The increasing prominence of HIV transmission through the sexual route have prompted calls for more strategies to prevent it.
THE auditorium at Hospital Sungai Buloh, Selangor, that was packed to the aisles during the hospital’s International AIDS Memorial Day celebration in May was, to its head of infectious disease unit Dr Christopher Lee, one of the most rewarding changes he has seen in his career as an infectious disease physician.
“The hall can accommodate about 250 to 280 people, but we packed in about 300. About a third of them are healthcare workers, and the rest of them are from NGOs and the (HIV) positive community,” he says. “Many of those from the positive community have only participated in an event like this for the first time. Most are surprised at the support they receive.”
It was certainly a far cry from the early days when the first case of AIDS was reported in Malaysia back in 1986. Then, there was little doctors could do for those who were diagnosed, and people were dying every day from the disease. Today, people who have lived on for years with the disease present in the auditorium are walking examples of how information, treatment and support have made a once fatal disease the chronic disease it is now.
“But a lot more has changed. The picture of HIV and AIDS is very different today than it is in the 80’s and early 90’s,” says Dr Lee. From a disease that affects predominantly injecting drug users, HIV and AIDS is now starting to affect more people who engage in unprotected or risky sexual behaviours.
And while Health Ministry figures show a decrease in the number of new infections in men for the past decade, the number of new infections in women have been on a slow but steady increase. “Nationwide, the percentage of new infections due to sexual transmission (48.5%) overtook injecting drug use (47.6%) for the first time, so we need to look at it a little bit more,” says Dr Lee.
From drug abuse to sexual transmission
It may be the first time sexual transmission has taken over as the most important risk factor of HIV transmission, but statistics have shown a fluctuating but increasing trend amidst the decrease in new infections caused by injecting drug use over the past decade. In 2003, injecting drug use was found to be responsible for 4,796 new infections. In 2010, that figure went down 30% to 1,737 cases. Instead, for the same period of time, new cases that are traced back to sexual transmission have increased slightly from 1,493 new cases in 2004 to 1,773 new cases in 2010.
So, while the total number of new infections has slowly dropped since year 2002, the percentage of people getting infected through sexual (which includes homosexual, bisexual, and heterosexual) contact has increased. These statistics reflect the reality on the ground, as people who are involved in the treatment and support work for HIV and AIDS like Kuala Lumpur AIDS Support Society (KLASS) vice president Nick Heow and Dr Lee have already noticed the trend. “Over the past few years, we have been seeing a trend in our hospital peer support group and also in KLASS: people who are newly diagnosed are getting younger, and many of them have gotten it through unprotected sex,” says Heow.
Although KLASS’s main objective is still to provide information and support to PLHIVs, they have started a roadshow last year around Peninsular Malaysia to talk to secondary school students about HIV and sex.“In every session, we give the students a manual with information about the virus and invite them to participate in games and discussions about the disease,” says Heow.“There are a lot of funny questions about sex, of course, but there were also a lot of questions about how the disease is transmitted too. Many of them have heard about HIV, but if you ask them for details, they might not know much,” he elaborates.
What Nick and those who run the roadshows found, is that students from big cities like Kuala Lumpur appeared to know more about the subject compared to students from smaller towns like Teluk Intan or Kuantan.“We realise that it is the students from smaller towns who needed more information about the virus and safer sex. However, they tend to ask very practical questions, like where can they get treatment if they contract the virus,” says Heow.
However, information alone may not be enough. Without the realisation that HIV can affect them, people may not take active steps to protect themselves.“I think while the school education system educates students about HIV, the problem is that most of them do not personalise it. They may think that someone else, like a drug addict, will get it,” says Dr Lee. “Personalising the message has always been a problem.”The questions he thinks students and the general public should ask are self-reflective.
Some of the examples are, “Can I get HIV? How can I get it? Now that you are in form 5, what happens when you graduate? What happens when you are in a relationship? Can you have sex? If you have sex, can you get HIV?” “The answer is that it is possible, depending on who your partner is,” says Dr Lee. “After that, if you ask yourself how you can pass on the virus to someone else, maybe it will occur to you that you can pass the virus on to your girlfriend if you had sex.“And if you have only had sex with a girlfriend you’ve known for a year, you might also realise that you do not really know whether she was exposed or not,” he explains.
While HIV prevention efforts in the country to date have been more focused on preventing injecting drug users from sharing the virus amongst themselves when they share needles, the increasing relevance of sexual transmission calls for a revision of prevention strategies that has to be put in place.
“The government has invested a lot of money into harm reduction programmes, like the needle exchange programmes and drug substitution therapy, and it has been showing positive results. But what about sexual transmission?” asks Hisham Hussein, chairman of the PT Foundation, a community-based, voluntary organisation that works with communities most affected by HIV in Kuala Lumpur.
“With drugs, abstinence is the best. But the authorities eventually realised that it is next to impossible to get all injecting drug users to abstain. So, they gave them clean syringes to reduce HIV transmission, because it is the next best thing to do,” says Hisham. “With sex, it is similar. You can’t really stop people from having sex. So, why can’t we (work out a similar programme) with condoms?” he says.
The challenge is that sex, and condom distribution is still considered taboo subjects in the country.
Says Malaysian AIDS Council president Tan Sri Mohd Zaman Khan, “We are increasing our efforts to educate the general public about the sexual transmission of HIV, particularly among women. However, the trouble is we still have people who don’t want to talk about it.” Even the distribution of free condoms can be challenging. “Although it is probably the best way to protect oneself from HIV transmission through sex, condom distribution is often viewed as a move that encourages people to have sex,” says Mohd Zaman.
“The public needs to understand that this is not our intention. What we are trying to do is prevent people from getting infected, and encouraging people to use condoms can help us do that.”
The way forward
In view of the changing trends of the way HIV is transmitted, strategies that are designed to deal with the situation is needed. “We cannot go about business as usual, because when the epidemic changes, our interventions must also change,” says Dr Lee. While harm reduction programmes should be continued, it is also equally important to educate the community about safer sex, says Mohd Zaman.
“This is not limited to sex workers, or men who have sex with men (MSN) or the transgender population only. Everyone should be educated.”
To address sexually transmitted HIV, the Health Ministry is taking a holistic approach, says Deputy Director General of Health (Public Health) Dr Lokman Hakim Sulaiman.“Through partners, the ministry also focuses on increasing awareness, encouraging partner counseling and partner notification, conducting contact tracing and testing, encouraging voluntary testing, scaling up pre-marital screening and enhancing antenatal screening.
As for condom distribution, Dr Lokman says it is already part of the Needle Syringe Exchange Program, which is accessible at any of the Health Ministry’s facilities and participating NGO sites.
With regards to condom use, Dr Lokman questions whether the issue is affordability (as a condom costs about RM1.00) or a reluctance to use condoms. “We have to be clear on this, and that is why the ministry is emphasising on creating awareness and advocacy with partner organisations.”
Currently the Health Ministry is also developing a new strategic plan to reduce the risk and spread of HIV infection, improve the quality of life of PLHIVs and reduce the social and economic impact of HIV and AIDS on the individual, family and society. “While acknowledging that the sexual route is getting important as the source of infection, we must not relax our focus on injecting drug users who still form a significant proportion of cases. The ministry is giving equal importance to both routes of infection,” he explains.
Courtesy of The Star