HIV In Key Populations

HIV and Gay and Bisexual Men

  1. Gay, bisexual, and other men who reported male-to-male sexual contact are disproportionately affected by HIV. In Malaysia, there is an estimated population size of 220,000 MSM individuals. Among them, 43.3% know their HIV status and 21.6% have HIV.
  2. Social and structural issues—such as HIV stigma, homophobia, discrimination, poverty, and limited access to high-quality health care, influences health outcomes and continues to drive inequities.

HIV and Youth

  1. More than 70% of new HIV infections were among people aged 20 to 39 years old. Besides, infection  in  children  below  13 years  old has  remained  lower  than  1%. According to the Global AIDS Monitoring 2020 report, children (below the age of 15 years) had a mean estimate of 326 individuals living with HIV, 18 of them were newly infected with HIV in 2019 while there was a total of 4 cases for AIDS-related deaths among this age group.  
  2. Having said so however, youth with HIV are the least likely of any age group to be aware of their infection and have a suppressed viral load. Addressing HIV in youth requires that young people have access to the information and tools they need to make healthy decisions, know their HIV status, reduce their risk for getting HIV, and get treatment and stay in care if they have HIV.

HIV and Sex Work

  1. Female Sex Workers (FSW) had a HIV prevalence of 6.3%. 35.1% were aware of their HIV status while 22.5% had ART coverage. Interestingly, most of them (83.5%) had condom use during their last sex.
  2. According to a recent study, cisgender women sex workers (CWSW) and transgender women sex workers (TWSW) together face an HIV burden 29-fold higher than the Malaysia’s general adult population. Pooled HIV prevalence was high, and was similar for both CWSW (11.1%) and TWSW (12.4%). Both groups reported lifetime HIV testing (62.4%), but CWSW were less likely to have ever been HIV tested (54.5%) than TWSW (74.6%). The coverage of prevention packages among PWID and TG populations have been moderate (50%-70%) as compared to the FSW and MSM populations (less than 50%).

HIV and Transgender People

  1. Sex vs Gender

Sex is assigned at birth, referring to one’s biological status as either male or female, or in simpler words, sex is assigned based on the body structures. Gender refers to how society considers appropriate for boys and men or girls and women.

  2. Terminology

    • According to the American Psychological Association, transgender refers to a term that describes a person’s “gender identity, gender expression or behavior does not conform with the sex to which they were assigned at birth”.
    • Transgender man is where a person is assigned female at birth and identified as a male. Transgender woman is a person who is assigned male at birth and identifies as a female. Cisgender is where a person whose sex is assigned at birth is the same as their gender identity or expression. Gender expression is where a person’s outward presentation of their gender (for example, how they act or dress).Gender identity is where a person’s internal understanding of their own gender.
    • Transgender (TG) in Malaysia had a population size estimate 37,000 and a HIV prevalence of 13.5%. 38.9% were aware of their HIV status while 34.6% had ART coverage. Interestingly, most of them (83.3%) had condom use during their last sex. The coverage of prevention packages among FSW and MSM have been poor (less than 50%). This is probably due to the fact that they are the most hard-to-reach and difficult to identify populations stemming from societal stigma and discrimination.
    • In Malaysia, an estimated 9.7%-12.4% of transgender women (TW) are HIV positive, with higher estimates among those engaged in sex work. Data pertaining to transgender man is still unavailable. An in-depth interview conducted among 35 participants consisting of stakeholders involved in HIV prevention, Ministry of Health, Religious Leaders and People Living with HIV, including transgender women. The study revealed that the situation of transgender women in Malaysia and HIV prevention is a highly sensitive and challenging environment for all stakeholders, given the Muslim context and current legal system.

  3. There are several challenges that place transgender people at higher risk for HIV

Racism, HIV Stigma, and Transphobia

Racism, HIV stigma, and transphobia can negatively impact risk-taking behaviors, knowledge of HIV status, HIV care, and other needed services for many transgender people.

            Lack of Knowledge

When health care providers are not knowledgeable about transgender issues, this can be a barrier for transgender people with HIV who are looking for treatment and care.

Few Multilevel Interventions

Interventions that address the structural, biomedical, and behavioral risks for HIV among transgender women and men are needed to address HIV disparities.

Unmet Need for Gender Affirmation

When transgender people do not feel supported through medical gender affirmation, they are less likely to engage in HIV prevention and care services.

HIV and PWID

  1. People who inject drugs (PWID) remained to be a significant key population with a population size estimate of 75,000 and HIV prevalence of 13.5%. Among them only 38.9% were aware of their HIV status, 34.6% had ART coverage and 25.7% (the lowest rate among the other key populations) had condom used during their last sex.
  2. It is interesting to note that sharing injection paraphernalia is the primary mode of transmission since the epidemic had begun to spread in Malaysia. Malaysia has initiated the Harm Reduction Program that consists of Needle and Syringe Exchange Program (NSEP) and Opioid Substitution Therapy (OST). The OST Program, covered by selected government and private health facilities since 2006 remained to be a positive prevention alternative as it showed an increase to more than 70% since 2017. On the other hand, the NSEP program, a collaborated program between NGOs and the Malaysian AIDS Council (MAC) at their outreach points nationwide had reported a drastic decrease in program coverage of less than 50% since 2017. This is in accordance with the Strategic Plan for Ending AIDS that encourages opioid injectors to shift to OST to ensure better ART uptake.