SECTION OF AIDS/STD, MINISTRY OF HEALTH MALAYSIA. Country Profile Current Status of HIV/AIDS Until October 2002

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1 SECTION OF AIDS/STD, MINISTRY OF HEALTH MALAYSIA Country Profile Current Status of HIV/AIDS Until October 2002 Dr Ahamad b Jusoh Ministry of Health Malaysia

2 PERLIS 1. Kangar PULAU PINANG 1. Timur Laut 2. Barat Daya 3. Seb. Perai Utara 4. Seb. Perai Tengah 5. Seb. Perai Selatan PERAK 1. Hulu Perak 2. Larut Matang Selama 3. Kerian 4. Kuala Kangsar 5. Kinta 6. Manjung 7. Batang Padang 8. Hilir Perak 9. Perak Tengah SELANGOR 1. Hulu Selangor 2. Gombak 3. Petaling 4. Ulu Langat 5. Sabak Bernam 6. Kuala Selangor 7. Kelang 8. Kuala Langat 9. Sepang NEGERI SEMBILAN 1. Seremban 2. Jelebu 3. Port Dickson 4. Kuala Pilah 5. Jempol 6. Tampin / Rembau DISTRICT HEALTH OFFICES IN MALAYSIA 2002 KEDAH 1. Langkawi 2. Kubang Pasu 3. Kota Setar 4. Pendang 5. Yan 6. Kuala Muda 7. Padang Terap 8. Sik 9. Baling 10. Kulim 11. Bandar Baru MELAKA 1. Melaka Tengah 2. Jasin 3. Alor Gajah JOHOR 1. Johor Bahru 2. Kota Tinggi 3. Segamat 4. Muar 5. Batu Pahat 6. Keluang 7. Pontian 8. Mersing PAHANG 1. Pekan 2. Temerloh 3. Bentong 4. Raub 5. Cameron Highlands 6. Lipis 7. Jerantut 8. Kuantan 9. Maran 10. Rompin 11. Bera TERENGGANU 1. Kemaman 2. Dungun 3. Kuala Terengganu 4. Marang 5. Ulu Terengganu 6. Besut 7. Setiu SABAH 1. Kota Kinabalu 2. Panampang 3. Papar 4. Tuaran 5. Ranau 6. Kota Belud 7. Beaufort 8. Kuala Penyu 9. Sipitang 10. Kudat 11. Kota Marudu 12. Pitas 13. Keningau 14. Tambunan 15. Tenom 16. Nabawan 17. Sandakan 18. Labuk & Sagut 19. Kinabatangan 20. Tawau 21. Semporna 22. Kunak 23. Lahad Datu 24. Labuan SARAWAK 1. Kuching 2. Bau 3. Lundu 4. Sri Aman 5. Lubuk Antu 6. Saratok 7. Saribas 8. Kapit 9. Song 10. Belaga 11. Sarikei 12. Bintangor 13. Matu Daro 14. Julau 15. Miri 16. Marudi / Baram 17. Sibu 18. Dalat / Oya 19. Kanowit 20. Mukah 21. Limbang 22. Lawas 23. Bintulu 24. Tatau 25. Kota Samarahan 26. Simunjan 27. Serian KELANTAN 1. Kota Bharu 2. Pasir Mas 3. Tumpat 4. Kuala Krai 5. Gua Musang 6. Machang 7. Pasir Puteh 8. Tanah Merah 9. Jeli 10. Bachok 131 DISTRICTS

3 HIV/AIDS Case Notification Patient MOH HIV97 (Modified) Screen Monthly State AIDS Officer Repeat Sample HIV97 (Modified) HIV97 Confirm ACT 342 HIV97 Notification Investigation Registration

4 Testing Strategy of HIV in Malaysia Since February 1995 Objective of testing Prevalence of infection Testing strategy Transfusion or donation safety All I ( 1 test ) > 10% I Surveillance 10% II ( 2 tests ) Clinical signs or All II symptoms of HIV infection or AIDS Diagnosis > 10% II Asymptomatic 10% III ( 3 tests )

5 HIV TESTING IN MALAYSIA Screening ELISA and particle agglutination (PA) 59 Ministry of Health designated anti-hiv screening centres 31 centres are using the ELISA and PA 28 centres use only PA Rapid Test Kit (mostly for antenatal screening) Supplementary Immunoblot (only at IMR KL) PCR (only at IMR KL and mostly for children less than 18 months of age) Tests currently used in NARL: Screening tests ELISA (Murex) & Particle Agglutination (Serodia) Supplementary tests: Line Immunoassay, W Blot 1 and W Blot 2 Others: Abbott p24 Ag test and PCR CD4 In all 14 states ( 1 each) Viral load NARL + 3 states

