The Health Ministry's decision to provide free access to an oral medicine taken to prevent contracting HIV from sex and injection drug use has received pushback from some healthcare professionals.
The objections centre around religious reasons, with critics being concerned that providing pre-exposure prophylaxis (PrEP) for free would be condoning homosexual sex, which is against Islam.
However, organisations advocating on the issue said not providing PrEP to men who have sex with men on the grounds of morality is depriving healthcare professionals of the most effective weapon in the fight against HIV.
"In this time of crisis, taking a moral high ground against key populations runs counter to the basic tenet of human decency," Malaysian AIDS Foundation chairperson Dr Adeeba Kamarulzaman said in a statement earlier this month.
During World AIDS Day on Dec 1, the Health Ministry announced it would provide free PrEP at government clinics next month.
It said the decision is in accordance with the Undetectable = Untransmittable (U=U) Concept.
In this concept, the person living with HIV is provided effective treatment to lower the viral load in the blood, so they cannot transmit it to others through sex or injection.
"The Health Ministry’s goal is to increase the antiretroviral (ARV) treatment for people living with HIV/AIDS.
"For couples living with HIV/AIDS, the PrEP treatment will begin in government clinics starting 2023.
"PrEP treatment has the potential to reduce risk of HIV infection through sex by 99 percent, when taken according to the prescription," the ministry said in a statement.
At private clinics, PrEP can cost between RM80 and RM140 a month.
Speaking about it shortly after she was sworn in as health minister, Dr Zaliha Mustafa said the programme is a pilot project to evaluate the efficacy in reducing the spread of HIV.
"The use is being studied. We have discussed it with (Islamic) religious experts on the matter of religious edict.
"Also, if we look at the use, it is not only for the LGBT community, but is also effective in stopping the spread of HIV in other communities," she told reporters.
Counselling against free sex
On Dec 17, some Muslim healthcare professionals expressed concern that providing free PrEP to those who practise "free sex" and homosexual sex may force Muslim doctors to act against their religious beliefs.
Their statement was published on Facebook by Dr Suhazeli Abdulllah, a family medicine specialist and chairperson of Ibu Sina's Medical Charity Organisation Malaysia (Papisma)'s board of advisers.
The statement was also signed by 15 other healthcare professionals, including professors and associate professors.
The healthcare professionals said they do not discriminate against HIV patients and believe they should receive adequate care.
They also have no issue with PrEP dispensed to married couples living with HIV.
However, they oppose giving subsidised PrEP to "practitioners of free sex", without also mandating counselling against sex out of wedlock and homosexual sex.
"We are non-judgemental but there is a limit according to our faith and we fear the retribution which could befall us all.
"We do not believe in practising without amar makruf, nahi mungkar (to call to goodness and prevent wrongdoing)," they said.
Morality argument
They likened their proposal to include "risk reduction counselling" to providing methadone to heroin addicts as a way to cure the addiction.
"The jurisprudence aspects of this policy should be revised to ensure this group of people who are going against nature (homosexuality) do not continue to thrive in this country," they added.
Some of the signatories of the Dec 17 statement had earlier this month signed a different statement calling for abstinence, and not PrEP as the key to preventing HIV infection.
The signatories also used inflammatory language to describe homosexual sex, including calling it "degenerative behaviour" and insisting that they were not engaging in hate speech.
The signatories include Isma leader and professor of gender and cardiovascular physiology Dr Rafidah Hanim Mokhtar.
Malaysian AIDS Council president Dr Raja Iskandar Raja Azwa said the moralistic argument against PrEP is a repeat of previous arguments against condoms in the fight against HIV/AIDS.
"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," he added.
Main mode of transmissions
Malaysian Society of HIV Medicine (MASHM) president Dr Chow Ting Soo said concern that risk-taking behaviour will rise with PrEP can be addressed if it is coupled with counselling.
PrEP should be seen not as a tool to promote sexual activities, he said, but as a tool to prevent HIV transmission because it supersedes the efficacy rate of prevention by using condoms or abstinence.
It has a 99 percent efficacy rate of preventing HIV transmission through sex and a 74 percent efficacy of preventing transmission through injection.
While drug use has been the main mode of transmission in Malaysia, in the last decade, sexual transmission has taken over.
Men who have sex with men are expected to be the main key population affected by HIV in Malaysia in 2030, according to projections published by the Health Ministry.
At the end of 2020, 92,063 people in the country were living with HIV, with 13 percent unaware until notified through the national surveillance system.
In 2020, 3,146 new cases were reported with this figure projected to be on the rise, reaching levels from three decades ago by 2030. - Mkini
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