Public health responses must be guided by science and evidence — Malaysian AIDS Foundation, Malaysian AIDS Council and Malaysian Society for HIV Medicine

DEC 7 — Malaysian AIDS Foundation (MAF), Malaysian AIDS Council (MAC) and Malaysian Society for HIV Medicine (MASHM) strongly disagree with the position taken by Dr Rafidah Hanim Mokhtar and her colleagues that effectively discriminated against the men who have sex with men (MSM) community from accessing the Pre-Exposure Prophylaxis (PrEP) for HIV prevention.

Their blatant objection to PrEP for the MSM community could not be far more removed from the current reality of the HIV epidemic in Malaysia.

“While we acknowledge the virtue of abstinence, we must also act based on scientific evidence in reducing the sexual transmission of HIV. Four decades of the HIV pandemic have shown that an insistence on abstinence alone is not enough to change the outcome of this global crisis,” remarked Professor Datuk Dr Adeeba Kamarulzaman, Chairman of MAF.

“In 2021, 96% of new HIV cases were caused by sexual transmission, concentrated largely among the MSM community. Despite the weight of their vulnerability to HIV, the MSM community is also among the hardest to reach with HIV prevention services — largely due to overwhelming prejudice and a punitive legal system that criminalises their behaviour. In this time of crisis, taking a moral high ground against key populations runs counter to the basic tenet of human decency. There should be a concerted effort by each and every one of us to mitigate the HIV epidemic using the most powerful prevention tool in our arsenal,” added Datuk Dr Adeeba.

“We need to treat HIV prevention and care as a health-related issue, not a moralistic one and recognise that history is repeating itself here with previous discussions around condoms and antiretroviral treatment and risk compensation,” remarked Associate Professor Dr Raja Iskandar Raja Azwa, President of MAC.

“Every new HIV diagnosis is a failure of our public health to capitalise on existing HIV prevention tools at our disposal including PrEP to prevent that HIV infection,” added Dr Raja Iskandar.

“PrEP is a highly effective method of HIV prevention among all other public health measures. There is a concern about the effect of PrEP on behavioural changes leading to an increase in the number of sex partners and activities due to perceived PrEP protection. Therefore, proper counselling on other methods of prevention of sexually transmitted diseases must be given on top of PrEP prescription. We should not regard this as a tool to promote sexual activities but rather as part of a prevention tool for HIV transmission.” Remarked Datuk Dr Chow Ting Soo, President of MASHM.

When taken as prescribed, PrEP is 99% effective in reducing the chance of acquiring HIV via sexual contact and 74% effective in reducing HIV transmission via injection drug use. This far supersedes other HIV prevention methods, such as condom use and abstinence. Looking at the current trend of HIV transmission, scaling up PrEP is the best way forward that will bring us closer to our goal to end AIDS by 2030.

In the last 10 years, the scientific evidence for the effectiveness of PrEP in preventing HIV transmission has been shown in several large studies. More recently a large-scale study in Australia involving 10,000 PrEP users showed that the new rate of HIV transmission has dropped by nearly 90 % — putting away any lingering doubt on the efficacy of PrEP as an HIV prevention tool.

The narrative against PrEP was ironically identical to the objection that we faced 10 years ago, when the MOH and civil society partners under the Malaysian AIDS Council were at loggerheads with detractors of the Needle Syringe Exchange Programme (NSEP) under the Harm Reduction initiative. Rolled out amidst punitive drug laws that rank among the toughest in the world, the programme has successfully reversed the trajectory of the Malaysian AIDS epidemic. A study conducted by the Centre of Excellence for Research in AIDS (CERIA) revealed that more than 13,000 new HIV infections were averted in the first 8 years of NSEP (2006-2013), while the estimated cost-savings in direct health care spending over the same period for HIV were about RM47 million.

The scaling up of PrEP by MOH could not come at a more critical time in our fight against AIDS. A recent report by UNAIDS showed that Malaysia is one of the few countries in the Asia Pacific region that is showing an increase in the number of newly reported cases. In contrast, many countries around the world including high-burden countries, have successively shown a decline in new cases as a result of large-scale expansion of antiretroviral treatment and PrEP. MAF, MAC and MASHM therefore wholeheartedly support the implementation of PrEP in the interest of protecting the health of Malaysians from HIV. We commend MOH for their planned PrEP implementation scale-up within the public sector as part of an additional evidence-based HIV prevention strategy to mitigate sexual transmission of HIV. We urge all stakeholders to follow the science and the precedent that was set by NSEP, making sure that evidence-based decision-making prevails in the face of an impending public health crisis.

*This is the personal opinion of the writers or publication and does not necessarily represent the views of Malay Mail.