We would like to draw the attention to the news regarding the plans of the Ministry of Health (MOH) to scale up pre-exposure prophylaxis (PrEP) usage for the prevention of HIV transmission.
PrEP is an oral medicine taken to prevent transmission of HIV via sexual intercourse or intravenous drug use, which will apparently be dispensed at the public health clinics in Selangor, the Klang Valley, Johor, Penang, and Sabah.
PrEP is currently given to HIV-negative people who were at risk of acquiring HIV, such as spouses of people living with HIV (PLHIV). PLHIV are patients who deserve to be protected and should receive the best treatment currently available.
However, the current plan is to scale up PrEP use to involve homosexual couples who are HIV negative, or on demand for men. We strongly urge MOH to review this plan.
We are of the opinion that MOH should advocate strongly on prevention methods, starting with abstinence. Public health messages and advice against practising rectal intercourse should be the mainstay of prevention.
The Economically Exorbitant Expense Of PrEP
“Prevention is better than cure” is the old adage in medicine which is founded not only on common sense and wisdom, but also from an angle of national economic and comprehensive social policy.
It is not the case that pharmaceutical prophylactic measures are not effective or do not reduce health care costs.
However, this is only true for a one-off or interventions with minimal frequency via medicine or vaccines. For example, the BCG vaccine is very cost-effective against tuberculosis, as were the Covid-19 vaccines against infections.
PrEP on the other hand, will require men who have sex with men (MSM) to take the medication daily as they are described as “those who are likely to have frequent exposures”. Considering that most MSM are young, this strategy will not only disrupt the moral fabric of our society, but economically it is an exorbitant expense.
Taxpayers’ money will be channelled to enable high-risk behaviour to continue which can be prevented provided they are given the right motivation from the aspects of health and morality.
Rather than encouraging rectal intercourse via the usage of PreP daily, the funds for PreP would be much better utilised for diseases which are not related to degenerate behaviour such as congenital diseases or non-communicable diseases (NCD).
Stifling The Freedom Of Opinion Of Religious Authorities In Their Respective Domains
Incidentally, we also regret that religious approaches in motivating people to leave this high-risk behaviour continue to be criticised and condemned. Any advice to uphold morality coming from religious personnel is openly denounced, as displayed in the recent case where the Malaysian AIDS Council (MAC) had condemned a religious scholar for making “disparaging remarks and hate speech”. Ironically, the public were not informed of the exact details being regarded as hate speech.
This current atmosphere stifles the freedom of expression and opinion of religious authorities in HIV-related matters. This encroachment on free speech and religious freedom will result in one which has transpired in our neighbouring country, Singapore.
The Singapore government recently decriminalised homosexuality, a law which the Christians and Muslims there insisted was needed to protect families, the institution of marriage, children, and freedom. The religious communities there have been relatively restrained in the face of an intolerant, vocal minority that seeks to overturn the order in all areas of society – be it marriage, education, businesses, or beliefs, while demonising all those who disagree as “bigots” or “haters”.
This is similar to what many religious preachers and institutions in Malaysia are currently facing.
The medical fraternity cannot allow this ideology which attacks traditional family institution to run rampant here. Not only does it destroy the building blocks of a society, but it also flies in the face of the most recent data from the UNAIDS report, which showed that the MSM population continues to increase in its over-representation of new diagnoses. It is important not to conflate the efficacy of the message with the persuasiveness of the messenger.
Abstinence and fidelity must not be condemned pejoratively by the medical profession, as it is still the primary mainstay of prevention even by the standards of the United States’ Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).
WHO defines health as a dynamic state of complete physical, mental, spiritual, and social wellbeing, and not merely the absence of disease or infirmity. Therefore, our treatment must be holistic, and not only focused on disease.
It defies logic that health care personnel have to enable the proliferation of high-risk behaviours, when we should be trying to stop it. As an analogy, let us consider for a moment other unhealthy behaviours such as smoking or eating sugary food.
The CDC estimates that every day in the US, more than 3,200 people younger than 18 years old smoke their first cigarette. Furthermore, every day, approximately 2,100 youths and young adults who have been occasional smokers will become daily and regular smokers.
However, the primary message from the CDC is single-minded, uncompromising, and unequivocal that smoking kills and smoking cessation has resulted in substantial health benefits. Even though this message has been shown not to dissuade the annual 1·2 million new smokers, it could never be justified for medical personnel to abdicate our professional responsibility to highlight behaviour and practices that are high-risk and should be stopped.
The same would apply to diet, exercise, and sexuality. A sequitur from the logic of the current stance would be that doctors telling people that doughnuts and high-sugar drinks are unhealthy does not deter people from eating such foods, so doctors should abstain from promoting this message as a core aim in healthy eating.
This clearly does not make sense, and there is no reason why we should single out and treat the high-risk behaviour of rectal intercourse any differently to other high-risk behaviours.
Abstinence Is the only key message that we should repeatedly promote to prevent HIV infection among the MSM community.
This is a joint statement by:
- Prof Dr Rafidah Hanim Mokhtar, Professor in Gender and Cardiovascular Physiology, Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia (USIM)
- Prof Dr Samsul Draman, Professor of Family Medicine and Consultant Family Medicine Specialist, Gender Dysphoria Flagship Leader, Kulliyyah of Medicine, Deputy Campus Director, International Islamic University Malaysia (IIUM)
- Prof Dr Anis Safura Ramli, Professor of Family Medicine and Consultant Family Medicine Specialist, Deputy Director and Principal Fellow of I-PPerForM, Research Centre of Excellence in Atherosclerosis and CVD Prevention, Universiti Teknologi MARA (UiTM)
- Prof Dr Harmy Mohamed Yusof, Dean, Faculty of Medicine, Professor of Family Medicine and Consultant Family Medicine Specialist, Universiti Sultan Zainal Abidin (UniSZA)
- Assoc Prof Dr Rosediani Muhamad, Family Medicine Specialist, Women and Sexual Health. Universiti Sains Malaysia (USM), Chairman of Asia Oceania Federation for Sexology.
- Assoc Prof Dr Ani Amelia Dato Zainuddin, Associate Professor in Obstetrics and Gynaecology, Consultant Paediatric and Adolescent Gynaecologist with Special Interest in Differences of Sex Development, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM)
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.