EFFORTS in combating HIV/AIDS in Malaysia have shown promising success whereby the rate of HIV transmission in the general population is at 0.05%, with the number of AIDS-related deaths steadily on the decline.
The National Harm Reduction Programme, Antenatal HIV screening and the Prevention of Mother-to-Child Transmission, and the availability of free antiretroviral treatment (ART) at public hospitals have all contributed to this success.
Provision of sterile needle and syringes and the methadone maintenance therapy since 2005 have halved the number of new HIV cases among injecting drug users (IDU). While there is much to celebrate so far, the number of new HIV infections reported in 2013 is still 3,393 persons too many. Further, we see an increasing trend in reported new HIV cases via sexual transmission.
Among these, 728 are women, the majority of whom do not belong in any of the key affected populations or live a high-risk lifestyle to contract HIV. Pockets of high prevalence still exist in key populations, with a recent study by our centre reporting a HIV prevalence rate of 11.2% in female and transgender sex workers in the Klang Valley alone.
From this cohort, the numbers of sexually transmitted infections are also high with syphilis reported at 26.2%, gonorrhoea at 6.6% and chlamydia at 16.3%. The rate of tuberculosis and Hepatitis C, two common co-infections with HIV, is also high at 6.7% and 3.9% respectively.
Analysis from the same study also shows low accessibility to healthcare among the 400 study participants.
A common trend is the “revolving door” of the criminal justice system, with 60% of the sample population reporting a history of detention and average number of times reported were 4.6 times in lock-up and 2.3 times in prison. Reasons for detention include sex work (70%), drug use (41%), and not having their identification card (10%).
This study highlights the need for a better policy involving sex work in our country to curb sexually transmitted infections.
The shift to sexual transmission as the highest percentage of HIV transmission also leaves many often marginalised communities, including female partners of IDU, female injecting drug users, female prisoners, and transgenders in need of assistance to improve HIV awareness and access to treatment should they be found to be HIV-positive.
Past and current programmes at controlling HIV transmission have been male-centric. While there have been excellent control on mother-to-child transmission, programmes aimed at reducing HIV transmission and ensuring linkage to and retention in HIV care among women who use drugs, and female and transgender sex workers are still lacking.
The need to address a target of zero HIV must be seen through public health lens as there is a high price to pay if this is not addressed. A return of investment analysis on the Harm Reduction Programme showed that the Government was able to save RM47.1mil in direct healthcare costs, the amount it would have had to spend on treatment and monitoring.
Such savings can be directed elsewhere, addressing the HIV issue in other key populations and re-routing the focus on women.
The Government must enable NGOs and researchers to access key populations by not only providing funding to NGOs and researchers, but also through changes in policy to reduce stigma against such populations, particularly women and those working in the NGOs themselves.
Every statistic represents a human being that can live with HIV to an age almost as old as expected in the general population, with the exception that these people require added assistance by society to be allowed to live as just another Malaysian.
Being HIV-positive today no longer immediately spells death. Advances in ART have shown promise that a functional cure can be seen as soon as in 10 years’ time. Further, treatment can also be a prevention method, as with the more people on treatment with undetectable HIV viral load, the less pool of virus will be circulating to cause more new infections.
However, access to screening to know one’s HIV status and access to treatment is still hindered due to stigma and discrimination towards people living with HIV (PLHIV). They are too scared to come forward to access treatment which actually works, where first line treatment is provided for free at government hospitals and clinics; and beneficial not only to individuals living with HIV but also the general public. Further, female PLHIV face added stigma due to gender-centric expectations of women being household custodians and mothers.
We have been successful in setting up systems and facilities, but without removing our own prejudice towards key populations and treating them as opposed to punishing them for their lifestyles, we cannot claim success in managing HIV.
Awareness programmes and sex education thus are importantly and urgently needed today. Every Malaysian – men, women and transgendered – must be provided with the knowledge and access to know their status and get tested early. Mandatory HIV testing has no evidence-based proof to assist in curbing HIV transmission; we must instead allow an empowered and enabling environment for those who think they are at risk to come forward for voluntary testing.
We must continue with what we are doing right, but we must also keep pushing the envelope towards improvement and betterment for the day Malaysia will finally see single digit numbers for new HIV infection cases, and finally reaching zero.
Lyana Khairuddin is Senior Lecturer, Centre of Excellence for Research in AIDS (CERiA), Universiti Malaya. Adeeba Kamarulzaman is Professor and Dean, Faculty of Medicine, Universiti Malaya, and Director, Centre of Excellence for Research in AIDS (CERiA), Universiti Malaya. This article was written to coincide with International Women’s Day.
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