Abstinence, Not PrEP as the Key Message to Prevent HIV Infection

We would like to draw the attention to the news regarding the plans of the Ministry of Health (MOH) to scale up Pre-exposure prophylaxis (PrEP) usage for the prevention of HIV transmission. PrEP is an oral medicine taken to prevent transmission of HIV via sexual intercourse or intravenous drug use, which will apparently be dispensed at the public health clinics in Selangor, the Klang Valley, Johor, Penang, and Sabah.

PrEP is currently given to HIV-negative people who were at risk of acquiring HIV, such as spouses of people living with HIV (PLHIV). PLHIV are patients who deserve to be protected and should receive the best treatment currently available.

However, the current plan is to scale up PrEP use to 𝗶𝗻𝘃𝗼𝗹𝘃𝗲 𝗵𝗼𝗺𝗼𝘀𝗲𝘅𝘂𝗮𝗹 𝗰𝗼𝘂𝗽𝗹𝗲𝘀 𝘄𝗵𝗼 𝗮𝗿𝗲 𝗛𝗜𝗩 𝗻𝗲𝗴𝗮𝘁𝗶𝘃𝗲, 𝗼𝗿 𝗼𝗻 𝗱𝗲𝗺𝗮𝗻𝗱 𝗳𝗼𝗿 𝗺𝗲𝗻. We strongly urge MOH to review this plan.

We are of the opinion that MOH should advocate strongly on prevention methods, starting with abstinence. Public health messages and advice against practising rectal intercourse should be the mainstay of prevention.

𝗧𝗛𝗘 𝗘𝗖𝗢𝗡𝗢𝗠𝗜𝗖𝗔𝗟𝗟𝗬 𝗘𝗫𝗢𝗥𝗕𝗜𝗧𝗔𝗡𝗧 𝗘𝗫𝗣𝗘𝗡𝗦𝗘 𝗢𝗙 𝗣𝗿𝗘𝗣

“Prevention is better than cure” is the old adage in medicine which is founded not only on common sense and wisdom, but also from an angle of national economic and comprehensive social policy.

It is not the case that pharmaceutical prophylactic measures are not effective or do not reduce healthcare costs.

However, this is only true for a one-off or interventions with minimal frequency via medicine or vaccines. For example the BCG vaccine is very cost-effective against tuberculosis, as were the COVID-19 vaccines against COVID-19 infections.

PrEP on the other hand, will require men who have sex with men (MSM) to take the medication daily as they are described as “those who are likely to have frequent exposures”. Considering that most MSM are young, this strategy will not only disrupt the moral fabric of our society, but economically it is an exorbitant expense.

Tax-payers money will be channelled to enable high-risk-behaviour to continue which can be prevented provided they are given the right motivation from the aspects of health and morality.

Rather than encouraging rectal intercourse via the usage of PreP daily, the funds for PreP would be much better utilized for diseases which are not related to degenerate behaviour such as congenital diseases or non-communicable diseases (NCD).

𝗦𝗧𝗜𝗙𝗟𝗜𝗡𝗚 𝗧𝗛𝗘 𝗙𝗥𝗘𝗘𝗗𝗢𝗠 𝗢𝗙 𝗢𝗣𝗜𝗡𝗜𝗢𝗡 𝗢𝗙 𝗥𝗘𝗟𝗜𝗚𝗜𝗢𝗨𝗦 𝗔𝗨𝗧𝗛𝗢𝗥𝗜𝗧𝗜𝗘𝗦 𝗜𝗡 𝗧𝗛𝗘𝗜𝗥 𝗥𝗘𝗦𝗣𝗘𝗖𝗧𝗜𝗩𝗘 𝗗𝗢𝗠𝗔𝗜𝗡

Incidentally, we also regret that religious approaches in motivating people to leave this high-risk behaviour continues to be criticised and condemned. Any advice to uphold morality coming from religious personnel is openly denounced, as the case recently where the Malaysian AIDS Council (MAC) had condemned a religious scholar for making ‘disparaging remarks and hate speech’. Ironically the public were not informed of the exact details being regarded as hate-speech.

This current atmosphere stifles the freedom of expression and opinion of religious authorities in HIV-related matters. This encroachment on free speech and religious freedom will result in one which has transpired in our neighbouring country, Singapore. The Singapore government recently decriminalised homosexuality, a law which the Christians and Muslims there insisted was needed to protect families, the institution of marriage, children and freedom. The religious communities there have been relatively restrained in the face of an intolerant, vocal minority that seeks to overturn the order in all areas of society – be it marriage, education, businesses, or beliefs, while demonising all those who disagree as “bigots” or “haters”.

This is similar to what many religious preachers and institutions in Malaysia are currently facing.

