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Malaysia tries to follow Australia's path

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Science  11 Jul 2014:
Vol. 345, Issue 6193, pp. 164-165
DOI: 10.1126/science.345.6193.164

A top researcher and advocate pushes for change.

In 1997, a year after Adeeba Kamarulzaman returned here with a medical degree from Australia and a specialty in infectious diseases, she spoke with the head of the Malaysian AIDS Council (MAC), Marina Mahathir, who was the daughter of the country's prime minister at the time. “I asked her, ‘Do you have needle and syringe programs here?’” Kamarulzaman recalls. It was a pertinent question given that Malaysia had a budding epidemic in people who inject drugs—and Australia had all but derailed HIV with its harm reduction efforts (see p. 156). “She said, ‘Are you kidding? We can barely say the word ‘AIDS.’”

Kamarulzaman set out to change the HIV/AIDS response in Malaysia, a multiethnic country with a Muslim majority that has ultraconservative views on many social issues. “It was clear to me that this was crazy,” Kamarulzaman says. “Patient after patient became infected by drug use and we weren't doing anything about it.”

That's no longer true, thanks in part to her efforts, but Kamarulzaman, dean of the faculty of medicine here at the University of Malaya, still has serious misgivings about her country's approach to its HIV/AIDS epidemic. “We have done all right in terms of getting harm reduction programs off the ground, but even so, I think the coverage is still far from where we should be,” she says. “And the real problems are now with prevention for MSM [men who have sex with men], transgenders, and sex workers. There's almost no kind of nationwide program to make any dent in the epidemic amongst these populations.”

Kamarulzaman, who also attended high school in Australia and speaks English with a slight Aussie accent, is related to Malaysian royalty and can speak her mind with little fear of serious consequences. She continues to do so. “She makes a lot of enemies, particularly in government offices,” says Hisham Hussein, who serves with her on the executive committee of MAC. “I can't see anyone in the country who can speak up like she can without fear or favor. No one. No one.”

Adeeba Kamarulzaman (left) talks the talk and walks the walk.

PHOTO: MALCOLM LINTON

Kamarulzaman has published more than 100 studies of HIV/AIDS in Malaysia that look at everything from harm reduction efforts to the molecular epidemiology of viral spread to the efficacy of new treatments. She also has won passionate supporters in affected communities. “She's my idol,” says Elisha Kor, an HIV-infected transgender woman who runs a program for sex workers at the PT Foundation, a nongovernmental organization (NGO) here that also helps MSM. “She brings a lot of opportunities to Malaysia, and opens the eyes of my government with HIV/AIDS issues.”

Stopping the spread of HIV among injecting drug users was Kamarulzaman's first campaign. In 2003, she received a grant from the U.S. National Institutes of Health that set out to influence drug policy, which then heavily focused on punishment, by gathering comprehensive data about HIV and users who injected—and accounted for 76% of the infections. She also created a harm reduction working group with help from Australian experts. But their data did little to sway the National Anti-Drugs Agency and the police. “It became clear that we were not going to get anywhere until we got the attention of the politicians,” Kamarulzaman says.

In January 2005, she secured a meeting with the Cabinet Committee on Drugs, which later approved a pilot project to convert injecting drug users to methadone. That June, the government, to Kamarulzaman's astonishment, announced it would also allow small-scale needle and syringe exchange. As these efforts grew, the government slowly moved away from a strictly punitive attitude toward drug users to a more compassionate view that they had health issues. Prisons began offering methadone maintenance programs. And in 2010, voluntary “cure and care” centers began to replace compulsory drug rehabilitation centers.

Harm reduction in Malaysia still faces many challenges, including excessively harsh drug laws. (Hanging remains a sentencing option even for marijuana.) The country relies mainly on NGOs to supply needles and syringes. But as Kamarulzaman wrote in a commentary in the 15 June 2013 issue of The Lancet titled “Fighting the HIV epidemic in the Islamic world,” harm reduction advocacy in both Malaysia and Indonesia has succeeded in part because it has emphasized “Islamic values about the preservation of life.”

Those same arguments, however, have not persuaded the government to confront sexual transmission. “It's a little bit more difficult to argue for sex work and MSM along those veins,” she says. Indeed, Shariah law in some states can imprison Malay Muslims for simply cross-dressing.

To Pang Khee Teik, one of the country's few openly gay HIV/AIDS activists, the government's inaction toward the lesbian, gay, bisexual, and transgender (LGBT) community has strong political overtones. In two infamous trials known as Sodomy 1 and Sodomy 2, the government beginning in 1998 prosecuted a former deputy prime minister who was hoping to lead the country, Anwar Ibrahim, for allegedly having sex with men. “They see LGBT as a political force and this has to do with the targeting of Anwar Ibrahim,” Teik says.

The Ministry of Health recognizes the problem; its recent report to the United Nations noted that in relatively small surveys of MSM, HIV prevalence had a “whopping increase from 3.9% to 12.6%” between 2009 and 2012. “New HIV infections via sexual transmission have outnumbered drug injection for the past 3 years,” says MAC's Hussein. “And until today, the government has not done anything new, and they are fully aware of what is happening.”

Kamarulzaman says the government “urgently” needs to address its shortcomings, but she takes the long view, saying, “Given where we were, I guess we have made a good start.”

Kajang Prison offers methadone and specialized HIV care.

PHOTO: MALCOLM LINTON

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