What to Know About HIV Testing and Treatment in Singapore

Many in Singapore fear taking a HIV test due to the stigma attached to it. However, it’s important to understand that HIV screening is an important step in maintaining sexual health, and doing so early leads to better treatment and a lower risk of contagion. Here’s all you need to know about HIV testing in Singapore and what to do pre and post exposure.

What is HIV?

HIV (human immunodeficiency virus) is a virus that attacks cells responsible for helping our body fight infection. It destroys CD4 lymphocytes, which are white blood cells that protect us against bacteria and harmful pathogens. Once infected, patients are more vulnerable to diseases and infections, and are at a higher risk of developing some cancers.

How is HIV transmitted?

In Singapore, over 400 new HIV cases are diagnosed every year. Unprotected sexual intercourse remains the primary mode of transmission; however other ways in which HIV is spread include:

  • The sharing of HIV-infected needles and other piercing instruments used for tattooing or acupuncture
  • An infected mother spreading the disease to her baby during pregnancy, at birth, or through breastfeeding
  • The receiving of infected blood through blood transfusions or donations

HIV, however, is not spread through social and physical contact such as touching and hugging as well as the sharing of food. Mosquito bites do not count either.

How do I know I have HIV?

The best way to know if you have HIV is to get tested. HIV symptoms also typically do not appear for many years upon infection. Some symptoms include fever, fatigue and swollen glands but are often dismissed as the common flu, followed by a clinically latent period where there are no symptoms at all. This can last up to 10 years, and during this period, patients may be spreading the disease around unknowingly. In Singapore, under the Infectious Disease Act, it is an offence for an HIV-infected person to engage in activities that may encourage the spread of HIV.

How do I get tested for HIV in Singapore?

Testing for HIV in Singapore can be done at almost any health provider or clinic. There are two main ways for HIV testing to be done — a conventional laboratory-based blood test which will take up to 2 weeks waiting time, or through the use of a rapid HIV test kit which will take just 20 minutes for results to be out. Should you wish to remain anonymous, there are currently 10 clinics in Singapore that offer anonymous HIV testing.

Get the full list here.

How much does a HIV test cost in Singapore?

The cost of getting tested for HIV in Singapore ranges from $10 to $150. Generally, rapid testing at Anonymous HIV Testing centres will set you back about $50-150. Local organisation Action For Aids also provides anonymous HIV testing for $10-$20. Testing can also be done at polyclinics in Singapore. However, these are usually lab-based and will take a longer waiting time. They are also not anonymous and must be reported to the Ministry of Health.

Is there a cure for HIV in Singapore?

There is currently no cure for HIV. However, there are treatments and medication available in Singapore to help suppress the virus if detected early. Patients who seek treatment for HIV early go on to lead healthy and normal lives and are also expected to have a near-normal life expectancy.

Additionally, patients may also wish to consider HIV PrEP (Pre-Exposure Prophylaxis) and HIV PEP (Post-Exposure Prophylaxis), which we will explain about further.

What is HIV PrEP (Pre-Exposure Prophylaxis), and how does it work?


HIV PrEP, or Pre-Exposure Prophylaxis, is a drug prescribed to individuals who are at higher risk of getting HIV in Singapore. Research has shown that when administered daily, the drug significantly reduces the chances of contracting HIV by nearly 99% from sexual intercourse with HIV-infected partners and 74% from injections.

However, HIV PrEP is not a free pass to engage in unprotected sex — since PrEP only offers protection against HIV, it is highly advisable to still use condoms to protect yourself against other sexually transmitted diseases.

Is PrEP a vaccine for HIV in Singapore?

No, Pre-Exposure Prophylaxis does not act as a vaccine. What it does is to prevent both the spread and occurrence of HIV in your body. As mentioned, it’s for individuals at a higher risk of contracting the disease, such as those with HIV-positive partners.

Am I suitable for PrEP?

Generally, Pre-Exposure Prophylaxis is recommended for those with multiple sexual partners and those with a HIV-positive partner and want to conceive. The drug can prevent both you and your foetus from contracting HIV during the pregnancy and during breastfeeding.

Should you wish to consider taking Pre-Exposure Prophylaxis, do consult a healthcare professional.

For those who have been exposed to HIV recently, it is advisable to take Post-Exposure Prophylaxis.

