HIV/AIDS Activism in Singapore

The first case of AIDS was diagnosed in Singapore in 1985. By the end of 2004, Singapore had a cumulative total of 2,386 reported cases of HIV/AIDS. Male-to-male sexual transmission was initially the primary vector, but cases of heterosexual transmission now comprise more than 70 percent.⁸

Even this comparatively low incidence has alarmed the government, prompting approval of anonymous testing as of 1990;⁹ institution of mandatory prenatal screening in 2004;¹⁰ and programs to educate registered sex workers, nightclub workers, and others on HIV and condom usage.¹¹ However, the socially conservative government has relegated outreach to MSM in particular almost exclusively to AfA.

Formed in 1988 by ten concerned physicians and activists, AfA initially focused on AIDS education among MSM, then expanded its outreach to the general public. AfA took the lead in HIV/AIDS services in part because it was “able to speak about sexuality without choking on it, in public in a neutral way and in private in a gay-friendly way.”¹²

It still considers advocacy for rights—to education, speech, medical care, sex—as among its goals, but sees outright activism for gay rights as beyond its mandate.¹³ AfA is privately funded (though the government has contributed increasing funds of late) and volunteer-based. Its activities range from publishing a magazine to running a free, anonymous HIV testing site, with programs for men, women, and people living with HIV/AIDS (PLWHAs).¹⁴ Its outreach work among sex workers is limited, not least by cleavages between local and migrant, and registered and freelance, sex workers. Singapore's injecting drug user community is deeply underground and most harm reduction strategies are illegal, so AfA does little with that community.¹⁵

Many Singaporeans fear even being tested. The government offers no subsidy for antiretroviral therapies or some opportunistic infections, nor does any local insurance unless infection is in a health care setting;¹⁶

foreign nationals (who comprise at least one-quarter of Singapore's population) are usually deported if they test positive;¹⁷ and employers may fire positive employees if their colleagues are unwilling to work with them and may escape paying for medical treatment if they deem the virus contracted through “misconduct.”¹⁸ Other policies hotly contested by AfA—with some success—include a requirement that those who die of AIDS be cremated within 24 hours, after funeral rites only at the hospital;¹⁹ and the housing of PLWHAs in an isolated (and expensive) ward at the Communicable Disease Center.²⁰

A 2004 spike in reported infections via homosexual transmission sparked a firestorm of criticism and debate. Senior Minister of State for Health Dr. Balaji Sadasivan warned in November 2004 of a potential epidemic among MSM as well as “heterosexual men having casual sex in other countries,” castigated AfA for not doing enough among MSM, and implied that an annual massive gay and lesbian party (which draws large numbers of gay foreign tourists) may be at least substantially to blame.²¹

AfA countered that the primary reason for the upsurge was probably the increase in MSM going for HIV tests;²² others added that unprotected sex, whether with men or women, rather than promiscuity per se, was the issue. Moreover, AfA challenged the public, corporations, and the government to take responsibility, rather than just scapegoating one voluntary organization.²³ Gay web portal Fridae.com, sponsor of the aforementioned party, Nation, and singled out by the minister for “advocating a promiscuous and reckless lifestyle,”²⁴ was more blunt:

Indeed, the police had required AfA to cease distributing condoms and safer sex information at the previous year's Nation party;²⁶

the Advertising Standards Authority had objected to AfA's explicit (but hardly obscene) safer sex postcards not long before; and Christian group Safehaven was denied a license to hold an AfA fundraising concert featuring an openly gay duo,²⁷ plus was hindered in publishing a series of anti-homophobia and AIDS awareness advertisements.²⁸

The links between gays and HIV/AIDS are clearly apparent in Singapore, both impressionistically and epidemiologically. Even so, AfA has gone to great lengths to “de-pink” its image, as by downplaying its ties with the Pelangi Pride Center, a GLBT (gay, lesbian, bisexual, and transgendered) resource center and community space it helped establish,²⁹

and contesting media reports on the cruisiness of the organization.³⁰ While not new, these efforts have been stepped up since 2004. Balaji's remarks have signaled a new interest by the Ministry of Health in outreach to MSM. Given AfA's better access to the community and expertise, the government is working with the organization, albeit discreetly. This collaboration has real benefits for AfA, especially in terms of funding and the ability to expand its programs. The tradeoff is that AfA is under closer scrutiny than in the past. Now, the organization must be more sensitive to government and societal preferences in its language, messages, and images, including giving more attention to moral messages and less to condoms.³¹

As AfA loses autonomy and the government gains interest in its constituencies, the NGO is shedding its ability to be a broader-based support group for those communities, especially gays and lesbians. The change has been controversial. All the same, as discussed further below, volunteers have always been divided over AfA's image, and by now, other organizations and networks have developed within the gay and lesbian community (albeit not so much in other target communities) to take the lead in non-HIV/AIDS-related areas. From the perspective of civil society more broadly, however, this process of tightening control effectively demonstrates what happens when NGOs become more “governmental” and the difference in organizational posturing and strategy likely when pockets of relative autonomy close.

