In October 2014, the Kuala Lumpur AIDS Support Services Society (KLASS) was selected as a sub-recipient under the Global Fund’s new funding model (NFM) to help conduct a new pilot HIV program targeting men who have sex with men (MSM).
Designed to encourage MSM to come forward for HIV screening, the new program addresses a critical gap in the control of a fast-changing epidemic. Initially driven by injected drug use, HIV in Malaysia is increasingly characterized by sexual transmission. As of 2013, sexual transmission accounted for close to three-quarters of all new reported HIV cases, and MSM in particular are becoming infected at alarming rates: between 2010 and 2013, for example, the percentage of new HIV cases in Malaysia attributed to homosexual transmission nearly tripled, rising from 8.2% to 22.3%, according to the Ministry of Health.
HIV prevalence among MSM is also believed to be very high. While an Integrated Bio-Behavioral Surveillance (IBBS) study conducted in 2012 reported a 7.1% prevalence among MSM, data collected by KLASS suggest that as much as a quarter of the MSM community may be positive.
“We’re seeing very high prevalence in this project,” says Reuben Kiew, an outreach worker with the non-profit organization. The KLASS office, a quiet, inviting space in central Kuala Lumpur, serves as a rare refuge for MSM in Malaysia—a place where they can talk openly about health issues and concerns without fear of punishment for violating Sharia law.
“The purpose of the project is to address the fears of the MSM community, which has been reluctant to come forward for testing in government clinics,” says Kiew. The few MSM who do present for testing tend to go to one of several large public hospitals or, if they have the money, he says, to a private provider. But public hospitals are becoming more and more congested, and most MSM can’t afford private care. KLASS, along with another sub-recipient, Intan Life Zone (ILZ), is encouraging MSM to present instead at smaller government-run community clinics, which are usually more conveniently located and can provide services more promptly due to lower patient volumes.
KLASS has been working with three of those community clinics since the start of the project in October 2014, and so far, says Kiew, “things are going very nicely”.
Before engaging clients, KLASS staff met with health workers at the clinics to sensitize them to the specific needs of MSM, including assurances of confidentiality and non-judgmental medical care and support. “We also look at how we can align with the clinics’ work flow,” he says, explaining that another objective of the pilot is to demonstrate the feasibility and effectiveness of collaboration between the community clinics and those organizations, like KLASS, working with at-risk groups.
Using an innovative, client-focused approach to case management, KLASS deploys a single outreach worker to accompany each patient through every step of the continuum of care, from confirmatory diagnosis to enrolment on ARVs and treatment adherence. “We walk the individual through from the beginning until that person has access to treatment and achieves viral load suppression,” says Kiew, who started out at KLASS as a volunteer counselor to clients who had been newly diagnosed. “It’s very labor intensive.”
“Most of the MSM seem to be very happy with the quality of care at the community clinics,” he says. “The doctors and nurses are friendly, and there aren’t long waiting times as compared to the bigger hospitals. So there have been no cases that have defaulted--all of them continue to follow up with treatment.”
Kiew hopes that, together, KLASS and ILZ can generate SOPs for HIV treatment and care at government-run community clinics around the country. “We document everything we encounter in the clinics,” he says.
Still, as Malaysia moves to achieve developed status by 2020, sustainability remains a concern. While approximately 95% of the country’s budget for HIV/AIDS comes from the government, the vast majority of that goes toward care and treatment, including the purchase of ARVs. “The government has demonstrated its commitment, and that’s good,” says Hairudin Masnin, a program officer with UNAIDS. “But what is lacking is the distribution of funds.” Indeed, last year, less than 10% of the national AIDS budget was spent on activities implemented by civil society organizations like KLASS. “They have to also increase their contribution to prevention,” he says. “So far, they have not been able to do this, and that’s where the Global Fund has stepped in.”
AIDS advocates warn, however, that given its low disease burden and relatively high GDP, Malaysia may become ineligible for Global Fund support after 2017, imperiling prevention efforts. Especially vulnerable, they say, are those that target MSM. “We are at high risk of losing funding for this work,” says Joselyn Pang, a project director with the Malaysian AIDS Council (MAC), an umbrella organization of NGOs and civil society groups working on HIV/AIDS issues and principal recipient on Malaysia’s Global Fund grant. Moreover, that work may only be reaching the tip of the iceberg.
“We’ve been focusing on key populations,” notes Masnin, “but we have no data whatsoever on the clients of female sex workers, for example, or the spouses of MSM.” After all, he adds, most of the MSM in Malaysia are bi-sexual, and many of them have female partners, “so it’s easily transmitted to women.” It’s great what the Global Fund has started, he says, “but what will happen after they pull out at the end of 2016? Will there still be a focus on MSM?”
If the nation’s social attitudes are any indicator, the answer may well be No. “It’s increasingly difficult to talk about LGBT issues in Malaysia,” says Pang. “But as sub-recipients of the Global Fund grant, we’re coming from a health perspective. We want MSM to get tested and to be healthy. And with notification rates as high as they are— of notified new cases in Kuala Lumpur and Selangor in 2013, MSM represented 43.3% and 36.1%, respectively—the government and civil society groups need to address this.”
KLASS aims to enroll a total of 556 patients by June 2016, but with just three case workers, the organization can’t hope to keep pace with the growing caseload. “Someone was saying we need a graduation period for clients once they’ve completed the journey from testing to viral load suppression,” says Kiew. “They said, how are you going to manage another 500 cases next year? And the truth is, we don’t know.”