Is Malaysia ready for an open discussion on sex and related issues, beyond the focus on abstinence as the sole way to prevent HIV/AIDS?
A senior lecturer at the University of Malaya and member of the Malaysian AIDS Council (MAC), Nur Afiqah had just finished telling Bernama that many teens and young adults were sharing sex tips on WhatsApp group chats, blanching as she described what she saw.
"It’s horrible because (there’s) so much unsafe sex happening there,” she said. “I've seen these conversations like how people are getting these young people in the WhatsApp groups and teaching all this weird stuff.”
The group chat included conversations on heterosexual, bisexual and homosexual sex, and using drugs like amphetamines to aid the acts.
As a faculty member at the Social and Preventive Medicine Department (SPM) at UM, Nur Afiqah recognised that not just young people, but most Malaysians – 77.4 per cent of them in 2020 – did not know enough about HIV/AIDS. It is especially concerning as sexual transmission accounts for almost all new infections in the culturally conservative and sexually repressive country.
When it comes to having frank discussions on sex and sexual orientation in Malaysia, she and other public health experts working on Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS) realise they can’t win. But they don’t plan to lose, either.
For that, they turned to online platforms, including Artificial Intelligence (AI), to bypass objections and the stigma to reach at-risk communities.
CHANGING HIV LANDSCAPE
HIV is a virus that infects the immune system and turns it against itself, while AIDS is the late-stage condition of the infection when the immune system no longer works. The virus is transmitted via body fluids, such as blood, semen and breast milk. There is no cure for HIV.
Since 2010, Malaysia has experienced a significant shift in HIV transmission patterns, with sexual contact surpassing intravenous drug use (IDU) as the primary mode of infection. In that year, 48 per cent of new HIV cases were attributed to sexual transmission, compared to 47 per cent from IDU—a sharp contrast to just five years earlier, when IDU accounted for 65 per cent of new cases. By 2022, sexual transmission had risen dramatically, accounting for 96 per cent of all new HIV cases.
This shift was somewhat predictable, given the government's implementation of harm reduction policies in 2005 to curb HIV transmission among drug users sharing needles. These measures included a needle-syringe exchange programme and the introduction of methadone treatment, an oral opiate replacement that reduced cravings without diminishing the will to recover.
However, the same progress cannot be seen in addressing sexual transmission, as awareness programmes largely emphasise morality and abstinence over safe sex practices. These initiatives often overlook the most vulnerable groups, including men who have sex with men (MSM), transgender individuals, and sex workers. In 2022, homosexual or bisexual relations accounted for 60 per cent of HIV cases transmitted sexually.
"When it comes to society in general, people still (regard it as) taboo to speak about sex,” said Nisha Ayub, a trans activist, to Bernama via Zoom. She started her advocacy work in 2006, providing HIV/AIDS information to sex workers and the trans community in Kuala Lumpur.
Considered the “moral disease” by many, HIV/AIDS thus causes a fair degree of stigma and discrimination to those it touches.
Despite the government's pledge to combat the stigma surrounding HIV/AIDS, it remains pervasive, as highlighted by data from the Ministry of Health.
Half of the 2,449 respondents in a 2022 online survey said they would not buy food items from a person with HIV, while 45 per cent think children with HIV should not attend school with other children.
UM’s implementation scientist Dr Rumana Akhter Saifi told Bernama that stigma and discrimination against people living with HIV (PLHIV) were common, especially against vulnerable communities, such as MSM. Implementation science is a discipline that helps implement scientific research and practices into real-life use.
"Clinician stigma is very prevalent. You might be surprised to learn that it’s not just among doctors—it’s also widespread among medical students," she said.
Addressing stigma is crucial to encourage at-risk individuals to get tested, adopt preventative measures such as Pre-Exposure Prophylaxis (PrEP)—a daily pill that prevents the virus from gaining a foothold—and seek treatment to help contain the spread of the disease. Reducing stigma among healthcare providers is therefore essential and can be effectively achieved through training and audiovisual therapy.
NON-HUMAN INTERVENTIONS
At the same time, at-risk Malaysians need access to assistance without relying on doctors to fully recognise their humanity. In such cases, removing the human element and replacing it with artificial alternatives may prove more effective.
