MONTREAL, August 25 – Mandatory premarital HIV testing is a waste of limited public health funding due to its negligible positivity yield of less than one per cent, says infectious disease expert Prof Dr Adeeba Kamarulzaman.
Given Malaysia’s “concentrated” HIV epidemic, which means that HIV transmission occurs largely in clearly defined groups such as sex workers, men who have sex with men (MSM), and people who inject drugs (PWID), Dr Adeeba said efforts to eliminate the disease should be put into self-tests for people who are at risk instead.
“It’s not cost-effective,” Dr Adeeba, an infectious disease physician from Universiti Malaya, told CodeBlue in an interview last August 2 here in Montreal, Canada, after the 24th International AIDS Conference (AIDS 2022).
“If that is really the case [that public health funds are insufficient], we should really put all our effort into self-tests for people who are at risk, you know, MSM. Do more community outreach to make them aware of this platform (Jom Test) that we have so they can order online, do the test at home, be supported online by counsellors, linked to care for treatment, and if they are high risk, link them to pre-exposure prophylaxis (PrEP).
“And for injecting drug users, we already have all these methadone clinics, so if you integrate that, if they come for methadone, and they are HIV positive, put them on treatment,” Dr Adeeba said.
The former International AIDS Society president added that antenatal HIV tests should be maintained.
Johor was the first state to introduce premarital HIV screening for Muslim couples in 2001, with other states adopting similar legislation thereafter. By January 2009, Muslim couples across the country were required to submit to premarital HIV testing.
A study on the first three years of the premarital HIV screening programme in Johor found 123 new HIV cases detected (0.17 per cent) out of 74,210 respondents, higher than antenatal screening (0.05 per cent) during the corresponding period.
However, researchers noted that the HIV positivity rate among antenatal mothers had been declining from 0.07 per cent in 2002 to 0.04 per cent in 2004. Total HIV cases in Johor dropped 38 per cent from 1,116 cases in 2001 to 691 cases in 2004, while screenings increased from 65,215 (2001) to 92,761 (2004), indicating higher coverage and public awareness on HIV.
Malaysia started antenatal HIV screening in 1997.
Unlike antenatal HIV screening, which contributed to Malaysia’s success in eliminating mother-to-child transmission of HIV and syphilis as recognised by the World Health Organization (WHO), the rationale for premarital HIV screening is based on religious opinion.
In 2018, the then-Pakatan Harapan government suggested expanding compulsory premarital HIV testing to non-Muslim couples.
The Open Society Foundations, previously known as the Open Society Institute, in an overview of mandatory premarital HIV testing published in 2010, concluded that premarital HIV testing not only compromises the principles of HIV testing, but also is an infringement upon human rights, especially of the “right to marry” and find a family.
Other issues highlighted include the lack of confidentiality, citing Malaysia as an example where Muslim couples have to “submit a certificate disclosing their HIV status to the state religious department when applying for a license to marry”.
Despite strong reservations from the international community about mandatory premarital HIV testing, a study that explored major stakeholder views of premarital HIV testing in Malaysia showed strong support for mandatory premarital HIV testing among participants, which included religious leaders, MOH representatives, and people living with HIV.
Premarital HIV screenings, using rapid tests, are available for free at government health clinics, according to the Ministry of Health’s (MOH) MyHealth website, with a nominal registration fee of RM1.
Results are available within five to 20 minutes. If the test is reactive, a HIV confirmatory test will be performed.
The cost incurred by the government for these tests is unclear. Random checks show that pre-marital health checks at private hospitals, which not only covers HIV but often, hepatitis B screening and venereal disease research laboratory (VDRL) tests for syphilis, can range from RM119 to RM2,500 per individual, depending on the package.
MOH’s “Ending AIDS in Malaysia” report in 2015 revealed that the country spent RM181 million (USD56.5 million) on HIV in 2013, a 2.6 per cent increase from the previous year.
Of the total expenditure on HIV for that year, 95 per cent (RM172 million) was contributed by domestic public funds, while international funds contributed to only four per cent.
In order to end AIDS – a global HIV response to achieve zero new HIV infections, zero AIDS-related deaths, and zero discrimination – Malaysia would require an average annual investment of US$69.6 million (RM257.5 million) from 2015 to 2021, the report stated.