What is HIV PEP (Post-Exposure Prophylaxis)?

HIV PEP, or Post-Exposure Prophylaxis, is a short term antiretroviral treatment used to reduce the likelihood of HIV in Singapore. It’s particularly used after potential exposure to the virus, either through sexual intercourse or accidental exposure. It is not meant to replace conventional HIV-prevention techniques, such as safe sex and the use of sterile needles during injections. As such, Post-Exposure Prophylaxis is only intended for emergency use and not for routine use.

When must I administer PEP?

The sooner, the better. It is mandated that the Post-Exposure Prophylaxis must be administered within 3 days (72 hours) after a potential HIV exposure. Following which, the medicine must be taken consecutively for 28 days.

However, Post-Exposure Prophylaxis is not a 100% guarantee against HIV, and HIV-prevention measures must still be in place even when you are on prescription. Further, Post-Exposure Prophylaxis may not work if you fail to take the medicine soon enough or inconsistently.

Am I suitable for PEP?

You should consider Post-Exposure Prophylaxis if you’re HIV negative and in the last three days:

  • Had sexual intercourse with a HIV-infected person
  • Was sexually assaulted
  • Was exposed to contaminated needles or blades
  • Suffered an eye splash injury
  • Was exposed to body fluid, ulcers, semen or sores with someone of HIV-positive or HIV-unknown status

Before using Post-Exposure Prophylaxis, always speak to a doctor. It’s important to note that if you are HIV-positive and are unaware, using Post-Exposure Prophylaxis may increase the risk of HIV developing resistance to the medication.

So with that said, a HIV test is required before getting access to Post-Exposure Prophylaxis.


290 Orchard Road #14-10
Paragon Medical Centre
+65 67337122

Gingivitis Treatment — What You Should Know

Gingivitis is a leading periodontal disease that affects many Singaporeans as well as many people around the world. It is caused by bacteria, resulting in the swelling of the gums. People with gingivitis will notice blood when flossing.

While gingivitis will go away on its own over regular brushing of teeth, left untreated it can lead to periodontitis and tooth loss. As soon as you notice that your gums are swollen and inflamed, it is important to visit a periodontist for gingivitis treatment.

The different type of gingivitis

There are two main types of gingivitis. These are:

Dental Plaque – causes of this type of gingival disease include malnutrition, plaque, certain medication, and systemic factors.

Non-plaque induced gingival lesions – a bacterium, fungus or virus can cause this type of gingival disease. Illnesses and even genetic factors could also contribute to it.

Causes of gingivitis

Teeth with dental plaque

Of all the various causes of gingivitis, the most popular and most common is plaque accumulation between and around the teeth. This causes the body to produce an immune response which can ultimately cause it to destroy gum tissue. Furthermore, this can lead to teeth loss.

But what is dental plaque?

This occurs naturally around the teeth. The main culprits are bacteria trying to attach themselves to the smooth part of the teeth.

However, these bacteria have a useful function as they can prevent other types of bacteria and microorganisms from taking over the mouth. Unfortunately, they will also cause periodontal problems including tooth decay.

Plaque needs to be controlled through regular brushing of teeth. Otherwise, it causes tartar or calculus which forms at the base of the teeth resulting in yellow colouring. When it reaches this stage, it cannot be removed through brushing. Your only choice is to go to seek the services of a professional.

If left untreated, the plaque and tartar will cause irritation around the gum which will lead to the inflammation and swelling of the gums.

Some other causes of gingivitis include:

Hormonal changes – significant hormonal changes occur during puberty, menstruation, and menopause or during pregnancy. This could cause sensitivity in the gums which increases the likelihood of gingivitis.

Genetics – people who have one or both parents affected by gingivitis are at a higher chance of getting gingivitis.

Certain diseases – diseases such as HIV, cancer, and diabetes are connected with a higher risk of developing gingivitis.

Smoking – smokers are at higher risk of developing gingivitis when compared to nonsmokers.

Certain medication – some medications that may cause less saliva resulting in gingivitis and overgrowth of gum tissue.

Malnutrition – lacking sufficient vitamin c in your diet has been linked to developing gingivitis.

Age – older people are more likely to develop gingivitis compared to younger people.