HIV/AIDS Activism in Malaysia

In June 2005, the World Health Organization (WHO) declared Malaysia “at the initial stage of an HIV epidemic.”³²

As of December 2004, 64,439 cases had been diagnosed there and current trends indicate a peak of 300,000 cases in 2014.³³ According to official (undoubtedly skewed) statistics, the primary vector for HIV transmission in Malaysia is intravenous drug use, which accounts for just over 75 percent of cases. Heterosexual transmission runs second (13.6 percent); infected individuals who identify as homosexual or bisexual comprise a relatively small percentage of cases (1.3 percent), though some may claim heterosexuality to avoid stigma.³⁴ Despite these numbers, the gay community has still taken the lead in HIV/AIDS intervention, particularly among MSM, complemented by self-help initiatives among the drug user and sex worker communities. The primary organization working with all three of these communities in Malaysia is PT Foundation. PT formed initially to deal with issues facing the gay and lesbian community. It took on more HIV-related work later, as the epidemic spread³⁵—but the country's low transmission rate among MSM probably owes much to PT's early mobilization and response.³⁶ The NGO offers counseling, outreach, safer sex supplies, and drop-in centers for MSM, drug users, transgendered individuals, and PLWHAs.³⁷ The umbrella Malaysian AIDS Council (MAC), comprised of PT and thirty-seven other NGOs, channels government funds, coordinates activities, and provides training and advocacy, but does not currently involve itself directly in service delivery.³⁸

Domestic public health authorities have not neglected HIV/AIDS, but their intervention among the highest-risk communities has been scant and primarily punitive. The government gazetted AIDS as a notifiable infectious disease and formed a National AIDS Task Force in 1985. An HIV/AIDS surveillance program, first initiated in 1988, includes voluntary or compulsory HIV screening among drug users and sex workers in correctional institutions, certain prisoners, foreign workers, patients with sexually-transmitted infections and tuberculosis, pregnant women, and blood donors. The government also runs programs in prisons and drug rehabilitation centers, has trained nearly 80,000 youth peer educators, and offers voluntary public (including anonymous) HIV tests.³⁹

In 2003, public health authorities commenced behavior surveillance among commercial sex workers and drug injectors. They found awareness high, but unsafe practices still rampant.⁴⁰

Advocacy work has “come some way in making it more acceptable to talk about AIDS” and to make treatment more accessible.⁴¹

Not least due to the MAC's efforts, the government now provides antiretrovirals free to all infected mothers and babies and for free or minimal cost to certain other categories of PLWHAs, imports generic drugs from India, and is considering local manufacture of a three-in-one combination therapy.⁴² Moreover, in an attempt to stem—rather than just treat—infection, public health authorities launched a pilot harm reduction program in October 2005. Above protests from religious leaders, they decided to offer needle and syringe exchange, condom distribution, and substitution therapy to drug injectors.⁴³

In Malaysia as elsewhere, “some pragmatism and concern about reducing the costs of AIDS has led to slightly more open recognition of homosexuality than had occurred earlier,”⁴⁴

despite a political culture infused with “Islamic values.” After the detention of a popular government leader for alleged sodomy in September 1998, public awareness of homosexuality rose even more. The case “provoked unparalleled discussions on sex and sexuality—sparing not even the minds of the young, who demanded to know what the fuss around sodomy was all about.”⁴⁵ All the same, denial remains “a big problem” and official prevention messages tend to be unhelpfully vague.⁴⁶ MAC president Marina Mahathir complains that, despite the large annual grant the Ministry of Health gives NGOs,⁴⁷ “the fact is that we operate in an environment where it's difficult even to talk openly about condoms or to do harm reduction programs … So in many ways, we are being given a lot of money to be set up for failure.”⁴⁸ Even so, PT in particular enjoys considerable freedom, and its “gay element has been overlooked by the state,”⁴⁹ letting “members of PT feel they can still render some social services indirectly to their members without being too visible”;⁵⁰ helping build tolerance among the gay, lesbian, and transgender communities;⁵¹and allowing distribution of information and safer-sex supplies to an otherwise-unserved constituency.⁵² PT was also the first NGO to incorporate a PLWHA perspective in its public campaigns, launching the division, Positive Living, in 1992.⁵³

To a greater extent than in Singapore, HIV/AIDS has mobilized the Malaysian transgender, sex worker, and drug user communities, (former) members of which are involved in outreach programs. Sex workers (including around 70 percent of Malaysia's estimated ten thousand transgendered population) are a “permanent target for abuse by the authorities,” necessitating safe spaces for members of the community to go to discuss HIV/AIDS as well as other issues. Even if public health officials tried to become more involved, they would face a significant hurdle in building trust.⁵⁴

