HIV/AIDS Health care Policy and Practice in Malaysia.

More than 2 decades .it has become a major disease of the developing world. Decimating the continent of Africa and spreading to Asia. Contracted primarily through heterosexual transmission and drug use. Thailandlarge sex industry and proximity to drug supplies fuelled the epidemic throughout 1990s. Public education is the cornerstone of a successful strategy. Educational strategies must be grounded in an understanding of human behavior and how behavior can change. Thailand embarked on campaign to promote 100% condom use. Aimed at educating and treatment of STDs to sex workers. Other countries dominated by moralistic preaching of abstinence from extra marital sex. Education, treatment of STDs and testing strategies could be carried out among this social group. Educating drug users on dangers of sharing needles, teaching them how to sterilize needles and exchanging clean needles for used ones has greater success in stemming the spread of HIV than telling drug users to stop drug abuse or try to scare them with threats of disease and death. This education method was adopted easily by Australia and Europe but slow in Asian countries Wodak 2004. In Malaysiageneral agreement that HIV/AIDS requires the attention of all development agencies of government because political commitment is essential for stemming the epidemic. Spread of HIV /AIDS involves sensitive issues..Sexuality, genderpower, inequality within marriage and sexual activity of unmarried young adults and sex workers.

Political leaders in dilemma take pragmatic approach or agreeing to religious leaders demands in advocating abstinence before marriage and faithfulness of all married couples.

State Policies and Practices with regard to HIV/AIDS prevention and treatment in Malaysia. The epidemic is slower than Thailand. The rate of infection is now exponentially increasing and a major problem.

What has been done the state promotes moralistic messages related to sexual abstinence and zero tolerance of drug abuse. Such an approach is unrealistic and non pragmatic Is a barrier to an effective strategy for stemming the disease.

The HIV/AIDS Epidemic in Malaysia. WHO ands UNAIDS (Joint United Nations Programs on HIV/AIDS) Malaysia considered a country with epidemic concentrated mainly among IV drug users. 2002, 76.3% of cumulative HIV cases and 61.8% of AIDS cases resulted from infection through injecting drug use (MOH 2004). This reflects countrys long standing drug problemattributed nearby the accessibility to the drug distribution region despite the mandatory death sentenced for drug pushers. Estimated that HIV prevalence among general public 0.03 to 0.4% .MOH 2004.

HIV prevalence is also low among antenatal mothers who were tested 0.04 % in 2002. 2001 consensus meeting (of government, non-governmental organizations and university personnel estimated that overall prevalence is 5 % in female sex workers and STD patients in selected urban centers slowly increasing WHO 2003. Heterosexual transmission has risen from 59.3 to 63.9 in all infected women in 2001. First case of HIV in Malaysia 1986, and yearly report of conformed cases of HIV and AIDS is increasing. End of 1990 total HIV infections increased to 992 (778 reported alone in 1990).end of 1995 number detected with HIV almost 6 times the number 5 years previously. Year 2000, 5,107 new infected cases with average 14 per day in 2002...Meaning each day 17.4 new infections. Drug users whom are rounded by the police and government rehabilitation centers and prisoners routinely tested. Part of the increase the infection is due to the introduction of new testing programmes such as testing antenatal mothers a Which begun in 1998 and compulsory testing of Muslim couples before marriage in southern state of Johor in 2001. 90% of the total infected with HIV (93.8%) and AIDS (91.8%) and of total deaths from HIV/AIDS (93.3%) are males. The number of women tested positive each year increased from 2.6% of total HIV infections oin 1993 to 5.0% in 1997 9prior introduction of the testing for antenatal mothers). By ethnicity the majority of those infected are Malays make up the majority of the total population (in 2000, Malays and other Bumiputra constituted 65% of the population). Most people who go for drug rehab are Malays. By ethnicity there is a pattern in the infection .HIV/AIDS transmission Malays and Indians mainly infected by drug users and Chinese likely to visit sex workers)through heterosexual. 80.2 % of those living with virus and 65.9% of AIDS patients are 20 to 39 of age.

Majority of factory workers (4.8%), fisherman (3.7%), long distance drivers (2.5%) and government staff (2.2%).

Summary Epidemic grows in alarming rate. Rate of growth over 2002 and 2003 averaging 18.3 newly detected cases per day for a small country with 25 million populations.

National Commitment and Action MOH entrusted to take action on HIV/AIDS. The MOH with the Malaysian AIDS Council (MAC) represent the nongovernmental sector. Discuss the social, economic, cultural, religious, legislative and all other related issues to the prevention, control and management of HIV/AIDS in Malaysia. National Technical Committee on AIDS which is responsible for the formulation, evaluation and review of all technical aspects of the national HIV/AIDS prevention and control programmes. In addition in each state a state action committee on AIDS chaired by the chief minister with the state health department as its secretariat. These committees plans and coordinate activities at state level. Look at HIV/AIDS as a development issue and this formation of high level inter ministerial committee was a step in the right direction. MOH is also responsible for Flu and SARS

National Strategic Plan. Formulated in 1988 and reviewed in 2001. Both government and NGOs ensure our community lives in a environment with least risk for HIV infection. The objective of the plan is to are set out in broad terms encompassing the mobilization of resources and the promotion of inter agency collaboration while the strategies envisioned and communication, early detection and surveillance as well as the provision of appropriate medical/health services and supportive care at the institutional and community levels.