The medical fraternity cannot allow this ideology which attacks traditional family institution to run rampant here. Not only does it destroy the building blocks of a society, but it also flies in the face of the most recent data from the UNAIDS report which showed that the MSM population continues to increase in its over representation of new diagnoses. It is important not to conflate the efficacy of the message with the persuasiveness of the messenger.

Abstinence and fidelity must not be condemned pejoratively by the medical profession as it is still the primary mainstay of prevention even by the standards of the US based Centre for Disease Control (CDC) and WHO.

World Health Organisation (WHO) defines health as a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity. So our treatment must be holistic and not only focused on disease only.

It defies logic that healthcare personnel have to enable the proliferation of a high risk behaviour when we should be trying to stop it. As an analogy, let’s consider for a moment other unhealthy behaviours such as smoking or eating sugary food. The CDC estimates that every day in the USA more than 3200 people younger than 18 years old smoke their first cigarette. Furthermore, every day approximately 2100 youths and young adults who have been occasional smokers become daily cigarette smokers.

However, the primary message from the CDC is single-minded, uncompromising, and unequivocal that smoking kills and smoking cessation results in substantial health benefits. Even though this message has been shown not to dissuade the annual 1·2 million new smokers, it could never be justified for medical personnel to abdicate our professional responsibility to highlight behaviour and practices that are high risk and should be stopped. The same would apply to diet, exercise, and sexuality. A sequitur from the logic of the current stance would be that doctors telling people that doughnuts and high-sugar drinks are unhealthy does not deter people from eating such foods, so doctors should abstain from promoting this message as a core aim in healthy eating. This clearly does not make sense and there is no reason why we should single out and treat the high-risk behaviour of rectal intercourse any differently to other high-risk behaviours.

Abstinence
Abstinence
Abstinence

…Is the only key message that we should repeatedly promote to prevent HIV infection among the MSM.

This is a joint statement by :

𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗼𝗿 𝗗𝗿 𝗥𝗮𝗳𝗶𝗱𝗮𝗵 𝗛𝗮𝗻𝗶𝗺 𝗠𝗼𝗸𝗵𝘁𝗮𝗿
Professor in Gender and Cardiovascular Physiology ,
Faculty of Medicine and Health Sciences
Universiti Sains Islam Malaysia (USIM)

𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗼𝗿 𝗗𝗿 𝗦𝗮𝗺𝘀𝘂𝗹 𝗯𝗶𝗻 𝗗𝗿𝗮𝗺𝗮𝗻
Professor of Family Medicine & Consultant Family Medicine Specialist
Gender Dysphoria Flagship Leader, Kulliyyah of Medicine
Deputy Campus Director, Office of Campus Director , Kuantan
International Islamic University Malaysia (IIUM)

𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗼𝗿 𝗗𝗿 𝗔𝗻𝗶𝘀 𝗦𝗮𝗳𝘂𝗿𝗮 𝗥𝗮𝗺𝗹𝗶
Professor of Family Medicine & Consultant Family Medicine Specialist,
Deputy Director & Principal Fellow of I-PPerForM, Research Centre of Excellence in Atherosclerosis & CVD Prevention,
Universiti Teknologi MARA (UiTM)

𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗼𝗿 𝗗𝗿. 𝗛𝗮𝗿𝗺𝘆 𝗯𝗶𝗻 𝗠𝗼𝗵𝗮𝗺𝗲𝗱 𝗬𝘂𝘀𝗼𝗳
Dean of Faculty of Medicine
Professor of Family Medicine & Consultant Family Medicine Specialist
Universiti Sultan Zainal Abidin (UniSZA)

𝗔𝘀𝘀𝗼𝗰𝗶𝗮𝘁𝗲 𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗼𝗿 𝗗𝗿 𝗥𝗼𝘀𝗲𝗱𝗶𝗮𝗻𝗶 𝗠𝘂𝗵𝗮𝗺𝗮𝗱
Associate Professor and
Consultant of Family Medicine Specialist, Women and Sexual Health.
Universiti Sains Malaysia (USM)
and
Chairman of Asia Oceania Federation for Sexology.

𝗔𝘀𝘀𝗼𝗰𝗶𝗮𝘁𝗲 𝗣𝗿𝗼𝗳𝗲𝘀𝘀𝗼𝗿 𝗗𝗿. 𝗔𝗻𝗶 𝗔𝗺𝗲𝗹𝗶𝗮 𝗗𝗮𝘁𝗼 𝗭𝗮𝗶𝗻𝘂𝗱𝗱𝗶𝗻
Associate Professor in Obstetrics & Gynaecology
Consultant Paediatric & Adolescent Gynaecologist with Special Interest in Differences of Sex Development
Faculty of Medicine
Universiti Kebangsaan Malaysia (UKM)