PrEP in Singapore

Pre-exposure prophylaxis (PrEP) is the use of medications used to prevent the spread of disease in people who have not yet been exposed to a disease-causing agent, usually a virus. The term typically refers to the specific use of antiviral drugs as a strategy for HIV/AIDS prevention. PrEP is one of a number of HIV prevention strategies for people who are HIV negative but who also have a higher risk of acquiring HIV, including sexually active adults at increased risk of HIV, people who engage in injection drug use (see drug injection), and serodiscordant sexually active couples.

When used as directed, PrEP has been shown to be highly effective, reducing the risk of acquiring HIV up to 99%. However, the increase in the numbers of Singaporean men who have sex with men who take PrEP medication has unfortunately been accompanied by a decline in condom use during anal sex and this leaves them vulnerable to other sexually transmitted infections. 

=Truvada=

Truvada is an antiretroviral drug combination of 300mg of tenofovir disoproxil fumarate (TDF) and 200mg of emtricitabine (FTC) 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 initially and given selectively, for instance, to the spouses and partners of people living with HIV/AIDS.

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, announced that 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 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. The use of PrEP is now recommended in national guidelines in many countries. The World Health Organization recommended in 2015 that PrEP should be offered as an additional prevention choice for people at substantial risk of HIV infection as part of combination HIV prevention approaches, and in 2017 published an implementation tool to guide countries on the introduction and implementation of PrEP.

In November 2020, Rayner Tan, then a doctoral candidate at the Saw Swee Hock School of Public Health who had been conducting research in HIV and sexually transmitted infections, noted the steeper drops in yearly cases after 2017, attributing it to the rollout of PrEP in 2016. Since 2018, annual incidence rates had been hovering in the low 300 range, down drastically from 434 cases in 2017. “Research underpinned both the efficacy of PrEP, as well as its acceptability and higher uptake among homosexual and bisexual men,” reported Tan. “If we are able to scale up access to HIV PrEP, our modelling studies at the school suggest that it is possible to eliminate the onward transmission of HIV as early as 2030."

Daily PrEP
Many Singaporeans take Truvada daily to prevent HIV infection if they have regular 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 every day without fail for at least seven days before sex to ensure adequately high steady-state levels in the bloodstream for efficacious protection against HIV infection. Drug levels above the minimum effective concentration are seen in the rectal mucous membranes by 7 days and maximum intracellular drug levels are seen at 20 days of daily oral dosing. It may subsequently be consumed daily, if required, for life.

On-demand PrEP
Sexually active individuals who consider PrEP expensive may save on costs by practising 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, meaning 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.



Medical consultations
PrEP is offered by clinics as part of a comprehensive HIV/STI prevention package. The medication does not, however, protect against sexually transmitted infections (STI) other than HIV. Patients on any regimen need to be followed up regularly. Doctors advise screening every three months for HIV and other STIs like syphilis or gonorrhoea 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 should automatically receive counselling as well. At NUH, patients get a comprehensive assessment of their HIV infection risk and individualised advice on how PrEP can help them in reducing the risk. 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. Patients who have trouble remembering to take their medicine (poor adherence) or who want to stop PrEP should inform their doctors.

First visit
A 4th generation HIV test (p24 antigen/HIV antibody combination test) with the blood sample sent to a laboratory for a conventional HIV enzyme immunoassay (EIA) is done. Alternatively, for expediency, a 4th generation rapid test/point-of-care test (POCT) such as Alere Determine HIV-1/2 Ag/Ab Combo may be performed using fingerprick blood immediately in the clinic itself. If there was recent high-risk exposure, it is advisable not to rely on a rapid test as this is less sensitive than a conventional EIA and has a window period which is several days longer. If the last high-risk exposure occurred within 4 weeks prior to the first visit, the HIV test is repeated after 4 weeks because of the window period during which the presence of HIV in the body cannot be detected with the testing method used.