Efforts to promote and disseminate the plan have been hampered by the lack of resources.In Malaysia official HIV/AIDS activities are overseen by the HIV/AIDS section under the disease control division of the department of public health. In contrast in Thailand recognizing that HIV/AIDS could become a threat to the nation.

Governmental Policies and Programs Educational Programs

1. Prevention main priority through moral values and healthy lifestyle practices. Early detection and prevention of spread through effective 2. Mobilizing community support and participation through special programs and collaborative efforts . 3. HIV/AIDS education in school health education programs and healthy lifestyle program. 4. Most extensive program HIV/AIDS prevention is the Keep healthy without AIDS program for adolescents-Program Sihat Tanpa ADS untuk Remaja or PROSTAR. 5. It trains peer educators who are then expected to train, plan and conduct suitable activities for other young people. 6. 7. 8. 2002 833 PROSTAR clubs in schools and districts as well as in special clubhouses throughout the country.. 928 activities were held reaching 72001 young peopleMOH 2004. Training programs for its own staff to promote safety and reduce stigma in relation to HIV/AIDS.

9. The role of Ministry of Education in the area of HIV/AIDS mainly revolves around the incorporation of information into the school curriculum 10.Training modules incorporating skills approach. This modules cover physical and social development, gender roles, sexually transmitted disease and HIV./AIDS as well as some aspect of sexually and preventive education. Screening and Compulsory Testing

Pre and post testing counseling is available FOC at all government health clinics throughout the country. Compulsory screening is aimed at specific groups-prisoners at 6 months and pre-release., drug rehabilitation centers by National Narcotics Agency of Ministry of Home Affairs and drugs users in police raid. Due to the stigma and discrimination of HIV/AIDS people..Infected individual tend to live underground and escape the compulsory testing. Voluntary screening program.women attending antenatal program. Low knowledge of HIV/AIDS testing there is little pre test counseling. Aim of the program is this screening and compulsory testing program is to detect and treat positive mothers to reduce rate of possibility of infection on their children ad all mothers and babies detected in this program qualify for free highly active antiretroviral therapy (HAART). Testing is expensive. For example in 2002 the MOH tested 359,411 mothers to identify 139 positive cases .If proper counseling testing was carried out and mothers were given a choice there may not be so many test. In Johor the Religious Department carries out compulsory testing before allowing couples to marry. This only applies to Johorean , the other partners from other state need not be tested, rendering the test irrelevant in such cases. Foreign workers are also screened for HIV/AIDS in addition to other diseases, before the Ministry of Human Resources will approve or renew their work permits. Only applied for documented migrant workers, not the illegal immigrants. In 2002, foreign workers made up 2.6% of total HIV/AIDS infection in Malaysia but 2003 this increased to 4.8% only for documented migrants. MOH also carries routine surveillance through collecting data from private and public health facilities. HIV/AIDS is an infectious disease subjected to notification procedures that is medical practitioners are required by law to notify the authorities of all cases that come to their attention and upon notification MOH will conduct epidemiological investigation and partner notification.

Treatment and Management Main objective of MOH to provide comprehensive health and medical care including counseling for those infected with and affected by HIV/AIDS as well as to reduce morbidity and suffering among them. IN Malsyai all treatment of secondary infectiobs is free and available at all government health centres. PEOPLE LIVING WITH HIV/AIDS (PLWHA) need antiretroviral drugs, two antiretroviral (AVR) in the HAART regime (generally consisting of three AVRs) will have to purchase the third one. The drug can also be purchased from India for cheaper rate and still people cannot afford it. This is because once it is started it becomes a monthly expenses. The RM 1200 is reduces to RM 350.In addition they have to pay for various other test from time to time to monitor the viral load in the blood. The final objective of MOH is to incorporate diagnosis and management of HIV into the primary health services but the challenges of training all relevant staff would be enormous.

The Malaysian Code of Practice and Management of HIV/AIDS . DOSH in 2001 developed this code. This code calls companies to have a written policy which clearly states the employers commitment to preventing the spread of the virus and protect HIV positive employees from discrimination and stigmatization at workplace. This includes protection for employment, rights of HIV positive persons to confidentiality and privacy. The code stipulates that disciplinary action be taken against employees who discriminate against HIV positive co workers. 2001, MOH together with DOSH conducted several activities aimed at encouraging the private sector to adopt this codebut very few companies adopted this.

