Dr Nur Afiqah Mohd Salleh sat quietly in a bustling café, her thoughts circling a pressing question: Is Malaysia prepared to engage in an open conversation about sex and related issues beyond the narrow focus on abstinence to prevent HIV/AIDS?

The senior lecturer at Universiti Malaya and member of the Malaysian AIDS Council (MAC) has witnessed firsthand how the country’s conservative cultural stance on sexuality complicates efforts to address the evolving HIV crisis.

She shared with Bernama her concerns about the alarming discussions happening among Malaysian youth on WhatsApp groups. “I have seen these conversations where young people exchange sex tips, including heterosexual, bisexual, and homosexual encounters, alongside drug use like amphetamines to enhance sexual experiences,” she said, visibly unsettled.

These online exchanges reveal a hidden reality: unsafe sexual practices continue unchecked among youths, despite abstinence-based education remaining the official narrative.

The statistics reinforce this troubling picture. In 2020, surveys indicated that 77.4% of Malaysians lacked adequate knowledge about HIV/AIDS. This gap is particularly dangerous considering that sexual transmission has overtaken intravenous drug use (IDU) as the leading cause of new infections.

Since 2010, sexual contact accounted for nearly half of new HIV cases, rising sharply to 96% by 2022. The shift correlates with Malaysia’s harm reduction policies introduced in 2005 aimed at curbing needle-sharing among drug users—an area where progress has been more visible.

However, sexual transmission prevention lags behind. Public health campaigns typically stress abstinence and morality over practical safe sex advice. Vulnerable groups—men who have sex with men (MSM), transgender individuals, sex workers—are often marginalised or ignored. In 2022 alone, 60% of sexually transmitted HIV cases involved homosexual or bisexual relations. Cultural taboos surrounding sex stifle open discussion and deepen stigma.

Nisha Ayub, a trans activist who has worked since 2006 to provide HIV/AIDS information to sex workers and transgender communities in Kuala Lumpur, described the challenge candidly: “Sex is still taboo in society. HIV/AIDS is labelled a ‘moral disease’, which fuels discrimination.” Despite government promises to combat stigma, data from the Ministry of Health (MOH) paints a grim picture. Half of respondents in a 2022 survey admitted they would avoid buying food from someone with HIV; 45% opposed children with HIV attending school with their peers.

This stigma extends within healthcare settings. Dr Rumana Akhter Saifi from Universiti Malaya’s Social and Preventive Medicine Department highlighted that prejudice against people living with HIV—especially MSM—is common even among medical students and clinicians. Such attitudes deter at-risk individuals from testing, accessing preventive measures like Pre-Exposure Prophylaxis (PrEP), or seeking treatment. Reducing stigma among healthcare providers is crucial and can be addressed through targeted training and audiovisual therapy.

Technological innovation offers a way to circumvent barriers created by stigma and societal judgement. Dr Rumana’s team at UM collaborates with Yale University to develop an AI chatbot designed to promote HIV prevention strategies tailored to Malaysian culture. This chatbot provides anonymous information on MSM-friendly clinics, encourages testing, and offers self-test kits for HIV. It represents a pioneering use of generative AI in public health outreach within the country.

Beyond the chatbot, mHealth applications are gaining traction. The MAC’s “TestNow” initiative allows users to order self-test kits online, while the “JomPrEP” app targets MSM and transgender users by facilitating access to PrEP and listing supportive healthcare facilities. These digital tools acknowledge that vulnerable populations often avoid traditional healthcare settings due to fear of discrimination.

Despite these advances, societal reluctance to discuss sex openly continues to hamper efforts. Condom use remains low partly because of lack of education and partly due to stigma. PrEP shows promise as a more user-friendly preventive option; a 2024 study reported it reduces HIV transmission risk by over 90%.

Yet, the programme has faced opposition from religious leaders who argue that providing PrEP encourages behaviours contrary to Islamic teachings. The controversy eased somewhat after the Perlis Mufti Department supported PrEP use, citing the greater risk posed by unchecked HIV spread.

The backlash against harm reduction strategies drives vulnerable groups further underground. Members may hesitate to disclose sensitive information about their sexual practices or drug use even when using anonymous apps or consulting healthcare providers.

This reluctance is compounded by Malaysia’s drug laws which mandate that clinicians report substance abuse cases to authorities. The legal environment fails to differentiate between addiction and experimental or recreational drug use, discouraging people who need help from seeking it.

Amphetamine-type substances (ATS)—including ecstasy and methamphetamine variants such as shabu-shabu and yaba—are increasingly abused not necessarily for intoxication but to enhance sexual experiences and daily routines. Nur Afiqah noted that MSM populations tend to under-report drug use due to legal risks and professional consequences, complicating treatment adherence and increasing risky behaviours.

Palani Narayanan of the Malaysian AIDS Foundation criticised the criminalisation approach for drug users, warning it undermines HIV prevention efforts by forcing those at risk into hiding. When people fear arrest or imprisonment, they avoid health services altogether.

Malaysia’s experience reveals complex challenges in confronting HIV/AIDS beyond abstinence messaging. The shift toward sexual transmission demands frank public discussion and inclusive education that respects diverse identities and behaviours without moral judgement. Technology offers promising avenues for reaching marginalised communities discreetly, though legal and societal barriers remain formidable.

Efforts must continue on multiple fronts: improving knowledge about HIV/AIDS across all segments of society; reducing stigma within healthcare; expanding access to preventive tools like PrEP; reforming punitive drug policies; and fostering safe spaces for open dialogue on sex and sexuality.

Malaysia stands at a crossroads. The question Dr Nur Afiqah Mohd Salleh pondered in that café is not merely academic—it reflects a national challenge needing courage, compassion, and pragmatic public health strategies to turn the tide against HIV/AIDS.

This article is adapted from the article originally published in The Malaysian Reserve