A UM research team led by Dr Rumana is working with researchers at Yale University on an AI Chatbot that promises to provide “culturally-tailored HIV prevention strategies” to increase HIV testing. It is the first time a gen-AI, like ChatGPT, is used specifically to encourage testing, according to a statement from the research team.
"And those who will be participating in the study will download the Chatbot and will get information on MSM-friendly clinics, and links to care. And the Chatbot will be there to answer,” said Dr Rumana, who is also a member of the Centre of Excellence for Research in Infectious Diseases and AIDS (CERIA) at UM.
She said the Chatbot will also provide self-test kits if requested, adding that all data is anonymised. She did not give a release date.
Other than that, there are other mHealth applications to cater to the needs of marginalised groups.
In collaboration with the MoH, the Malaysian AIDS Council (MAC) offers resources on its website, including links for HIV assessments and the option to order or purchase self-test kits through its TestNow initiative. It also developed an app called JomPrEP, designed for MSM and transgender individuals, which focuses on providing PrEP to those who test negative for HIV but engage in high-risk behaviour. Currently, the app is in a testing phase and available exclusively to study participants.
MAC President Assoc Prof Raja Iskandar Raja Azwa said the app, adapted from a mobile health (mHealth) application developed by the University of Connecticut and Yale University, also provides a list of clinics and health facilities that are friendly to MSM and transgender communities.
"Generally for vulnerable populations or populations who are stigmatised, you’ve got to think of extra ways of trying to reach them because they often don't access traditional health facilities and often there's concern that traditional health facilities may not be so welcoming to these populations,” he said.
He said cross-sectional studies have found that almost all MSM use or have access to smartphones, adding 99 per cent of them accessed the Internet daily with smartphones.
UNDERGROUND
Society's reluctance to openly discuss sex has long hindered health authorities' efforts to educate the public and promote condom use as a preventive measure against HIV and other STIs. Additionally, condom usage faces challenges, including low adherence rates.
PrEP, however, proved easier for people to use, making it more effective. A 2024 study by Yong et al. found that it reduced the risk of transmission by over 90 per cent. Despite its effectiveness, PrEP still faced backlash.
Earlier this year, there was some objection to health authorities providing PrEP for free or at cost to at-risk communities, such as MSM and transgender women. Muftis (Islamic legal experts) from Penang and Selangor argued that offering PrEP to everyone who needed it would encourage homosexuality, which is considered against Islamic teachings.
However, the brou-haha seems to have subsided after the Perlis Mufti Department issued a statement supporting the use of PrEP. It emphasised that the risk of HIV spreading unchecked outweighed concerns about the potential misuse of PrEP for engaging in deviant sexual behaviour.
Nevertheless, every single backlash and outrage drives vulnerable communities deeper underground. While online interventions may reach them, members of these communities may not feel comfortable disclosing their sexual or drug habits to the app or their healthcare providers.
Although intravenous drug use now accounts for a small portion of HIV transmissions, drugs remain a significant factor. Instead of using drugs to get high, people abuse amphetamine-type substances (ATS), such as ecstasy, shabu-shabu, yaba, or pilkuda, to enhance their daily routines and sex lives.
Nur Afiqah has observed this trend in the data she reviews, noting that MSM, who typically exhibit higher health-seeking behaviour, are reporting lower-than-expected rates of drug use.
"The MSM group is less likely to discuss drug use due to the significant legal repercussions associated with it. We also have more professionals among MSM, and because of their careers, they have more to lose," she explained.
She said it poses a problem when individuals seeking HIV assistance are unable to disclose their drug use to healthcare providers, noting that the use of ATS can complicate therapy or treatment, potentially interfering with adherence and increasing risky behaviours.
Under Malaysian law, clinicians are obligated to report drug abuse to health authorities. Experts have criticised this law for failing to distinguish between recreational or experimental drug use and addiction.
Only individuals who voluntarily seek rehabilitation are exempt from receiving a criminal record.
Palani Narayanan, Director of Drug Policy at the Malaysian AIDS Foundation, said the crime-and- punishment approach to drug use risks are undermining efforts to combat HIV/AIDS.
"The problem is, when you criminalise drug use, you're also criminalising the person who uses drugs," he said.
"When individuals feel they are criminals and could face police arrest and incarceration, they find it extremely difficult to come forward and seek help."
--BERNAMA