The symptoms of gingivitis

People who have mild cases of gingivitis will often not experience any discomfort in the mouth. However, common symptoms include:

  • Tender and inflamed gums that are painful when touched
  • Swollen gums
  • Bright red gums
  • Bleeding after flossing or brushing
  • Receding gums
  • Soft gums

Diagnosis of receding gums

If you notice any of the above signs and symptoms it is important that you visit a periodontist in Singapore. They will conduct an oral examination and check for signs of calculus, plaque or tartar.

They will also check if you have periodontitis as well as examining the pocket depths between your teeth and gums.

Treatment of gingivitis

Dentist checking teeth condition of man

If the periodontist catches your gingivitis in its early stages, it can offer medication and treat it completely. Note that the treatment process will usually be a joint effort between you and your periodontist.

The periodontist will begin by removing the tartar and the plaque. If you have sensitive gums then this can be a bit uncomfortable. However, the procedure is necessary in order to completely remove the tartar.

Note that the periodontist may require you to make several visits in order to completely remove the plaque in a process known as scaling.

Furthermore, the doctor will advise you on the proper way to observe oral hygiene to prevent further development of plaque.

If you have damaged teeth, it is important that you get them fixed. Note that dental issues could also play a part in the development of plaque and could make it more difficult to clean it such as having crooked teeth or poorly fitted crowns or bridges.

As for the patient’s role in all this, you must ensure that you clean and brush your teeth at least two times a day. It is also important to floss teeth once every day to remove any food particles between the teeth. For those hard to reach areas, a good solution is to rinse the mouth with antiseptic.

When looking for a periodontist, it is important to get treatment from one who has many years of experience such as Dr Marlene Teo. They can offer quality treatment and mitigate the risks associated with gingivitis.

Final Thoughts

Gingivitis is a common gum disease that affects many Singaporeans. It can lead to periodontitis if left untreated. This is why it is important to understand the signs and symptoms and to see a periodontist immediately you notice that you have any of these. Luckily it can be treated resulting in healthy-looking teeth.


Dr Marlene Teo
360 Orchard Rd, #03-06/07 next to Lido,
International Building, Singapore 238869
+65 8588 9868

Get Healthier, Smoother and Blemish-Free Skin with Acne Scar Removal in Singapore

Many Singaporeans want to healthier and smoother, blemish-free skin. Day by day, we can see new wrinkles, dark spots, sagging skin and they can be very unpleasant. However, probably the most unflattering of all skin imperfections are acne scars that have always plagued our faces since our adolescent years.

Acne is one of the most common skin problems that people of all ages face. While acne is always associated with teenagers struggling with the growing pains of puberty, this skin condition can strike at any age. It can affect adults and can appear anywhere on the face, back, chest, neck, shoulders, upper arms and buttocks.

What causes acne?

Acne formation in the human skin

Acne forms when pores in the skin or the hair follicle gets blocked by:

  • Too much oil or excessive sebum production.
  • Pores blocked by dead skin cells or cosmetic products
  • Bacterial build-up

The pore blockage can sometimes appear as blackheads, whiteheads, pimples, cysts, and nodules.  When these materials accumulate under clogged pores, acne or inflammation and pus formation are formed. Acne can be aggravated by a lot of factors such as:

  • stress
  • unhealthy diet and lifestyle
  • hormonal changes e.g. pregnancy or periods
  • greasy cosmetic products that are hard to remove
  • certain oral medications
  • high humidity and heat
  • family history of severe acne

Why seek treatment for acne scarring?

Prompt treatment for acne scars should be sought because it can worsen as time goes by. If you can treat the scar as early as possible, you will be able to give your skin the protection it needs to prevent further scarring.

Treatment for acne scar removal in Singapore is usually sought by patients for physical, emotional and social reasons. The presence of acne scars makes you look less attractive and may also affect your self-confidence. It is also not just a cosmetic issue – it is also a medical one that affects the skin, caused by clogged pores, bacteria, and excess oil. Treating it will help you regain healthy skin again. The unsightly nature of acne and the scars left behind can cause one to suffer from low self- esteem, making treatment even more important.

What are the different types of acne scar removal treatments?