6 Working Procedure S p e c i m e n s r e c e i v e d f r o m S p e c i m e n C o u n t e r C h e c k s p e c i m e n s a n d f o r m s r e c e i v e d a r e c o r r e c t D a t e s p e c i m e n s r e c e i v e d i s s t a m p e d o n t h e r e q u e s t f o r m s C h e c k e a c h s p e c i m e n s v o l u m e r e c e i v e d i s e n o u g h f o r t e s t s S p e c i m e n s a n d f o r m s a r e l a b e l l e d w i t h N A R L L a b o r a t o r y R e f e r e n c e N u m b e r S e p a r a t e a n d t r a n s f e r s p e c i m e n s i n t o v i a l s D a t a o f p a t i e n t s / i n d i v i d u a l s r e q u e s t e d f o r t e s t i n g a r e e n t e r e d i n t o c o m p u t e r C h e c k f o r f o l l o w - u p c a s e s P e rfo rm A n ti-h IV te s tin g s a c c o rd in g to ris k g ro u p S tra te g y II S tra te g y III P a e d i a t r i c H I V f o r H i g h R i s k G r o u p f o r L o w - R i s k G r o u p & B l o o d D o n o r E nter tests results into com puter P r e p a r e r e s u l t s f o r s i g n a t u r e D i s p a t c h r e s u l t s t o r e q u e s t i n g c e n t r e s

7 Testing Strategies of HIV Testing Specimens received for Specimens refered from 1 st Line Screening Screening Centres A b b o tt 3 rd G e n E IA A b b o tt 3 rd Gen EIA & Serodia Particle Agglutination Reactive Non-reactive Serodia PA Report as: Negative E IA + / P A + E IA + / P A - E IA - / P A - In High Risk Individuals In Low-Risk Individuals Report as: Negative Report as: HIV-Ab Positive Im m u n o b lo t P o sitiv e N o B a n d s *O th e r B a n d in g P a tte rn s Report: Positive R e p o rt: In d e te rm in a te F u rth e r te s ts : p 2 4 A g, P C R Follow-up 3, 6 months for repeat tests. * = If p24 band is present, only PCR is carried out as supplementary testing.

8 AIDS Case Definition [ EXPANDED WHO CASE DEFINITION FOR AIDS SURVEILLANCE (MODIFIED ABIDJAN) ] For the purpose of epidemiological surveillance, an adult (>12 years of age) is considered to have AIDS if a test for HIV antibody positive results, and one or more of the below are present: 10% body weight loss or cachexia,, with diarrhoea or fever, or both, intermittent or constant, for at least 1 month, not known to be due to a condition unrelated to HIV infection; Cryptococcal meningitis Pulmonary or extra-pulmonary tuberculosis; Kaposi sarcoma Neurological impairment that is sufficient to prevent independent daily activities not known to be due to a condition unrelated to HIV infection (for example, trauma or cerebrovascular accident) Candidiasis of the oesophagus (which may presumptively be diagnosed based on the presence of oral candidiasis accompanied by dysphagia) Clinically diagnosed life-threatening or recurrent episodes of pneumonia, with or without etiological confirmation Invasive cervical cancer

9 HIV/AIDS Situation in Malaysia First case of HIV/AIDS was reported in Malaysia in ,155 HIV cases were reported from Jan-July 2002 vs. 5,938 in 2001 Average number of reported HIV cases per month increase from 494 in 2001 to 593 in Estimated HIV prevalence per 100,000 population increase from 24.9 in 2001 to 26.4 in 2002 Proportion of HIV cases attributed to IDU decreased from 80.5% (2001) to 78.1%(2002), sexual increased from 14.3% to 17.8% and vertical from 0.9% to 1.2%

10 HIV/AIDS Situation in Malaysia A total of 380 mothers were confirmed infected until July 2002 i.e. 1998:56 cases, 1999:89, 2000:85, 2001:79 & 2002:68 Proportion of mothers screened and found infected with HIV (prevalence) were.035% in1998,.032% in 1999,.030% in 2000,.022% in 2001 and.033% in A total of 21,538 prisoners and 4,549 inmates were screened from Jan June this year. 2,117 prisoners and 727 inmates were found infected with HIV. Proportion of infected prisoners were 9.8% (.09% %) and inmates were 15.9% (0% %). A total of 4,530 patients were screened out of 4,647 attendees of PPHIV and 150 were found infected (3.3%).