A renal function test which measures the concentration of serum creatinine is performed and the patient screened for syphilis, hepatitis B virus (HBV), hepatitis C virus (HCV), gonorrhoea, syphilis and chlamydia infection.

Patients are counselled on:
 * the efficacy of PrEP: "PrEP is highly effective if taken as prescribed as part of an overall HIV prevention strategy which includes the the use of condoms."
 * adherence or compliance to medication: "It is important to take PrEP every day for daily PrEP, and according to the schedule for on-demand PrEP for it to be effective."
 * engagement in follow-up care: "It is important to return for visits to get tested for HIV and assessed for adverse effects to the medication, as well as to renew the prescription so that PrEP therapy is not interrupted."
 * sexual health: "PrEP does not prevent other STIs, and regular testing and treatment for other STIs is needed to maintain sexual health. PrEP also does not prevent pregnancy and contraception should be used to prevent pregnancy if needed."

Subsequent visits
Three to six-monthly visits are advised. Patients continue to be screened for HIV, HBV, HCV, gonorrhoea, syphilis and chlamydia. Renal function tests are performed every 6 to 12 months.
 * A 3rd or 4th generation HIV test (either a rapid test/POCT or routine HIV EIA) is done once every 3 months.
 * To assess kidney function, the serum creatinine concentration is measured once every 12 months if the patient is less than 40 years old and/or the estimated glomerular filtration rate (eGFR) is greater than 90ml/min. If the patient is older than 40 years of age and/or the eGFR is less than 90ml/min, serum creatinine is measured 6 monthly.
 * STI screening once every 3 to 6 months and treatment of any detected syphilis, gonorrhoea and chlamydia. The frequency of screening will depend on the patient-reported sexual risk behaviour.
 * Measurement of anti-HCV antibodies every 12 monthly. Screening once every 3 months may be considered for patients with very high-risk behaviour such as MSM and transgender women.

Stopping PrEP

 * Assessment of the continuing need for PrEP: Doctors should determine the if the patient still requires PrEP based on an assessment of the patient's risk of contracting HIV every 12 monthly. Patients should continue taking daily PrEP for 28 days after the last sexual exposure putting them at risk of HIV infection before discontinuing the medication. Only cisgender MSM can safely stop PrEP after taking a dose 24 and 48 hours after the last at-risk exposure.
 * Referral to care for patients who seroconvert: All patients who test positive for HIV should be referred for treatment at a HIV care centre on an urgent basis. HIV-infected patients can be started on HIV medication without interruption.
 * When it has been decided that PrEP is to be stopped, doctors should consider repeating the test for hepatitis B surface antigen (HBsAg) unless there is documented immunity.
 * Patients who are HBsAg-positive should have their liver function and hepatitis B viral load monitored after cessation of PrEP as there is a risk of reactivation of hepatitis B infection.
 * Advice on re-initiation of PrEP: Patients should be counselled that they should consider restarting PrEP if the risk of HIV infection emerges once again.

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

=Availability in 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 was then seeing more than one in two people living with HIV in Singapore. 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 the following year,. 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 explained that the introduction of PrEP allowed the hospital to play a powerful preventive role, reaching out to people at risk. Dr Tan Kok Kuan said an original Truvada tablet for PrEP cost about SGD$30 each, with additional charges 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 available at the pharmacies of the larger government medical establishments:
 * Department of STI Control (DSC Clinic) - The charge for a medical consultation is $100 to $200 per visit. Truvada at its pharmacy costs around $300 to $400 for a bottle of 30 tablets. Operating hours are from 8am to 12am and from 1pm to 4pm from Mondays to Fridays. It is closed on Saturdays and Sundays. Telephone number: 62939648. Email enquiries and appointments: apptdsc@nsc.com.sg. Address: 31 Kelantan Lane, Singapore 200031.
 * National University Hospital (NUH) - Started in 2016, the specialist Be Prepared Clinic (called BePrEP Clinic for short) at NUH prides itself in being a "confidential, holistic service that covers specialist expertise in Sexually Transmitted Infections (STIs) and HIV prevention". It not only provides PrEP medication but also offers counselling services. The consultation fee is $100 to $200 per visit and Truvada at its pharmacies is charged at $300 to $400 per bottle of 30 tablets. Its address is 5 Lower Kent Ridge Road, Singapore 119074. Telephone number: 91862301. Email enquiries and appointments: bpc@nuhs.edu.sg.
 * National Centre for Infectious Diseases (NCID) - Open from Mondays to Fridays, the PrEP Care Clinic at the NCID offers a comprehensive range of HIV and STI-related services. Each medical consultation costs $100 to $200 and Truvada at its pharmacy can be bought for $300 to $400 per bottle of 30 tablets. Its operating hours are from 8:30am to 5:30pm from Mondays to Fridays and from 8am to 12 noon on Saturdays. It is closed on Sundays and public holidays. Telephone number: 63577000. Email address: prepcare@ttsh.com.sg. It is located at Clinic J, Level 1, National Centre for Infectious Diseases, 16 Jalan Tan Tock Seng, Singapore 308442.
 * Tan Tock Seng Hospital (TTSH)
 * Singapore General Hospital (SGH)

