Richard Bellamy reflects on the 16 months he spent in Singapore working as a registrar in infectious diseases and HIV medicine

On World AIDS Day, in particular, we should think about the difficulties faced by people living with HIV and AIDS. Although advances in antiretroviral treatment have made AIDS a manageable chronic disease, people with HIV and AIDS still live with a potentially fatal condition, numerous drug side effects, and society's prejudice. In Singapore, people with HIV and AIDS face an additional challenge--finding the money to pay for their extremely expensive drugs, at least £400 ($624; a634) every month for triple therapy.

The Singapore health service has a limited list of drugs which patients can be prescribed at subsidised rates. Antiretrovirals are not included, so patients must meet the full costs. Initially, I thought this burden was a sign of a cruel and insensitive government. After a few months in Singapore, however, I realised that local people place greater value on support from their families than from the State. It was wrong to judge the system with my Western values; Singaporeans would be just as shocked by many aspects of British society, such as our system of caring for elderly people. People with HIV and AIDS in Singapore accept that it is their responsibility to pay for their treatment and they constantly impressed me with their determination to do so.

Working with people living with HIV and AIDS in Singapore provides many challenges for doctors. The numerous opportunistic infections which can affect those with AIDS present considerable diagnostic difficulties. During my time in Singapore I saw many cases of Pneumocystis carinii pneumonia, tuberculosis, oesophageal candidiasis, disseminated Mycobacterium avium, cytomegalovirus disease, cerebral toxoplasmosis, Cryptococcus neoformans meningitis, cerebral lymphoma, salmonellosis, intestinal cryptosporidiosis, and microsporidiosis. I also saw several relatively uncommon conditions such as histoplasmosis, penicilliosis, nocardiosis, and progressive multifocal leukoencephalopathy. I had seen a limited number of opportunistic infections in the United Kingdom, because of the success of antiretroviral treatment.

The financial limitations of treating HIV in Singapore mean that doctors and patients have to use their initiative. Every time I prescribed a medicine in Singapore I asked myself two questions, "Is this affordable for the patient?" and "Does this offer the best possible value for his or her money?" Similarly, whenever I asked for a blood test, I had to think of whether the cost was justified by the information the test could give me.

We had the prices of every drug we were likely to prescribe and the costs of the tests we were ordering. It would be no use sending a patient to the pharmacy with a prescription for new drugs only to find out later that they had not been able to buy them. Before going to Singapore I rarely considered how much the drugs and investigations I requested would cost. The financial discipline I learnt in Singapore has made me a more cost effective user of NHS resources. I expect all of us could benefit from a similar experience.

Many people living with HIV and AIDS in Singapore can't meet the high costs of triple therapy. As a result doctors often need to use dual therapy, which is no longer regarded as acceptable in the West. Although not ideal treatment, dual therapy can produce undetectable viral loads and immune system recovery for many patients, greatly improving their physical health and life expectancy. The treatment of opportunistic infections can be just as expensive as antiretroviral drugs. For example, fluconazole must be used for life after an episode of cryptococcal meningitis (at Singapore price of around £400 per month in 2001). These huge costs have forced patients to travel to other countries to purchase illegal generic drugs. Fortunately, in my experience, these drugs work just as well as the more expensive branded drugs they replace. Doctors in Singapore have also pioneered many alternative cost saving drug regimens for treatment of HIV and its complications. The generally good results should give hope to many people living with HIV and AIDS around the world.

I was confronted with several ethical dilemmas while working in Singapore that I hadn't thought about before. Firstly, I had to consider my position regarding drugs bought illegally in Thailand and elsewhere. I quickly realised that I could not discourage patients who were already doing this as their lives often depended on it. After some time I considered whether I should actually be recommending to patients that they travel abroad for cheaper drugs if they could not afford the full price. If I did not make them aware that this option was available I was not giving them the best chance of staying healthy. Surely, therefore, I was failing in my duty to them?

Another dilemma I faced was that drug company representatives would sometimes give me free samples of expensive drugs for treating opportunistic infections. To whom should I give this treatment? Should it be to the next patient needing it, to a patient with no money, or to a patient with a reasonable prognosis? The answer was not usually straightforward.

The final dilemma I faced was enrolling patients in clinical trials. The World Medical Association stresses that patients entering clinical trials should not receive incentives, because they will not be able to make an impartial decision about whether to participate. A patient in a trial of antiretroviral treatment receives free drugs, free visits to the clinic, and free investigations--a huge incentive. For many of our patients, the only way to save their lives was to get them into a clinical trial. I quickly realised I would not be doing my patients any favours if I refused to tell them about these trials. Many patients in Singapore would not be alive today were it not for the trials they participated in. I often read in medical journals that much of the HIV research in communities that are short on resources is unethical. I would now contend the opposite, however; it is unethical not to involve these communities. As World AIDS Day approaches, I hope that we can have a new commitment to enable the developing world to benefit from both antiretroviral research and treatment.