11 Reported HIV Infection Malaysia, 1986 Oct HIV Cumm '10/02 '01 '00 '99 '98 '97 '96 '95 '94 '93 '92 '91 '90 '89 '88 '87 ' Country Profile: Current HIV/AIDS Situation

12 Reported AIDS Cases Malaysia, 1988 Oct 2002 AIDS Cumm '00 '01 '10/02 Country Profile: Current HIV/AIDS Situation

13 Prevalence Rate/ population of HIV Infection: Malaysia & 2002 (estimate) '86 '87 '88 '89 '90 '01 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 Year

14 Prevalence of HIV Infection Cases by State Per Kdh Prk Png Sel N9 Mlk Jhr Phg Trg Kltn Sbh Srk Mal Rate per 100,000 population Country Profile: Current HIV/AIDS Situation

15 HIV/AIDS CASES BY END OF 2001 By December 2001 (cumulative) HIV : 44,278 AIDS : 6,025 Death : 4,543 In 2001 HIV : 5,938 (the highest number of reported cases since 1986) AIDS : 1,302 Death : 975 The increase of 831 HIV cases (from the year 2000) was due to increase number of cases detected among injecting drug users (+23.8%) and unknown (+13.9%). While cases were mainly among injecting drug users and young people: Increase of HIV infection among women and children through heterosexual transmission Its may signify that the HIV epidemic in this country was spread outside the traditional sub-population i.e. injecting drug users (IDU)

16 MODE OF TRANSMISSION Sharing infected needle by drug addict The most high risk behavior among Malaysian 76.7% of of 36,547 of HIV 62.3% of 4,128 of AIDS Cases infected through sharing of infected needle: Predominantly males (98.6%) Between the age of 20 and 39 years old (78.2%) Malays (80.9%). Heterosexual transmission 5,534 (11.6%) of HIV 1,570 (23.7%) of AIDS Over representation of non-malays in this group (non IDU) compared to National Census Mother to child transmission (MTCT) Increased from 4 cases in 1995 to 57 cases in 2001 Due to an increase awareness of MTC transmission of HIV after an introduction of the program in early 1998.

17 HIV/AIDS BY LAST OCCUPATION Of the 44,278 known last reported occupation 18,442 (41.6%) were of odd-job workers with an estimated income less than RM 1,000 per month 6,439 (14.5%) were unemployed 2,264 (5.1%) were factory workers 1,876 (4.2%) were fishermen 874 (1.9%) were long distance drivers 266 (0.6%) cases were classified as sex-workers HIV AND YOUTH (20-29 yrs old) 17,828 (37.4%) of cumulative In the year ,958 out of 5,938 Increase of 319 cases (19.5%) compared to year 2000 Due to the detection of more HIV infections among IDUs who are mostly young people aged years.

18 HIV & BLOOD DONATION 384,711 blood donor were screened for HIV in (.027%) were infected 27 donors infected in every 100,000 donation. Since the beginning of the epidemic 19 HIV infection due to blood transfusion have been reported to MOH 10 cases occurred before cases were infected outside the country 1 case due to window period 4 cases accidentally acquired the infection in both government and private hospitals.

19 MOBILE POPULATION 1,876 (4.2%) fishermen 874 (1.9%) long distance drivers Of 500,132 foreign (migrant) workers screened in ,264 were medically unfit 1% (91) of those unfit was due to HIV positive.

20 HIV/AIDS & WOMEN Infection among women HIV : 9 cases (1.2%) in 1990 to 466 (7.8%) cases in 2001 AIDS : 0 in 1990 to 114 cases reported in 2001 Most significant after 1997 upon the implementation of HIV screening program among antenatal mothers In the year 2000 Screened 286,390 and 85 (0.03%) were HIV positive In the year 2001 Screened 343,030 and 79 ( 0.023%) were HIV positive. A survey carried out in Kuala Lumpur in 2000 Of 208 sex workers (including transsexuals), an infection rate was 6.94% Of 128 couples with HIV infection in Hospital Kuala Lumpur in 1997 revealed Only 49.2% use condom after knowing partner s HIV status Safe sex were practiced mostly by Chinese (59.2%) followed by Indian (50.0%) then Malays (34.0%).