PrEP is also available at certain GP (general practitioner) clinics like the 10 branches of Dr. Tan & Partners,, Dr Tan Medical Center and Pulse Clinic Singapore. The cost of Truvada at these establishments is about SGD$900 for one month's supply, before GST. The drug may be obtained on the very first visit after a HIV test which can be completed within 15 minutes.

Other GP clinics offering PrEP are:
 * Prudence Family Clinic:
 * DB Medical:
 * Cross Street Medical Clinic:
 * Anteh Dispensary:

=Government subsidy=

Medisave cannot be used to pay for PrEP. However, in a move unanimously lauded by HIV doctors and activists, the Ministry of Health added 16 antiretroviral drugs used for the treatment of HIV, including Truvada and Edurant, to its list of subsidised drugs with effect from 1 September 2020, making them much more affordable for thousands of Singaporeans. The 16 drugs were also added to the Medication Assistance Fund which allowed patients who could not afford them to draw from it to help pay for the cost. All subsidised patients who purchased any of the 16 drugs would henceforth receive 50% or 75% worth of subsidies, depending on their means test status. Prior to this, people living with HIV could only receive help from the Medication Assistance Fund on a case by case basis.

=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 (contactable at +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 Bangkok Christian Hospital and the Thai Red Cross AIDS Research Center. The latter is colloquially referred to as the "snake farm" or "Sapha Ka Chat" 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[dot]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 Sala Daeng BTS station. 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 along Jalan Mahmoodiah in 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 must fork out the full payment for 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, Dynamix International and Pulse Clinic Online 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 SGD$115 and above so it is worthwhile using the code to get a 3-month supply. It offers Ricovir-EM (30 tablets per pack) from SGD$50 onwards and Tenvir-EM (30 tablets per pack) also from SGD$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)

Green Cross Pharmacy
Some Singaporeans procure their medication online from Green Cross Pharmacy, an international supplier. One month's supply of PrEP costs approximately USD$10 plus delivery charges. 

=Public education=

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



On 11 June 2022 from 10am to 12 noon, gayhealth.sg conducted a PrEP workshop held as part of Pink Fest 2022 which was attended at full capacity. It sought to provide participants with knowledge on everything PrEP-related. Held at the Action For AIDS office, workshop participants also got the opportunity to take part in a year-long study during which they received subsidised PrEP medication and consultations.



=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.
 * Clara Chong, "Drugs used for HIV treatment now subsidised by MOH", The Straits Times, 6 September 2020.
 * https://www.moh.gov.sg/cost-financing/healthcare-schemes-subsidies/drug-subsidies-schemes
 * Shabana Begum, "New HIV cases this year likely to dip below 300 for first time since 2003", The Straits Times, 1 December 2020.
 * https://dearstraightpeople.com/2022/06/05/prep-guide-singapore/

=Acknowledgements=

This article was written by Roy Tan.