Innovating the End of AIDS

By Bakhtiar Talhah
President of the Malaysian AIDS Council

This past year, the global AIDS response sector has embarked on Ending AIDS, a United Nations Sustainable Development Goal that envisions the end of AIDS as a public health threat by 2030.

In the Malaysian context, Ending AIDS means a 90 per cent reduction of new HIV infections from 2010, with a target of fewer than 800 new cases annually beginning 2021 (for comparison, in 2015, a total of 3,330 new HIV cases were reported).

The question that should be on everyone’s mind now is not, can we get there, but rather how do we get there?

In getting there, we must first understand the lay of the AIDS landscape in Malaysia.

The Malaysian AIDS epidemic – which to date has affected 108,519 lives since 1986 – is, in general, under control, characterised by the 60 per cent reduction in new HIV infections since the height of the epidemic in 2002. This feat is often attributed to the success of the harm reduction programme in turning the tide on new HIV infections among people who inject drugs.

In stark contrast to this positive development, however, sexually transmitted HIV has been on the rise, overtaking unsafe drug injecting as the leading cause of new HIV infections since 2010. Last year, sexual transmission accounted for 78 per cent of all new HIV cases, a complete 180-degree turn from the scenario 10 years ago.

So, what lesson can we glean from the harm reduction success story?

For one, we know for a scientific fact that prevention works. Not only has harm reduction – needle exchange and opiate substation therapy – averted more than 12,000 HIV infections but also saved the government RM 47 million in direct health care costs since its implementation in 2006.

However encouraging the notion of a harm reduction model for sexual transmission sounds, preventing the spread of sexually transmitted HIV is not as straightforward as giving away free condoms. Don’t get me wrong. Making condoms and safe sex education accessible helps, so much so that last year we distributed over 2 million condoms to a total of 8,247 sex workers, transgender women and men who have sex with men – key populations disproportionately affected by HIV – via 166 outreach points nationwide.

But the reality is, designing health interventions targeting human sexual behaviour is a lot more complex and requires a great deal of ingenuity.

Unlike the decision not to share needles, which for many people who inject drugs is just a question of access, the single act of using a condom hinges on a myriad of factors – trust, knowledge, pleasure, perceived risk, self-esteem, shame, power disparity, gender dynamics, substance use and, of course, access.

Cognizant of the complexity surrounding sexual behaviour as well as the reality that there is no one-size-fits-all solution, we introduced the case management approach to sexual health programming for men who have sex with men. Using social networking apps as an outreach point, this innovation customises the experience of accessing community-friendly health services to the individual needs of a client. Under the guidance of case management specialists, clients are walked through every step of the way in the continuum of HIV care – from risk assessment, testing, prevention all the way to treatment literacy and adherence in the case of HIV diagnosis.

A ‘package of prevention services focused on and tailored to the needs of men who have sex with men’, such as the case management model, is being echoed by the Ministry of Health Malaysia in its National Strategic Plan for Ending AIDS 2016-2030, as a key intervention under its reduction of sexual transmission priority programme.

The 15-year national AIDS response blueprint also outlines that, in order to end AIDS by 2030, 95 per cent of key populations need to be tested for HIV and know their results.

To that end, the Ministry of Health Malaysia in collaboration with the Malaysian AIDS Council, last July, launched the community-based HIV testing programme, whereby 36 community health workers have received training and accreditation to conduct HIV rapid tests and make referrals to government-initiated HIV treatment and care services. This community-friendly alternative complements the free anonymous HIV testing provided at government health clinics and is hoped to boost HIV testing uptake among key populations which currently stands at less than 50 per cent.

Another innovation that is set to mark the beginning of the end of AIDS in Malaysia is the One Stop Healthcare Centre for Integrated HIV Treatment, Care and Support in Kuching, Sarawak – a project that is being spearheaded by our fundraising arm, the Malaysian AIDS Foundation. Despite its diversity in geographical features impeding access to readily available HIV services, Sarawak has all the makings of a successful Ending AIDS endeavour – consistently low yearly HIV notification rates and a renewed commitment to the local AIDS response led by the state government – ahead of all the other states in Malaysia.

It is indeed reassuring to note that the beginning of Ending AIDS is filled with promising innovations. While reflecting on them this World AIDS Day (observed globally on Dec 1 each year), I could not help but also think, with trepidation, of the barriers and challenges that might threaten their sustainability and success.

The Malaysian AIDS Council (MAC) was established in 1992 to serve as an umbrella organisation to support and coordinate the efforts of non-governmental organisations (NGOs) working on HIV and AIDS issues in Malaysia. MAC works in close partnership with government agencies, the private sector and international organisations, to ensure a committed and effective NGO-led response to the HIV epidemic.

In addition to providing nationwide coverage of HIV prevention, treatment, care and support services, MAC and its Partner Organisations serve as the common voice for communities most affected by HIV and AIDS in the country.

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