Woman applying acne cream on her face

People with acne scars would always want them to be removed. Depending on the severity of acne and type of lesions present, the following treatments may be prescribed (often in combination with each other):

  1. Over-the-counter (OTC) Remedies
    • Alpha hydroxy acids, also known as AHAs, are a group of natural acids that are commonly used as skincare to remove the top layer of dead skin cells, which helps prevent acne and improve the appearance of acne scars. Alpha hydroxy acids are water-soluble, which means it can help in dealing with dry, damaged skin.
    • Salicylic acid is another natural acid that is often used as an ingredient in skincare products aimed at controlling acne. It helps clear debris such as dirt or dead skin cells that can block your pores and lead to acne. It also helps minimize any swelling or redness that may occur, which makes the acne scars less noticeable.
    • Another practical remedy for acne scars is topical retinoids, which helps reduce acne scar appearance and discolouration. It also accelerates cell regeneration and improves skin quality. It can make your skin more sensitive to the sun though, so it’s best paired with a good quality sunscreen.
    • Lactic acid has been shown by various trials and studies to help in reducing the appearance of acne scars. It helps improve the texture and pigmentation of acne scars, which makes them less noticeable in the long run.
    • Sunscreen is important for dealing with acne scars because sunlight can worsen their appearance by making them look darker and dryer. It is recommended to wear sunscreen with a sun protection factor (SPF) of at least 30.
  1. Clinic Grade Treatments
    • Chemical peels are procedures that use strong acids and are great for skin resurfacing, a process wherein the top layer of the skin is removed. The underlying skin layer then effectively ‘resurfaces’ and replaces the top layer. One intended effect of this is that your acne scars will look less noticeable and successive chemical peels will make your acne scars fade away gradually.
    • Another skin resurfacing technique is microdermabrasion. There are two methods for microdermabrasion. One uses a special device that gently sands away the skin’s outer layer. The other method is done by spraying fine particles of aluminum oxide or sodium bicarbonate which then removes dead skin cells.
    • Laser skin resurfacing is another option. It achieves similar results as chemical peels and microdermabrasion but instead uses a laser device to perform the resurfacing.
    • Dermal fillers can be used to reduce the appearance of depressed acne scars. Injecting the fillers can help fill out the acne ‘crater’ and also improve the quality of your skin.

If you’re looking for advice or help on any acne scar removal treatments, you may consult with Dr Chua Cheng Yu by setting up a doctor’s consultation. He is one of Singapore’s leading aesthetic doctors and you can contact him through phone (+65 8858 6689) or email (drchuacy@gmail.com).


Dr Chua Cheng Yu
13 Stamford Rd, #B2-35 Capitol Piazza,
Singapore 178905
+65 8129 9789

4 Common Reasons Why Parents Bring Their Children to ENT Doctors in Singapore

One of the most challenging parts of being a parent is providing for your child’s health care needs. Our children are one of the precious things we have in our life. All we want is to give them the best. It breaks our hearts seeing our children suffering and in pain. This is why, when they don’t feel well, we seek consultation from a doctor or specialist immediately.

In Singapore, one of the primary reasons why parents have their children visit a doctor is because of ear, nose, and throat (ENT) problems. Ear infections and enlarged tonsils are the most common ENT problems found in children in Singapore every year. That is why an ENT doctor in Singapore such as those working at entspecialistsingapore.com plays an important role in a child’s health care especially in treating various ENT disorders.

Dr. Dennis Chua is one of the best ENT doctors in Singapore. He is an ear, nose and throat specialist with a sub-speciality focus in plastic and reconstructive surgery. He has more than 15 years of medical experience in treating ENT patients with breathing issues such as sleep apnea, snoring problems, sinus diseases, thyroid diseases, pediatric allergies, snoring, tonsillitis, ear infections, and facial plastics and reconstructive surgery.

He is currently a visiting consultant to KK’s Women and Children Hospital and was able to encounter several ENT paediatrics conditions. Allergies, snoring, sleep apnea, acute and chronic tonsillitis and otitis media with effusion are some common ENT disorders of his pediatric patients.

In this article, he explains to us these common childhood ENT disorders so that parents will have an idea and know what to do in case one of these ENT disorders happen to their child.

Allergies and Rhinitis

Little girl with allergy

Nasal allergies and nasal obstructions are very common conditions in Singapore, especially in children. Blocked nose, runny nose, rubbing of eyes and nose, and frequent sneezing are some signs of allergies. If you see symptoms like these, bring the child to an ENT doctor in Singapore as soon as possible to avoid further complications.

