As the conference opening session would make clear, in some respects, Malaysia’s HIV response has been a model in the region — but cultural and religious sensitivities and taboos constrain it in others.
‘Why Malaysia?’ was a question I heard from more than one researcher at the airport and in the express train into Kuala Lumpur for the IAS 2013.
Not that any one was complaining. As the air-conditioned train sped us from the gleaming airport, through what I’m guessing were palm oil plantations, pink marble mosques floating somewhere off in the hazy distance, we could definitely see the allure to the place. And we all anticipated we would be eating quite well during the week.
But exactly what was it that had impressed the conference organiser, the International AIDS Society, to decide to hold the conference in this conservative religious country with a relatively small population of people living with HIV (~81,000). Usually a country has got do something profound to merit the honour for some progressive stance or accomplishment.
And indeed, in a few areas, the country has done exceptionally well in the fight against HIV.
“Malaysia was selected to host this conference – the first in Asia, and the first for a Muslim country – in part because of it’s great decisions to adopt harm reduction to stem the raging epidemic amongst people who use drugs in 2005, against much public opposition,” said Professor Adeeba Kamarulzaman, during the conference opening session. (Prof Kamarulzaman is the director of the Centre of Excellence for Research in AIDS (CERiA) at the University of Malaya — and the local conference co-chair of the meeting).
In 2002, Malaysia’s epidemic was indeed growing quickly — with 7000 new HIV infections, primarily among people who inject drugs. Then in 2005, the Minister of Health in Malaysia introduced a national harm reduction programme that was considered controversial. This led to the first pilot methadone maintenance therapy (MMT) project that October and the first needle and syringe exchange programme (NSP) was implemented in early 2006.
“Desperate times call for bold measures and our HIV/AIDS epidemic at the time was spiralling out of control, being largely driven by injecting drug use. We knew that clean needle exchange and methadone had worked successfully in so many countries in reducing new HIV infections. And so is the case here, people who inject drugs were accounting for about 60% of new infections. Today the figure sits at around 20% – a huge success story,” Datuk Seri Dr. S. Subramaniam, Malaysia’s Minister of Health said at the conference opening. “Through this multi-sectoral involvement and the participation of both government agencies, primary practitioners and NGOs we have managed to reach 62 percent of the estimated injecting drug users in this country with harm reduction activities.”
“We have been experiencing a constant downward trend in the annual rate of new HIV cases, from it’s highest rate of 28.5 per 100 000 in 2002 to 11.7 per 100 000 in 2012,” he continued. “The government has targeted a further reduction of new HIV cases at 11 per 100 000 by 2015 – although we have another two and a half years to achieve this, I’m proud to say that this target may be achieved within this year itself.”
This was an act of great political will in the conservative country — and a model for its neighbours.
“The integration of harm reduction has been widely accepted as an important landmark in the government’s change of attitude towards drug use in Malaysia,” wrote the authors of a WHO Good Practices in Asia report.1 “Indeed, the paradigm shift from a repressive approach to drugs relying on punishment and law enforcement action to an approach that now fully integrates and accepts public health imperatives implemented in collaboration with health professionals and law enforcement officers has been documented and recognised as an important success for the country and the region as a whole.”
The report concluded that the development of the Malaysian response to HIV and had been timely and well-coordinated and its overall implementation “grounded in good scientific evidence and recognition of the value of multisectoral partnerships and political leadership.”
The country has also taken bold steps to roll-out programmes for the prevention of vertical transmission and treatment.
Malaysia introduced antenatal HIV care screening in pregnant women in 1998. More than 80 percent of the pregnant women in Malaysia have access to antenatal care in public healthcare facilities. In 2012, a total of 449 000 pregnant women in Malaysia who attended antenatal care were screened for HIV screening , approaching nearly 100 percent among those attending public facilities. All of the 270 pregnant women who were diagnosed as HIV-positive received antiretroviral therapy for prevention of mother-to-child transmission in HIV, resulting in a rate of vertical transmission of only two percent in 2012.
“We are trying to achieving the elimination of HIV vertical transmission in the very near future,” said Minister Subramaniam.
Antiretroviral treatment for people living with HIV was made possible when the government introduced compulsory licensing on antiretrovirals in 2001, which allowed generic medications to imported into the country. In 2012, 15,084 people living with HIV were on ART which cost the government 59 million Malaysian ringgit (approx. 18.6 million US dollars).
