'-dideoxy-5-fluoro-3'-thiacytidine)
 * Generic versions of TDF/FTC (Teno-EM by Thailand's Government Pharmaceutical Organization, Ricovir-EM by Mylan, Tenof-EM by Hetero and Tavin-EM by Emcure)

=Public education=

Talks and seminars on PrEP are periodically conducted by Action for AIDS (AfA) and its subsidiaries, DSC Clinic, Oogachaga, Drs. Tan & Partners, The Greenhouse SG, Lifeline SG, BePrep Clinic and other organisations.



=See also=


 * Pre-exposure prophylaxis
 * Post-exposure prophylaxis
 * Post-exposure prophylaxis for HIV infection in Singapore
 * Importing/bringing antiretroviral drugs into Singapore
 * PrEP Online
 * PrEP Singapore
 * Be Prepared Clinic
 * Earliest cases of HIV/AIDS in Singapore

=References=
 * Neo Chai Chin, "Pre-exposure pill could be game-changer in HIV prevention", TODAY, 29 November 2016.
 * Joyce Teo, "PrEP signals start of 'new phase of HIV prevention'", The New Paper, 6 December 2016.
 * Joyce Teo, "What is PrEP?", The Straits Times, 6 December 2016.
 * Blowing Wind discussion on the cost of HIV medication in Singapore:.
 * Blowing Wind, "PREP / Truvada Discussion (Compiled)".
 * Blowing Wind discussion, "Getting PrEP in Singapore".
 * PrEP Online:.
 * Jonathan Moyer, "PrEP Insider Guide to Bangkok: Locations & Cost", Dear Straight People, 30 November 2019.
 * Dr Wong Chen Seong, "Guidance for the Prescription of HIV Pre-Exposure Prophylaxis in Singapore", National Centre for Infectious Diseases, 30 November 2019.

=Acknowledgements=

This article was written by Roy Tan.