21 HIV & WOMEN Of 466 HIV infected females Route of infection 12.2% (56 cases) were infected through sharing needle (IDU) 277 (59.4%) were infected through sexual intercourse 23 (4.9%) were babies that were infected vertically 110 cases (23.6%) were not known Age group 38 cases (8.1%) were below 12 years 8 cases (1.7%) were between years 167 cases (35.8%) between years 159 cases (34.1%) between years 74 (15.8%) were above 40 years 14(3.0%) unknown Female 1.4% of reported HIV through IDU 44.3% of reported HIV through heterosexual route

22 INFECTED ANTENATAL Of the 309 mothers detected through antenatal screening program since 1998 till 2001 Age group 63.4% were between the age of 20 to 29 years old 33.8% were between 30 to 39 years old Parity 28.5% of them were in gravida one 24.5% in gravida two Route of infection 97.9% were infected through sexual intercourse 2 cases were infected through sharing needle (IDU) Of 70.4% of the husbands who were detected positive after testing 51.4% of them were infected through sharing needle 36.4% through sexual intercourse 12.2% who denies all risk activities 44.1% of husband refused HIV testing

23 Antenatal Mothers Screened and Detected Positive to HIV Infection : Malaysia , , , , , , ,000 50, Screened 161, , , ,030 Positive % +ve

24 INJECTING DRUG USERS 8 out of every 10 reported HIV infection reported until 2001 were IDU HIV & IDU : 33,919 AIDS & IDU : 3,703 Out of 5,938 HIV cases reported in ,724 or 79.6% were IDUs Drug addicts screened Increased from 19,342 in 2000 to 35,765 inmates in 2001 HIV positive had increased by 43.7% from 2,468 to 3,548 cases Infected inmates decreased from 12.8% in 2000 to 9.9% in 2001 Study of behavioral patterns of 1,950 male drug addicts in 16 drug rehabilitation centers that was conducted in 1998 (detail later) 67% of them were injecting drug users 64% were sexually active of which 90% didn t use condom 390 (20%) were infected 81% shared needles 80% used heroin at an average of 3 injections per day 28% were sexually active

25 HIV Prevalence among injecting and non-injecting drug users, by region: Malaysia Non-IDU IDU North West South East 35.6 % inject 58% 52% 68% 76%

26 HIV Prevalence in Certain Sub-Populations Drug Users 8.25% (ADK Oct. 2001) Injecting Drug Users 19.0% (ADK & MOH 1999) CSW 11.5% (MOH/WHO 2001) Pregnant Women 0.03% (MOH 98-01) Blood Donor % (MOH: samples, 01 ) Long Distant Truck Drivers - 2.7% (MOH : 839 samples, 2001) Factory Workers - 0% (MOH : 3,600 samples, 2001) Fishermen - 1.7% (MOH : 542 samples, 1999)

27 HIV Epidemic States: WHO/UNAIDS 2001 Low level epidemic HIV has never spread to significant level any subpopulation, although HIV infection may have existed for many years (HIV prevalence has not consistently exceed 5% in any defined subpopulation) Concentrated epidemic HIV has spread rapidly in a defined subpopulation but not well-established in general population (HIV prevalence is consistently > 5% in at least one defined subpopulation and is < 1% in pregnant women in urban areas) Generalized epidemic HIV is firmly established in the general population (HIV prevalence is consistently > 1% in pregnant women) Severity

28 Behaviour Surveillance Survey (BSS) Behaviour is a component of 2 nd Generation Surveillance System. 2GSS is new HIV surveillance concept adopted by WHO/UNAIDS. Change in behaviour pattern of high risk population will affect the epidemic e.g. condom uses among CSW, sharing needle among IDU. Repeated behaviour surveys in fix group of sub-population, once a year in 5 sites in Malaysia Kuala Lumpur (CSW,IDU) Penang (CSW,IDU) Johor Bharu (CSW,IDU) Kota Bharu (IDU) Kuching (CSW) Started with a workshop on 13&14 Jan 2003 (1 st ) and (early March 03 2 nd ). Pilot project using WHO budget.

29 DR AHAMAD BIN JUSOH MD MPH Senior Assistant Director (HIV/AIDS Surveillance) Section of AIDS/STD, Division of Disease Control, Department of Public Health, Ministry of Health Malaysia. Tel: Fax: