KUALA LUMPUR, July 28 – Malaysia’s battle against HIV over the past two decades has produced mixed results, with new HIV infections falling by two-thirds from a peak of 6,978 cases in 2002, while AIDS-related deaths have rebounded in more recent years.
The Ministry of Health’s (MOH) Global AIDS Monitoring 2021 Progress Report showed that by the end of 2020, about 87 per cent of an estimated 92,063 people living with HIV (PLHIV) in Malaysia were aware of their status, 58 per cent of reported PLHIV received antiretroviral therapy, and 85 per cent of those on antiretroviral treatment became virally suppressed.
Despite making positive progress, Malaysia still fell short of meeting the global 2020 HIV goals of 90-90-90, with a scorecard of 87-58-85.
The MOH attributed Malaysia’s failure to meet the 90-90-90 goals to the shift in the local HIV epidemiology landscape from needle-sharing to sexual transmission and also to stigma and discrimination faced by PLHIV that impedes efforts to link newly diagnosed PLHIV with care.
The global AIDS target has been updated to achieve 95 per cent of those living with HIV to know their status, 95 per cent of those who know their status to be on treatment and 95 per cent of those on treatment to be virally suppressed – meaning the amount of HIV in their body is kept very low by antiretroviral drugs so that they are not infectious to others – or 95-95-95.
Prof Dr Frederick Altice, professor of medicine, epidemiology and public health at Yale School of Public Health at the United States’ Yale University, told CodeBlue in an hour-long interview last June that Malaysia will need to take more aggressive steps to make treatment more accessible if the country aims to end AIDS as a public health threat by 2030.
Dr Altice said Malaysia could do this partly by reducing stigma directed at HIV, homosexuality, or both and allowing non-prescribing clinicians such as nurses to provide antiretroviral treatment to HIV patients.
Closing The Gap Between Testing And Treatment
Malaysia’s HIV testing or screening rate is relatively high, which allows 87 per cent of PLHIV to be aware of their status. The country has a number of programmes, both voluntary and involuntary, carried out in different settings for different groups to test for HIV.
HIV screening is free in government health care facilities via two main programmes: pre-marital and confidential HIV testing. Muslim couples are required by state fatwa (religious decrees) to test for HIV before marriage. Johor was the first state in Malaysia to require Muslim couples to undergo pre-marital HIV testing in 2001.
There were also plans by the federal government in 2018, under the Pakatan Harapan (PH) administration, to make HIV tests mandatory before marriage for non-Muslim couples. However, PH’s collapse put the plan on the back burner.
Anonymous HIV testing is also available at public health facilities. According to the MOH’s Guideline for Anonymous and Voluntary HIV Screening, individuals who want to take the anonymous HIV test are not required to register their details at the registration counter. Instead, they can proceed to see an officer on duty for the test.
The HIV confirmation test will be conducted under strict confidentiality. The medical officer will fill in the HIV confirmation test application form (HIV-97), which the officer will send with the blood sample. The person’s details and the blood test result will only be known by the doctor or health staff who performed the test.
Testing also occurs in prisons and compulsory drug detention centres, resulting in high HIV status awareness among people who inject drugs (PWID). However, as statistics indicate, linkage to care is limited upon diagnosis.
“So your first gap is between diagnosis and treatment. And so, how do you close that gap? You diagnose them, and they get a pill that same day,” Dr Altice said.
“The problem is that the next step of getting on to antiretroviral therapy, this is where the rubber hits the road. Because these doctors are giving them vitamins to practice with, there are all kinds of other sorts of things, as opposed to having to change the goal.
“Change your goal, to get a person on to therapy within 24 hours of a diagnosis. That’s what I do. So they walk in, if they tell me they’re ready for treatment, they’re getting it that day,” Dr Altice said.
In Malaysia, out of 87 per cent of 92,063 PLHIV in the country who are aware of their status, only 58 per cent of reported PLHIV received antiretroviral therapy.
“That’s a 30-point gap. And we know who’s not getting it – the people who inject drugs, the former prisoners, the people who drink alcohol – and the medicines are much more forgiving now. People say, ‘Oh, you’re gonna get resistant.’ I’m not so sure it’s going to happen very often. There’s a legacy of treatment, and people are not moving with the times. The medications are easy. I mean, you can put me out of business,” Dr Altice said.
In addition to offering immediate prescriptions, Dr Altice said Malaysia could create an HIV care network via a hub-and-spoke model to decentralise antiretroviral therapy access.
“In Africa, doctors don’t see any patients; it’s a nurse, medical assistant, or community outreach worker. But you need a way, what I call a hub-and-spoke model if you’re going to do that, where you’ve got a doctor sitting in some hub, and you’ve got all of these outreach people.
“Those people need to be well trained so that if there’s a problem, they can get that person into that, so you can’t just let them hang out there. I don’t want a community outreach worker treating 100 per cent of the people. I want them to treat 90 per cent, and when they get into trouble, they need to have a backup plan, so plan B.
“That’s another way to sort of improve access. The system needs to be changed. These big, centralised HIV clinics are associated with dropout care. Every study on that area has always shown that,” Dr Altice said.
HIV is treated with antiretroviral medicines, which stop the virus from replicating in the body. This allows the immune system to repair itself and prevent further damage.
Sustained, regular HIV care, including initiating and maintaining antiretroviral therapy, is vital to HIV-infected patients’ overall health and prevention of HIV transmission.
Recent research shows that HIV-infected patients who received ongoing, regularly scheduled care had significantly lower viral loads, higher CD4 cell counts, and reduced morbidity and mortality than those who missed even one medical visit over two years.
A CD4 count is a test that measures the number of CD4 cells in your blood. CD4 cells are white blood cells that fight infection and play an essential role in the immune system. The CD4 cell count of a person who does not have HIV can be anything between 500 and 1500.
If a person has HIV and does not take HIV treatment, their CD4 count will fall over time. The lower the CD4 cell count, the greater the damage to the immune system and the greater the risk of illness.
Overcoming HIV Stigma And Discrimination
In Malaysia, sharing injection paraphernalia or equipment has been the primary mode of HIV transmission since the beginning of the HIV/AIDS epidemic in 1986.
However, the country observed gradual changes in the HIV epidemic landscape in the past decade from predominantly PWID to sexual transmission. As a result, the proportion of sexual transmission for HIV infection increased to over 90 per cent in 2019.
In 2021, about 63 per cent of reported HIV cases in Malaysia were linked to homosexual or bisexual relationships, and 33 per cent to heterosexual relationships.
Health Minister Khairy Jamaluddin told Parliament, in a written reply on March 14, that HIV infection via sexual transmission can occur through unprotected sex with an infected person, such as not wearing a condom, irrespective of a person’s sexuality.
He said the MOH’s HIV data is based on risk factors rather than sexual orientations like lesbian, gay, bisexual, transgender, and queer (LGBTQ).
“If you take a look at the levels of stigma in this country, and we’ve done this, looking across students and population, etc., is that if you take a look at how people feel towards, let’s say, a diabetic patient, these feeling thermometers are like approaching 100 per cent – this is from doctors and medical students,” Dr Altice said.
“They’ll go, ‘I’ll treat them. I’ll give a little bit of insulin’ even though you know that the patient is overeating or whatever, so you know, there’s less blame that goes into that.
“And then people with HIV. There’s a step-down, but they have a bit of a [holdback]. What if their dirty sexual partner or drug-using husband or wife gave it to them? So there’s a level of innocence that goes on here.
“The next layer down is people who inject drugs, and you know, and I was surprised by this, I thought that they would be the lowest. I said, ‘Oh my God, it’s Malaysia. They’ve had these anti-drug laws for a gazillion years’, and they are mean laws; they are tough. And so I thought, okay, they’re going to dislike them the most.
“People on the bottom of the bucket are men who have sex with men (MSM), and part of that is criminalisation in both secular and Shariah law. So you’ve got the double whammy of disdain, if you will.”
Dr Altice pointed out that even though drugs are haram under Shariah law, there is a sense in the religion of Islam that people can be rehabilitated through treatment so that they can get closer to God.
“So I mean, we met with the imams to get that right. We went to Iran to figure that out. Or to get a, you know, to get a perspective, at least, on the interpretation from the Qur’an from, you know, people who are really religiously very conservative,” he said.
“And, so I think that what happens when you have the most criminalisation, the study shows that HIV prevalence increases as criminalisation laws go up.
“But the other part of that is what ends up happening is people feel discriminated against; there’s a sort of internalised stigma. And so they hop off and do things and then, you know, the other thing that we know that is really effective in MSM is pre-exposure prophylaxis (PrEP), but it’s not easily accessible.”
Focus On Treatment, Not How Patient Got HIV
To overcome HIV stigma and discrimination, Dr Altice suggested removing risk-based assessment when dealing with HIV patients.
“If you (as a patient) are coming in to see me and, ‘Oh, you’ve got HIV, it’s confirmed’. I say, all right, I have limited time with you today. I’m going to give you your medications. This is this. Take it every day; take five minutes to get them to do that.
“Next time, I’m going to talk about what you do sexually and what you do with your drugs. And you’ll deal with that because there’s this voyeuristic idea that you must do everything. Well, you don’t.
“What you really need to do is to make sure that they don’t have an opportunistic infection, and they’re not going to have a bad reaction to their medicines. And then you have a lifetime to get to know your patients and do all these other sorts of things,” Dr Altice said.
“And so I think that we as doctors, and I’m guilty of it, I’d love to know everything about my patient, but I don’t know it the first time. I need to be able to ask the question: what’s going to get in the way of you taking your medicines, what are you going to do if you have a side effect. If you’re having problems taking your medication, will you reach out to me, and we’ll come up with something else? You sort of need to give them a menu. And then you deal with all those other sorts of things.
“If you say, ‘okay, how did you get HIV?’ They say, ‘I had sex with a man, or I was with a prostitute’ or, you know, any of these other things, and the patient puts up their shield. So, focus on the treatment. It’s a public health issue.
“It’s focused on getting your medication, and when you go into a doctor, you have a complaint, what do you want? You want a pill or a shot; you want to get treated.
“You don’t want a lecture, and you don’t want, in some places here, they give vitamins for practice taking. What do you think you’re doing? If a person accepts your medicine, they’re going to take it most of the time. So there’s no data, zero data. There’s not a single study on the planet that supports that,” Dr Altice said.