Pre-exposure prophylaxis in Singapore

=Truvada=

Truvada is an antiretroviral drug combination of 300mg of tenofovir disoproxil fumarate and 200mg of emtricitabine formulated into tablets. It 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. The drug should be taken daily without fail to ensure adequate levels in the bloodstream for protection against HIV. It may be consumed for life. 

Teno-Em


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

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 and sold at a very affordable price of SGD$30 per bottle of 30 tablets. 

=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 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 on 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, Dr. Tan & Partners, Dr. Tan and Partners Bencoolen, Dr. Tan & Partners at Scotts, Dr. Tan and Partners Katong, Dr. Tan and Partners Novena, Dr. Tan and Partners 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.

=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, 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.

Pulse Clinic
Pulse Clinic is a popular health clinic with multiple locations in Southeast Asia, from Hong Kong to Kuala Lumpur. There are two branches in Bangkok – one in Silom, and another in Nana. However, patients can only get tested for HIV in Silom.



Popular with tourists, patients can obtain a PrEP prescription within 30 minutes at Pulse Silom as long as they have made an appointment. The clinic will test patients not only for HIV, but also hepatitis B and syphilis, on top of a renal function test. Patients can get both Truvada and Descovy as well as the generic versions at Pulse.

Cost: The HIV test, medical consultation, and one month of PrEP medication starts at 4,500THB (SGD$198). Excluding testing and consultation, the price of one bottle of 30 tablets of Teno-Em at Pulse Clinic is just over ฿1,000 (SGD$44).

Operating hours: Daily from 11:00am to 7:30pm

Location: 60/4 Silom Road, Suriyawong, Bangkok.

Telephone number: +66 959156385

Website: https://www.pulse-clinic.com/PrEP/

Safe Clinic
Boasting a team of only HIV specialist doctors and technical nurses, foreigners can rest easy knowing that the specialists at Safe Clinic are all proficient English speakers. Safe Clinic also has an in-house laboratory technician, which means that patients can receive their results directly without having them outsourced to external labs.



As of December 2019, Safe Clinic has been recognised in an MOU (memorandum of understanding) with partners including USAID, the Thai Red Cross AIDS Research Centre, and FHI 360. With this status, Safe Clinic operates in a uniquely accredited capacity with certified staff and HIV specialist doctors.

Conveniently located near Asoke BTS or Sukhumvit MRT, Safe Clinic is open till late which makes means expatriates can easily make a trip there after work.

Pricing: 30 tablets of PrEP cost between ฿1,000 to ฿3,200 (SGD$44 to $141).

Operating hours: Daily from 12:00 noon to 9:00pm.

Location: Room 314, 3rd floor, Times Square Building Mall, 246 Sukhumvit Road, Khwaeng Khlong Toei, Khet Khlong Toei, Bangkok 10110.

Telephone number: 083-534-4555, 02-006-8887

Website: https://www.bangkoksafeclinic.com/

Thai Red Cross Anonymous Clinic
This may come as a surprise to some but the Thai Red Cross Anonymous Clinic is actually very foreigner friendly. The staff there can converse in English and it is fast becoming a popular destination among expatriates based in Bangkok.



The Thai Red Cross Anonymous Clinic opened in 1991 and holds the distinction of being the first HIV voluntary counselling and testing clinic in Asia. While it offers a wide range of tests for HIV and other STIs, its main draw is that patients can get a test done here anonymously.

Pricing: A HIV test costs 200 baht and takes around an hour for a regular session. In 2019, the Thai Red Cross launched a new service called Xpress in which patients can book their test online and opt to receive the results via email, SMS, or LINE without the need to wait at the clinic itself. The Thai Red Cross also provides PrEP at an affordable rate of only 15 baht per day (including all basic lab tests). Patients should keep in mind that going after hours means that they will incur an additional fee.

Operating hours:

Testing services – Mondays to Fridays from 7:30am to 3:00pm

Prescriptions – Mondays to Fridays from 8:30am to 4:00pm

After hours – Wednesdays and Fridays from 4:30pm to 7:30pm; Saturdays from 8:30am to 4:00pm

Location: 104 Ratchadamri Road, Pathumwan, Bangkok.

Telephone number: +66 225167115

Website: http://en.trcarc.org/Homepage/?page_id=632

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 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.



=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



=PrEP Singapore=

With the establishment of prepsingapore.com, an organisation which works with Singapore and Thai clinics (such as Dr Natthakhet mentioned above) 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 SGD$70 for one month's supply (plus an additional SGD$50 for shipping and handling charges) 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.

=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

=References=


 * Neo Chai Chin, "Pre-exposure pill could be game-changer in HIV prevention", TODAY, 29 November 2016.
 * Blowing Wind discussion on the cost of HIV medication in Singapore:.
 * Blowing Wind, "PREP / Truvada Discussion (Compiled)".
 * PrEP Online:.
 * Jonathan Moyer, "PrEP Insider Guide to Bangkok: Locations & Cost", Dear Straight People, 30 November 2019.

=Acknowledgements=

This article was written by Roy Tan. Thanks to Otto Fong for information on the price of Teno-Em at Chula MD Pharmacy and the photo of its external facade.