Non government Efforts the MAC

1992, MOH with NGOs initiated formation of the MAC for better collaboration among the NGOsin addressing issues pertaining to community based responses to HIV/AIDS. MAC played a major role in channeling of government funds to NGOs for HIV/AIDS work. To date the council has 37 affiliated members all of whom are NGOs directly or indirectly involved in HIV/AIDS work. The MAC coordinates NGO efforts in order to reduce unnecessary duplication and program overlap as well to ensure program effectiveness. MAC channels funds to NGOs affiliates which mainly conduct educational programs as well as care and support it also conduct its own public education activities focused on where needs are highest. MAC resources centers act as library to provide information for professionalss and young people as well as treatment. It also has pediatric AIDS fund which supports infected and affected children and special loans scheme which provides financing for infected and affected women to expand or start a small business. Most important role MAC has taken is in the area of advocacy. In its capacity of advocating for the rights of PLWHA, it published the Malaysian AIDS charter in 1995.it also played an active part in the development of the Malaysian code of practice for the workplace. MAC through law, ethics and human rights division has fought for the rights of PLWHA and aided in many cases of PLWHA who have lost their jobs. The provision of lifelong medications to women whose statuses were detected at these clinics also resulted directly from the advocacy efforts of the MAC. MAC also pressed upoin sex education in schools and for harm reduction for IV drug users to be officially adopted. Some political leaders attempted to introduce sex education in schools but parents and religious leaders objected to it.

Two Major Challenges: Sex and Drugs. Primary problems surrounding work on HIV/AIDS.prevention revolve around two major taboo subjects: Sex and drugs.

There is an element of denial that these two major subjects have to be confronted in order to deal effectively with HIV/AIDS epidemic. The reluctance has to do with official quarters not wanting to be seen or to run the risk of being construed in any way to be condoning drug abuse or encouraging sexual activity among unmarried persons. Results in unrealistic prevention strategies that do not deal with the facts: that unmarried persons most have sex, that IV drug users will continue injecting with shared needles, and that drug users have sex and will spread the infection to their partners.

Youth and Sex Youth population is increasing and is a challenge as they reach maturity earlier getting married later and exposed to sexual health risk. Social norms remain conservative and state and cultural institutions continue to work on a premise that appears to deny the existence of sexual activity among young people. Studies in school have found that young people do have knowledge about etiology, effcets and causes of HIV/AIDS. But there is glaring omissions such as like using condom as a means of prevention is not often taught for fear of being seen to be promoting sexual promiscuity among the young. 13% of PROSTAR program educators were not able to give accurate answers on condom use which the evaluators attributed to the lack of emphasis given to the messages on sex and the use of condoms. Lack of emphasis on helping young people to develop the skills that enable them to make wise choice. MOH now demands teachers to teach HIV/AIDS .Impart skills to young people. Teachers find this embarrassing and uncomfortable to teach. Although it is imparted in the curriculum it is a big challenge to change mindsets and approaches among teachers. Another challenge by Ministry of education is to provide sexual and reproductive health including HIV/AIDS education early enough to reach those children who will drop out before completing their high school education. Tendency for boys drop out earlier. Boys are more likely to involve in premarital sex than girls.leading to high risk group.

98% of drug users are males and whom did not complete high school.

Drugs and AIDS: the twin epidemic Increase in drug use directly influences the HIV/AIDS epidemics. Cases of HIV increase with the use of drug. The denial syndrome comes to a head when the twin taboos of drugs and sex intersect and this is reflected in the official reluctance not only to make clean needles available but also condom available. Most drug users deny on having active sex partner.

Stigma and Discrimination. Prevalent in Malaysia that not many PLWHA dare to reveal themselves to the public. Also people are aware of the nature of HIV/AIDS still not willing to cooperate to work with PLWHA, share food or utensils with them. This prevents the people PLWHA from seeking further management. Some rejected by family and friends

Care and support for the infected and the affected. More people with HIV develop AIDS care and support is required. Often marginalized. NGOs run PLWHA homes. They have access to free medical treatment for all secondary injections. Fee charges for hospitalization are not high at government hospitals and if individuals can prove to the medical social workers that they are not able to pay fee is waived. Privatization of health care is thus a threat. and it is the recognition of this that Marina Mahathir then the president of MAC to endorse the citizens health manifesto calling for a moratorium on the privatization of healthcare pending a thorough review.

The challenge ahead for state health care services would be the increasing cost of providing adequate medical care to the increasing number of PLWHA. Children becoming orphans by the e epidemic, HIV positive without home, staff of orphanage afraid of being infected and therefore reject them.18000 AIDS orphans have lost one or both parents to HIV/AIDS. Malaysia did not pass the law to protect HIV positive childrens should not be discriminated because this will single them out and this result in public orphanage often refused entry. Not many family adopt children with HIV positive and children whose parents were drug users or sex workers face the most discrimination.