Malaysia makes progress against HIV, but challenges remain

Abstract

Malaysia has taken great strides in tackling HIV, but difficult issues remain for the mainly Muslim country, including the use of condoms outside of marriage. Sima Barmania reports. No one understands the complexities of the HIV epidemic in Malaysia more than Adeeba Kamarulzaman, local cochair of the International AIDS Society conference taking place in Malaysia this month (June 30–July 3). Kamarulzaman, Director of the Centre of Excellence for Research in AIDS (CERiA) and Dean of the Faculty of Medicine at the University of Malaya in Kuala Lumpur, has been involved in HIV treatment and prevention since the mid-1990s. She describes how the country's epidemic has changed over the past two decades. “In the first wave, it was mainly through heterosexual transmission from neighbouring countries such as Thailand, then the second wave was through intravenous drug use, but now in the third wave what we are seeing is drug users, plus female partners of those drug users, and transmission through men who have sex with men.” The first case of HIV/AIDS in Malaysia was documented more than 25 years ago and there are more than 81 000 people presently living with HIV in the country. Kamarulzaman is acutely aware of the sensitive nature of the matter in the predominantly Muslim nation and commends the former president of the Malaysian AIDS Council on her leadership. “In the early years we have to credit Marina Mahathir for really being the voice of HIV, she created awareness in a country where such issues were not easily discussed.” When Kamarulzaman took over the presidency of the Malaysian AIDS Council in 2006 (to 2010), it was at a time when the epidemic was full blown. The focus was on treatment rather than prevention, she explains passionately. “I thought we are never going to see an end to the epidemic if all we are doing is treating, we needed to focus on prevention and harm reduction.” Thus began a move to incorporate HIV prevention and convince the government to implement needle exchange programmes for people who injected drugs intravenously. Shaari Ngadiman is the deputy director of disease control at the Malaysian Ministry of Health and head of the government's HIV/AIDS response. Speaking to The Lancet, he explains some of the government's strategy: “Our epidemic was mainly amongst those who were sharing needles, so we took more measures to initiate harm reduction programmes in these groups. There are 70 000 people on drug substitution treatment and harm reduction has played a major role in decreasing the HIV epidemic.” Thus far, the needle exchange programme has been well received and successful in mitigating the spread of HIV and Ngadiman acknowledges that the Ministry of Health are “not the only players” and work closely with the National Anti-Drug Agency and the prison department, to name a few. “The good thing is that we have good partnerships”, he says and explains that the Ministry of Health also worked with other governmental departments, including the Ministry of Women, Family and Community Development and the Malaysia Department of Islamic Development (JAKIM). In 2001, JAKIM gradually (state by state) introduced premarital HIV screening for prospective Muslim couples. While the department made screening obligatory, Ngadiman explains that Muslim couples are screened on a voluntary basis through clinics run by the Ministry of Health. Although premarital HIV screening may be contentious to some observers, Ngadiman believes it has had the synergistic effect of decreasing HIV transmission and emphasises that the purpose is “not to prevent marriage but to know your HIV status” and to subsequently counsel and educate people. Additionally, he tells The Lancet that in 2004 the Ministry of Health and Ministry of Education partnered to produce modules in secondary schools teaching students about HIV/AIDS and sexually transmitted infections. He admits rather candidly that the initiative was launched “but teachers were not comfortable teaching the material”. However, he adds undefeated: “There is a hiccup, it is not running smoothly but we are taking steps to improve it.” In 2008, the health ministry started working with the Ministry of Defence to ensure that school leavers embarking on their national service programme took an HIV education module and thus far 120 000 have gone through the scheme in an attempt to “minimise the gaps”, says Ngadiman. Furthermore, Ngadiman explains that the Ministry of Health has been working with JAKIM and have produced a training module to educate religious leaders about HIV, including the modes of transmission and how to reduce stigma. Ngadiman believes that working with the religious department is crucially important to reduce the spread of HIV in a country where “religion is important in every issue”. Religious leaders have an important part to play, he notes: “What you