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Put the ‘Key’ in Key Populations

Posted 29 juin 2013, 04:49 , by Guest

By Datuk Dr. Raj Karim, Malaysian AIDS Council President

The global scientific community celebrated the 30th anniversary of the discovery of HIV last May, and we have certainly come a very long way since then. The many scientific breakthroughs in HIV research over the past couple of years hint at the possibility of a functional cure, and now there’s even talk of plausibly ending AIDS by 2050, provided we have the collective political will to achieve universal access to antiretroviral treatment, HIV prevention services and total elimination of mother-to-child transmission.

I couldn’t think of a better way to welcome the 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) to our shores than with such resounding optimism. Civil society actors in the Malaysian HIV response sector are extremely excited to see how these scientific findings will be shared at IAS 2013 and benefit the people who need HIV science the most – key populations!

Malaysia, whose HIV epidemic until recently was predominantly driven by injecting drug use, has been making significant progress in addressing HIV associated vulnerabilities amongst people who inject drugs. Thanks in large part to the introduction of a comprehensive Harm Reduction package of services by the Ministry of Health in 2006, new HIV infections attributed to injecting drug use dropped by a whopping 50% within the short span of four years between 2009 and 2012, and the country’s epidemic in general is experiencing a steady decline in reported annual HIV cases.

I can only imagine what the statistics must mean for the return on investment gained by the Government, the country’s single biggest contributor to the national HIV response, in terms of money saved on the management and treatment of HIV and, more importantly, the number of new HIV infections averted by the Harm Reduction programme. This is something I personally look forward with great anticipation to at IAS 2013, where the research team from the Centre of Excellence for Research in AIDS (CERiA) will be presenting the results of a landmark study looking into the cost-effectiveness of the seven-year-old Harm Reduction programme in Malaysia.

In stark contrast to all this talk of positive return on investment in the Harm Reduction programme for people who inject drugs is the dire need for scientific evidence to inform effective programming for intervention of sexual transmission of HIV. Unprotected sex is the next frontier for the Malaysian HIV response. It accounts for more than 63% of new HIV cases reported last year, twice the percentage it was some five years ago. The situation is just as, if not more, alarming in key populations, with HIV prevalence as high as 13% in men who have sex with men and 4.2% in female sex workers. Looking at the growing number of new HIV infections in women and girls (one in every four in 2012 compared to one in every ten a decade ago), coupled with the fact that young people in their prime, sexually active and of reproductive ages 13–29 made up one-third of all news cases last year, unprotected sex is indeed all around and we can’t afford to turn a blind eye on it! Needless to say, a sexual transmission ‘Harm Reduction’ strategy to address HIV in these key and vulnerable populations is imperative!

Let’s pull the focus back to the original Harm Reduction programme and what made it so successful. The fruit of the Harm Reduction programme’s labour is undeniably a direct reflection of the Government’s commitment to achieving the Millennium Development Goal of reversing the trend of HIV transmission by 2015. But we must also not forget the role of the key population in question – people who inject drugs – in the design, development, implementation and evaluation of the programme. The Harm Reduction programme in Malaysia owes much of its success to the meaningful participation of people who inject drugs who are engaged at every critical level of the process to ensure that the responses are respectful of their human rights and dignity. For there is nothing about them without them!

Key populations are just as crucial as the scientific evidence itself in guiding the response to a particular HIV issue. Many pioneering HIV scientists in the 1980’s acknowledged the unbridled activism and undivided support from communities affected by the sudden outbreak of a then unknown etiology as being the catalytic force behind the discovery of the HIV and the subsequent prevention and treatment sciences.

HIV science in Malaysia is gradually gaining traction. The establishment of CERiA in 2007 has since set into motion the efforts to strengthen our HIV evidence base on key populations through strategic partnerships with the Government and civil society counterparts such as the Malaysian AIDS Council (MAC), which led to the successful implementation of the country’s inaugural Integrated Bio-Behavioural Surveillance in 2009 to study HIV prevalence and risk behaviour of three key populations in the capital city of Kuala Lumpur. This project was a shining example of meaningful engagement of key populations in scientific processes – half of the work force of the project comprised sex workers, people who inject drugs, transgender women, men who have sex with men and people living with HIV, who were trained to administer HIV blood tests and gather quantitative data among others.

As I’m browsing the IAS 2013 programme-at-a-glance page, I could nit help but be amazed at the wealth of knowledge that HIV science has generated and at the same time be reminded of the crying shame if the knowledge is not translated into action. Therefore, enhancing key population’s engagement in and contribution to HIV science is key to ensuring that the knowledge is translated into actions that are sustainable, inclusive and high-impact.

Take for instance Treatment as Prevention, a strategy that would be “taken into serious consideration” by the Ministry of Health. We have the knowledge that starting antiretroviral treatment (ART) early after being infected reduces the risk of transmission to an uninfected partner by 96%, but what we don’t adequately have is a blueprint to create the critical mass that is instrumental in making the strategy work. The success of the Treatment as Prevention strategy relies heavily on early detection of HIV infection, as well as universal access to early ART for all people living with HIV. We all know too well that in spite of HIV testing and treatment infrastructures in Malaysia being readily available, many people at risk of HIV, due to fear of being stigmatized, choose to be in the dark about their HIV status until it is too late.

Ultimately, the game-changers in any given HIV response are the key populations themselves; they hold the key to unlocking the blueprint to which I alluded in the Treatment as Prevention strategy. In the absence of action by key populations, science, in this and many other instances, is alas nothing but a number.

As we look to turn the tide on HIV, one message is becoming increasingly clear: it is time for us to put the ‘key’ in key populations!

Datuk Dr. Raj Karim is the President of Malaysian AIDS Council (MAC), the country’s peak non-governmental organization that serves as a coordinating mechanism for efforts on HIV prevention, treatment, care and support by its 49 Partner Organizations nationwide. MAC works in close partnership with the Centre of Excellence for Research in AIDS (CERiA), University of Malaya – the local co-organizer of IAS 2013 – on numerous HIV-related health behavioural research initiatives and intervention programmes. Learn more at