To look for more possible allergens, I do a skin prick test to my patients. It is a painless test and the results will be ready within 30 minutes. Most of the patients who were positive on the skin prick test are usually found to be allergic to house dust mites. I advise parents to start with their surroundings. Here is a short checklist for allergens avoidance:

  • Always keep the bedroom clean
  • Change bed sheets every week and wash them in hot water
  • Sunning bed sheets for at least 3 hours
  • Reduce soft toys in bed
  • Clean curtains regularly
  • Use of air purifier to prevent dust mites from getting back to the air

Allergic rhinitis can lead to childhood asthma if not treated early. I usually prescribe Sublingual Immunotherapy (SLIT) to some of my patients to stop the ‘atopic march’. It is a form of immunotherapy that involves putting liquid drops or a tablet of allergen extracts under the tongue. It is an alternative treatment for allergy shots. The drops work by allowing the immune system to tolerate the allergen as soon as the sublingual allergy drops to reach the gastrointestinal tract.

Recurrent Acute Tonsillitis or Chronic Tonsillitis

Little girl with Tonsillitis

I was able to deal with several cases of tonsillitis or tonsillar enlargement in children, and as much as possible I do not require surgery. Tonsillitis (infection of the tonsils) is a common infection during childhood – mostly in ages between 5 to 15 years old. A child with tonsillitis has symptoms like fever, difficulty or pain in swallowing, sore throat, loss of appetite, chills, headaches and bad breath.

Tonsils help our body fight infection by producing white blood cells. However, it can also be vulnerable to bacteria and viruses that enter our bodies. Most of the time, tonsillitis is caused by a virus like the common cold or bacterial infection. I usually prescribe antibiotics if necessary and advise my patients to stay hydrated and get enough rest. However, if my patient has frequent attacks of tonsillitis, I recommend getting a tonsillectomy.

Tonsillectomy is a surgery to remove tonsils. The surgery can help reduce the number of throat infections in children. It also alleviates the trouble in swallowing and breathing problems. You can go home after the surgery and it will take 1-2 weeks to fully recover.

Snoring or Sleep Apnea

Snoring regularly and loudly is not normal in children. It can be a sign of an allergy, stuffy nose, respiratory infection or it can be a symptom of sleep apnea. There is also a possibility of obstructive sleep apnea (OSA) if the child snores and gasps for breath, which can cause general health problems.  If this is not treated it can cause behaviour problems, poor academic performance, bed-wetting, and cardio-pulmonary disease.

Tonsillitis and adenoids are some of the causes of OSA, as they can obstruct breathing. An adenoidectomy or tonsillectomy can effectively restore the child’s breathing pattern and cures OSA. But if the child has Down Syndrome, obesity, neuromuscular diseases, or mucopolysaccharidoses, a sleep study is recommended before surgery.

Otitis Media with Effusion

Otitis media with effusion (OME) is a collection of fluid in the middle ear. It is more common in children between 6 months and 3 years of age. Sore throat, cold or upper respiratory infection with a poor function of the Eustachian tube causes this fluid to accumulate in the middle ear. OME can affect the speech development of the child and can result in hearing loss. I do a physical examination first to assess the condition and, if needed, I require a hearing test. The treatment depends on the child’s condition but mostly it includes antibiotics to treat the infection and a nasal decongestant to drain the fluid.


I believe that parenting is the hardest job ever especially if our child is sick. That is why it is important to seek consultation right away if we see signs and symptoms of ENT disorders from our children. Many good ENT doctors in Singapore can help us or we can get in touch with Dr. Dennis Chua for consultation and treatment.


ENT Specialist Singapore
3 Mount Elizabeth, #08-02 Medical Centre,
Singapore 228510
+65 6235 3886

Frequently Asked Questions about HIFU Facelift Treatments in Singapore

When it comes to facelift procedures, Singapore is no stranger to it. Each year, many Singaporeans unhappy with their saggy skin or wrinkles undergo a facelift to fix that problem and gain better confidence with themselves. It’s a quite common procedure and doctors and clinics have a lot of experience in dealing with these cases.

However, a lot of people are afraid or uncomfortable about going under the knife due to various reasons such as health or religion, which is why non-surgical facelift procedures are on the rise. One of these procedures uses high-intensity focused ultrasound (HIFU) technology, which is a relatively new treatment that uses ultrasound energy to penetrate the underlying skin layers and stimulate the production of collagen and elastin.