Feeling more empowered about their sexuality on account of outreach activities, transgendered sex workers have been able to take more control over their personal health, including negotiating condom use. A main objective of these initiatives has been “to build up the community,” involving its members at every level. Transgender activist Khartini Slamah suggests these goals have been substantially met, as have more concrete public health objectives.⁵⁵

As for intravenous drug users, while it is harder to speak of an organized community, advocacy and exasperation have helped to sway government policy. Frequent raids and ever-harsher penalties have driven users ever farther underground, where they have less access to new or clean equipment, while failing to curb drug use.⁵⁶

A few NGOs have arisen to serve the drug user community, mostly via harm reduction. The most prominent is IKHLAS, a division of PT. IKHLAS relies heavily upon members of the community—recovering addicts, supplemented by gay men and others—as staff and volunteers, to serve over 2000 male, female, and transgendered clients per month.⁵⁷ Some of its services are technically illegal, but the center has a tacit understanding with the police for mutual nonobstruction.⁵⁸ However, “with a single drug treatment approach of abstinence only still largely vigorously embraced by the government and the wider community, NGOs targeting their activities towards drug users … experienced difficulties with their operations.”⁵⁹ The government's recent embrace of harm reduction strategies may help.

Overall, then, despite the relatively low incidence of the virus among MSM, the advent of HIV/AIDS redirected nascent community mobilization among gay and lesbian Malaysians and spurred more active involvement among affected groups. PT retains an important niche as the only legally registered gay organization, and while concerned not to emphasize that identity too brazenly, still runs or hosts sexuality support programs and acknowledges its roles beyond HIV/AIDS service provision. The transgender and sex worker communities have also become more cohesive and empowered through NGO-based self-help initiatives. Drug users remain so deeply stigmatized and underground as to stymie coherent organizing, yet the legitimacy of PT and the MAC has encouraged the government to work even with recovering addicts, acknowledging their relevant expertise and access, and—it seems—starting to espouse NGOs' nonpunitive, nonjudgmental approach.

Mobilization and Community

These two states present notable case studies of the identity-building dimensions of civil societal mobilization and the likely divergence between state and civil society on HIV/AIDS intervention. The immunity that HIV/AIDS organizations in Singapore and Malaysia enjoy has allowed them to play critical roles in spurring and supporting queer—especially GLBT—mobilization, including fostering a sense of a “gay community,” despite legal proscriptions on homosexual behavior and associations. Particularly in the organization's early days, gays and lesbians “naturally gravitated toward AfA” for support, as it was broadly known to be headed by and sympathetic to gays. Lesbians in particular may still rely heavily on such organizations, given a dearth of alternative venues.⁶⁰

The conflation of homosexuality with AIDS in the popular imagination is awkward: having one's identity associated with disease and “contamination” hardly feeds self-esteem or commands respect, and addressing sexuality only through the lens of HIV/AIDS perpetuates this stereotype.⁶¹

Partly for this reason, and partly in line with global trends away from a focus on HIV/AIDS among GLBT people,⁶² queers (meaning anyone outside the bounds of heteronormativity) in Southeast Asia have never organized exclusively around HIV/AIDS, and gays and lesbians in particular may have been decreasingly prone to do so since the mid-1990s. The internet and the development of other gay venues besides HIV/AIDS organizations make it easier to envision and support gay and lesbian identities and activism without the safety net of an official public health mission now than when AfA and PT started, despite the still-repressive political climate and socially-conservative culture for these groups in both states.⁶³ For example, People Like Us (PLU) in Singapore, first launched in 1993 to focus on legal rights and other issues (but not HIV/AIDS),⁶⁴ continues to organize despite having twice been denied registration. It is largely due to PLU's efforts that the media in Singapore now make the distinction between homosexuality and AIDS, while PLU's taking on the mantle of GLBT advocacy releases AfA from being expected to speak for the gay community.⁶⁵ Even if lacking legal standing and resources, such organizations may feel more free than HIV/AIDS organizations to define themselves as they choose and not to self-censor or eschew activism for fear of losing official space (given that they have none to revoke).⁶⁶ Still, it is the legitimacy accorded by legal registration and an acknowledged social welfare function that makes HIV/AIDS organizations so distinctive among queer groups, so visible and accessible even to individuals not (yet) identified as “gay,” and so foundational in the development of queer communities.