“We are committed to increase the coverage of ART to more than 80 percent of those in need by 2015,” Minister Subramaniam.
However, there are some serious threats to the country’s successful HIV response.
One — which received attention from activists at the conference— is the Trans-Pacific Partnership Agreement, a multilateral trade pact being negotiated by the U.S. and 11 Asia-Pacific nations that will impose aggressive intellectual property rules likely to jeopardise access to affordable medicines in developing nations — including antiretroviral therapy (watch for related story).
Another issue is that, while harm reduction has cut HIV transmission in half, it hasn’t eliminated it. Dr Adeeba emphasised that more needs to be done.
“Scaling up of harm reduction programmes continue to be hampered by policies and laws that continue to criminalize drug use – some 48% of the 37000 prisoners in Malaysia are in prison for minor offences relating to drug use with approximately 5% of them living with HIV with little or no access to antiretrovirals while co-infection with tuberculosis not only threatens the individual but also the prison guards and the community at large,” she said. “I believe that Malaysia is not alone in this. Around the world, and particularly in Asia, clean needles and methadone alone are not going to be enough to achieve the global target of reducing HIV infection amongst people who inject drugs by 50 per cent by 2015. A serious review of the social and structural determinants as well as the laws and policies that impede our progress in HIV prevention amongst people who inject drugs must therefore be undertaken.”
In addition, even as the rate of HIV transmission began falling among people who inject drugs, it began to rise among other key populations at high risk of HIV — commercial sex workers, and men who have sex with men.
“It would seem that advocating for and implementing harm reduction programs targeted at people who inject drugs here in Malaysia was a walk in the park compared to addressing HIV prevention for other key affected populations in Malaysia such as men who have sex with men (MSM), sex workers and transgender people. Cultural and religious sensitivities and taboos continue to hamper our ability to implement what science has proven,” she said.
“The UNAIDS goal of 15 million people on treatment by 2015 will only be achieved if we address the underlying causes of stigma and discrimination. This means dealing directly with the vulnerabilities of those who are most at risk of acquiring or transmitting HIV, including people who use drugs, sex workers, transgendered people and men who have sex with men. This means moving away from a moralistic and judgmental perspective towards an evidence-based approach that reduces harm to the individual and at the same time confers a benefit to public health,” said another speaker at the opening session, Andrew Tan, who, as an HIV-positive gay man in Malaysia, knows first hand the cost of ‘dual stigma’.
“I have often beat myself up in the past, I can do without additional discrimination from others. When I was first diagnosed I felt like a useless human being, my world falling apart around me – can you imagine it? I felt I was not a good son, I thought my business career was over. I was literally so afraid of infecting my family that I stayed at work late, coming home at midnight hoping that everyone had eaten and gone to bed. Even now I worry about the possible repercussions of going so public today – how will this impact the people around me – my family for one, my colleagues at work for another. It gets me thinking it’s about time we had a law against discrimination in the workplace,” he said.
“Stigma and discrimination are still very much alive. But I do believe that with more people like me coming forward, we can change the situation dramatically. The proof is clear – we have managed to half the number of new infections in Malaysia over the past decade largely due to the courageous decision of our Malaysian government, to implement harm reduction measures among people who use drugs. Engagement with this community has produced incredible success. Think what we can do, what we can accomplish if we engage with all key affected populations in Malaysia and beyond,” he continued.
Prof Kamarulzaman agrees that the Malaysia’s experience — that basing policy upon evidence— should work just as well fighting HIV in other key affected groups as it did in people who inject drugs.
And indeed, Minister Subramaniam said the government recognises this as well, and consequently has integrated interventions targeting MSM into the Malaysia’s HIV approach.
“There are challenges ahead in dealing with the changing nature of HIV and AIDS in Malaysia but I am confident that we will respond for two reasons: We always considered evidence-based approaches and we will always value the unique role of partnerships between government and civil society in reaching out to key affected populations,” he concluded.
Of course, this was the opening ceremony — when country officials would obviously want to put their best forward. Other presentations made during the conference that painting a somewhat less rosy picture about the situation on the ground will be discussed in an upcoming article.
1) WHO & Ministry of Health Malaysia: Good Practices in Asia: Effective paradigm shifts towards an improved national response to drugs and HIV/AIDS. Scale-up of Harm Reduction in Malaysia. Geneva, 2011.