What is High-intensity focused ultrasound (HIFU)?

HIFU is a cosmetic treatment that uses ultrasound energy for skin tightening. The treatment works by encouraging the production of collagen, which is the protein responsible for keeping the structure of the skin. Our skin naturally produces collagen for this purpose, but when we age, the rate of collagen production slows down and the skin starts to sag and becomes wrinkly, especially on the facial region.

HIFU technology was originally used to treat tumours and has seen its first use for cosmetic reasons around 2008 in the USA. Eventually, HIFU as a facelift procedure has gained popularity particularly to those people who are unsure of surgery and would prefer a less invasive procedure. CambridgeMedical is one of the first skincare clinics that started to offer this non-surgical facelift in Singapore. Their service is called HIFU Plus+ and can be used on both Saggy Cheeks, Neck Eye, Corners Brow Areas and Double chin.

HIFU facelift treatment

What can HIFU facelift treatment do for patients?

The following are just a few of the things that HIFU facelift treatment can offer for patients:

  • reduction of the appearance of wrinkles
  • tightening saggy skin on the neck (often called a turkey neck)
  • lifting the skin on the eyebrows, eyelids and the cheeks
  • smoothening the skin
  • enhancing the jawline appearance

What are the differences between HIFU facelift treatment compared to traditional facelift surgery?

Since it is a non-invasive procedure, HIFU facelifts only risks are some mild swelling and redness after the treatment. Compare this with traditional facelift surgery, which can have several complications such as infection, bleeding, blood clots and hair loss at the incision area.

HIFU facelifts also have very little to no downtime after the procedure. Most patients can return to their work immediately after the procedure, unlike traditional facelift surgeries where patients have to take a break of about 2 to 4 weeks for recovery. HIFU facelifts are also less expensive in general compared to traditional facelifts.

One disadvantage of HIFU facelift treatments is that the results generally last shorter compared to the long-term results of facelift surgery. Also, a HIFU facelift treatment may require at least 2 to 3 sessions spaced about 3 months in between to ensure the best results.

Is there any pain or discomfort during a HIFU facelift treatment?

There should be very little to no pain at all during the session. In fact, there is no need for any strong anaesthesia as the most discomfort that patients feel are light electric tingles and a slight prickly feeling. Numbing cream is enough for the procedure and it has been described by patients as very safe, quick and comfortable experience. Expect some redness and swelling immediately after, but this is a perfectly normal occurrence and should disappear in a few days.

How is HIFU facelift treatment done?

Before the treatment, the patient must remove makeup and skincare products. The doctor will then clean the target area and apply a numbing cream to reduce discomfort. A special ultrasound gel is then applied over the area to aid in the treatment. The doctor will then place the HIFU machine on the target area, which is then adjusted to its best settings using an ultrasound viewer.

For about 30 minutes to a little over an hour, the machine delivers ultrasound energy to the target area. Some heat and mild prickly sensations will be felt during this, which tells us that the device is working and is properly applying the ultrasound energy into the skin.

After the treatment, the device is then removed by the doctor. Patients can go back to work or resume their normal activities without any downtime. Some mild swelling and redness may occur in the target area, but this should subside in a few days.

How much does HIFU facelift treatment in Singapore cost?

HIFU facelift treatment cost

There are several brands of HIFU machines, as well as different clinics with doctors of varying experience, which all contribute to the costs of undergoing a HIFU facelift treatment. Some HIFU treatment plans only need one session whereas others require at least 3 to 5 in total.

In general, one full treatment plan will cost about $2000 up to $5000 in total regardless of the number of sessions, and the exact cost will depend on various factors.

Is HIFU facelift treatment right for you?

The top calling card of HIFU facelift treatments is that they offer patients a non-invasive alternative to facelift surgery, at a minimal cost and time investment. Although other non-invasive facelift procedures also exist, HIFU is one of the more popular ones and thus, a lot of patients can attest to its effectiveness.

Ultimately, whether or not HIFU facelift treatment is the right treatment for your skin problems depends on you and your doctor. Although this guide may help you in deciding, nothing beats the first-hand opinion of an experienced doctor who has done a preliminary examination of your health. He/she should help you understand the pros and cons of the treatment as well as offer you alternatives.