Programs around HIV/AIDS, particularly the demands of surveillance and targeted prevention strategies, have helped to promote the spread of identities like “sex worker,” “MSM,” “gay,” and “bisexual,” as well as movements based on such identities, despite “the fact that for most people behavior does not necessarily match neat categories.”⁶⁷

The unity implied by speaking or organizing in line with these categories is more semantic than real. The idea of a “gay community” or “queer community” is problematic at best, as is even the “PLWHA” moniker: those so labeled may vary dramatically in demographic traits, diagnoses, treatment protocols, political preferences, and identity.⁶⁸ For example, men outnumber women in AfA by a ratio of twelve to one and are more likely to identify as gay.⁶⁹ Similarly, PT's MSM Program caters primarily to English-speaking, Kuala Lumpur-based, gay-identified Chinese men—an inaccurate reflection of Malay/Muslim-majority Malaysian society.⁷⁰ Lesbians are underrepresented in HIV/AIDS organizations broadly,⁷¹ and transgendered individuals often serve in and are served by discrete sub-programs, gaining little sense of common identity with non-trans gays and lesbians.⁷² As for “straight queers,” from bio-female sex workers to promiscuous heterosexuals, they are unlikely to self-identify as “queer” or to identify significantly with a positive community, even if similarly marginalized. From a different perspective, HIV/AIDS services “all too often duplicate[e] structures of oppression and discrimination,” with different forms of outreach, education, and surveillance directed at those of different education and class levels.⁷³ For that matter, a core reason AIDS activists have tried for years to delink practices and identity, as by referring to “MSM,” is to encourage individuals “to recognize the risks involved without having to reorganize their identity and claim to be gay,”⁷⁴ suggesting further limits to the communities fostered.

It would be a stretch to say a queer or even GLBT political movement has emerged in either Singapore or Malaysia—and the queer communities mobilized around or affected by HIV/AIDS (gay and lesbian, trans, drug-using) remain stymied also by “a lack of capacity and an almost paralysing fear of the cost of coming out.”⁷⁵

What momentum there is in that direction is coming ever less from HIV/AIDS organizations and more from next-generation GLBT groups like Singapore's PLU. Moreover, gay identities in particular may be more about a cultural affiliation than a political one, and as Altman rightly points out, most who engage in sex for money “have no sense of this comprising their central identity” and little interest in lobbying around this (hard to specify, often transient) category.⁷⁶ PT transgender activist Sulastree makes a further distinction: bio-female sex workers are more likely part time and temporary than their transgendered counterparts, who also tend to have a sense of community already and may suffer penalties in Malaysia for cross-dressing as well as for prostitution. As such, while many of the core issues that sex workers face are the same, building solidarity and encouraging bio-women's involvement with organizations like PT may be especially daunting.⁷⁷ Similarly, those with seemingly the strongest community service orientation among drug users are those in recovery, seeking to support others not least in finding paths out of the community.

Coincident trends, most notably continuing Islamization of state and society in Malaysia and an ever more consciously cosmopolitan, pragmatic orientation to Singapore public life, highlight the role of political culture in shaping mobilization and policy approaches and suggest how far the two states' courses may diverge. Malaysia is taking steps to address a public health crisis among intravenous drug users without going any further than absolutely necessary to acknowledge sexual minorities, even by so much as curbing those minorities' quiet self-organization. For its part, Singapore will find homophobic repression increasingly at odds with cultivating a hip, metropolitan image as well as inconvenient for public health purposes. Regardless, the still-powerful government is reluctant to loosen an anxiously heteronormative order overmuch (not least for practical reasons like fear of declining birthrates) and most Singaporeans remain chary of nudging ill-defined “OB” (out-of-bounds) markers, so radical mobilization remains unlikely there, as well.⁷⁸

These considerations highlight a primary benefit of leaving HIV/AIDS services to NGOs rather than government agencies: NGOs may be able to understand HIV not just as a public health issue, but as embedded in a wider context of marginalization and empowerment. Remedies such as mandatory testing or criminalizing unprotected sex by the seropositive,⁷⁹

Singaporean activist Alex Au argues, trample on human rights, put all blame on individuals, and focus on punishment and laws rather than education and behavior. Such a “law-and-order approach” may “put the very people who are the agents of infection in opposition to the public health effort,” and still not provide them with adequate information and resources.⁸⁰ Similarly, argues Malaysian social work professor Ismail Baba, societal non-acceptance may push transgendered individuals “into margins of society where using drugs and finding sex are the only way to make a living.”⁸¹ Bureaucratic health agencies may find a more patient, nuanced approach, especially to gay sex, hard to muster.⁸² Left largely to their own devices, HIV/AIDS organizations may sidestep concerns that stymie government initiatives while empowering communities in enduring ways. Activists not afraid to address the communities most at risk—not least because they themselves are often from them—may effectively fill the gaps left by squeamish public officials. In the process, these organizations assert the efficacy and self-sufficiency of civil society and the fallibility of government, while vindicating their right to organize, to mobilize, and to be openly part of what is, at least in some sense, an identity-based “community.”