do is between you and god, but we must prevent transmission, changing people takes time but the role of religious leaders is also to prevent disease.” While in the past some religious leaders in Malaysia have been decidedly unhelpful with regards to discussions about HIV/AIDS, many are now engaged in HIV prevention. One such person is Arrahman Awang, an Ustad (religious leader) who works for JAKIM as an assistant director. Awang has been responsible for the Islam and HIV/AIDS manual for Islamic religious leaders, imams, and leaders of non-governmental organisations. He explains that the programme has been operating since 2003 and has been approaching imams in Malaysia. “There are around 20 000 imams in Malaysia but we have only engaged with 3000 of them so far.” He explains that the Muslim leaders initially focused their attention on reducing stigma and discrimination against people living with HIV/AIDS, then counselling them by way of Islamic principles. Now the approach in Malaysia is to utilise Khutbahs (religious sermons done in mosques) and Halaqahs (Islamic values) to raise awareness about HIV. Awang is awaiting an action plan to enable implementation of the Islam and HIV/AIDS training manuals to small groups in mosques within villages. Awang fervently believes that religious leaders can use Islamic principles to “inspire hope of the mercy of Allah and use of the rule of necessity”—the concept that “one harm should be removed by a lesser harm”. “Needle exchange has been widely accepted by Islamic leaders as a necessity to avoid the spread of HIV/AIDS”, he says. However, there are more delicate issues surrounding HIV prevention. “Condom use outside marriage is forbidden and only permissible within the confines of marriage. There is a fatwa [Islamic religious ruling] on this”, states Awang. Approaching the topic of condom use highlights some of the highly sensitive areas pertaining to HIV prevention and harm reduction in Malaysia. Nonetheless, these issues are not insurmountable explains Ilias Yee, clinical coordinator at CERiA, who vehemently proposes that, “harm reduction is compatible with Islam”. He explains that the often mentioned “lesser of two evils concept is available in Islam but is not readily applied” and results in an “all or nothing approach” that marginalises people—the antithesis of the central tenets of Islam. “Islam is all about reaching out”, he says warmly, “it is not just judging and conforming.” It seems that some groups are easier to reach out to than others—for example prisoners. More than 60% of incarcerated people in Malaysia have drug problems, increasing the likelihood of HIV infection, thus designing programmes to address drug misuse decreases HIV transmission. However, some high risk groups are much harder to reach out to, such as men who have sex with men. Yee explains: “Homosexuality is culturally frowned upon, it is often hidden, and the majority may be married, so designing HIV interventions for men who have sex with men is challenging.” Malaysia's transgender community is also another thorny topic. “We try to educate the public and religious leaders not to discriminate against transgender people but when they enter the mosque to pray, they get shoes thrown at them”, he explains. The anecdote is a stark indication that there is still some way to go to address stigma and discrimination against some high-risk groups and that much more can be done to address HIV prevention. Nevertheless, Malaysia has made great inroads in controlling its HIV/AIDS epidemic. In a nation where issues surrounding HIV are exceedingly sensitive, engaging with religious leaders is certainly no small feat. Such collaboration is a positive step in the right direction, and one that requires a continued concerted effort by all those involved. Fighting the HIV epidemic in the Islamic worldEarly in the HIV/AIDS epidemic, most predominantly Muslim countries regarded HIV as a disease associated with sexual promiscuity, homosexuality, and drug and alcohol use—behaviours forbidden by Islam. Home to more than 1·6 billion Muslims, the Islamic world was widely believed to be somehow protected against HIV/AIDS. Adherence to Islamic beliefs, together with widespread practice of male circumcision, was thought to protect against the risk of HIV infection, and subsequently to account for a comparatively low HIV prevalence in Muslim majority countries in sub-Saharan Africa and the Middle East. Full-Text PDF Adeeba Kamarulzaman: fighting HIV/AIDS in MalaysiaAdeeba Kamarulzaman sounds remarkably calm over a phone line from Kuala Lumpur, given that she will soon be co-hosting one of the biggest HIV conferences in the world. A long-time HIV/AIDS champion and Dean of the Faculty of Medicine at the University of Malaya, Kamarulzaman was an obvious choice to help lead the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention ( IAS 2013 ) in Kuala Lumpur this month. Full-Text PDF