Malta was declared as the country with the highest rate of HIV diagnoses within the EU/EEA. An overwhelming rate of 15.9 per 100,000 has been reported in the 2021 HIV/AIDS surveillance in Europe, published by the European Centre for Disease Prevention and Control (ECDC) and the World Health Organisation Regional Office for Europe. Since 2011, rates of HIV diagnoses have more than doubled locally.
HIV is a viral infection caused by Human Immunodeficiency Virus. Once inside the body it attacks the immune system cells and replicates by gradually impairing the typical immune cell functioning. When left untreated, HIV can weaken the immune response over time and develops into AIDS ( Acquired Immune Deficiency Syndrome). At this stage, the body becomes vulnerable to what is called opportunistic infections; infections that occur more frequently when the immune system is damaged. These include various skin and lung infections, as well as different types of tumours and cancers. These infections can cause long term health problems or even be life threatening. With the current available treatment options, the development of AIDS can be prevented.
Despite the current situation in Malta with regards to the HIV pandemic, changes made to improve our local sexual health policy, free access to pre-exposure prophylaxis and adequate access to HIV testing have not been observed, explained Dr Mark Josef Rapa, a Lecturer in Bioethics at the University of Manchester, and the Founder of PrEPingMalta and member of the European AIDS Treatment Group (EATG). Dr Rapa was interviewed about HIV in Malta.
What are the main reasons for the high rate of HIV diagnoses in Malta?
Dr Rapa explained that the most obvious reason for the high rate of diagnoses in Malta is due to the poor access to effective prevention tools. “Condoms are not the most effective HIV prevention method; PrEP is, and PrEP is not easily accessible” they remarked. PrEP refers to Pre-Exposure Prophylaxis; a combination of two drugs in a single pill that is used to prevent HIV negative individuals from acquiring the virus.
“Nevertheless, this is not sufficient an explanation. One must dig deeper and look at the level of awareness around HIV and HIV prevention and sexual health at large.” Furthermore, Dr Rapa shed light on “the poor sexual health education we have received, and the non-existent sexual health policy” and argues that these are two factors that contribute largely to the high rate of diagnoses.
“We also need to be asking ourselves how we talk about sex. Are we sex-positive or do we still see having sex as something dirty and shameful? It is evident that there is an element of shame that people experience when considering going for a test; some even experience shame when having sex. Of course, this is not made any better by the lack of sexual health campaigns.”
Misconceptions about HIV.
HIV is heavily stigmatised, which contributes to the misconceptions that many have concerning the consequences of infection and it’s acquisition. Unfortunately, HIV stigma may also result in discrimination of individuals with HIV. Dr Rapa emphasised that “these misconceptions are not only stigmatising people living with HIV, but are also preventing people from getting tested out of fear, and/or lead some to think that they could not be at risk of acquiring HIV.”
While there are several dangerous beliefs about HIV, they explicitly listed the following as ones which are most prevalent locally:
1. HIV is a death sentence.
“While there is no cure for HIV, those on treatment go on to live a long and healthy life.”
2. Engaging sexually with someone living with HIV automatically means that you are going to acquire HIV.
“People living with HIV can get the virus to an undetectable level by taking Anti-retroviral therapy. An undetectable level means that the virus is untransmittable (U=U). In other words, you cannot acquire HIV if you have sex with a person living with HIV who is on treatment with undetectable viral load.”
3. HIV is only prevalent in men who have sex with men (MSM).
“There is an inherently dangerous misconception that only MSM who engage in high-risk activities or have multiple partners can acquire HIV. This is not the case. HIV is not Santa. It does not care if you have been naughty or nice. It’s a virus. It is transmitted through the exchange of bodily fluids during anal or vaginal sex, sharing of needles, during pregnancy and breastfeeding. It’s worth mentioning that, globally, over 50% of the people living with HIV are women.”
How to reduce the risk of becoming infected with HIV.
To reduce the risk of acquiring HIV, Dr Rapa recommended the use of condoms, taking PrEP, or both. They stated that “PrEP reduces the risk of acquiring HIV by over 99%. Condoms are also highly effective and also prevent other Sexually Transmitted Infections.”
PrEP may be taken daily or on demand as necessary by men, women, transgender people and injecting drug users. It’s use is dependent on how frequently the individual engages in sexual activity.
Further information about PrEP and how to access it in Malta can be obtained from: www.hivmalta.com / www.prepingmalta.com / www.sexualhealth.gov.mt
Getting tested for HIV.
Dr Rapa advocated for testing once a year as a “good sexual health practice for anyone sexually active. A person who has more than one sexual partner may consider getting tested more often.” They continued with the suggestion of testing every three months in the case that one is “having sex without condoms with new or casual partners.”
There are a variety of options to choose from for HIV testing in Malta. Dr Rapa listed the GU clinic, where a full sexual health screening is provided free of charge and certain private clinics in which similar testing services are offered. Additionally, they mentioned that HIV self-testing kits may also be purchased from pharmacies.
“Those who are worried that they have been recently exposed to HIV (within the last 72 hours) should immediately call the GU clinic or go to the Emergency on the weekend. For anyone possibly exposed to HIV, within the first 72 hours from exposure access, there is the possibility of taking Post-Exposure Prophylaxis (PEP); a one month treatment that can stop the virus from taking hold”, they stated.
If you do not know your HIV status, or wish to get tested for HIV in Malta, an appointment for testing may be booked at the GU clinic by contacting 25457494.
HIV positive individuals.
Dr Rapa recommended that anyone who is HIV positive to talk to HIV/Infectious disease consultants to discuss treatment options. “With the current treatment options, people living with HIV have the same life expectancy and quality of life of people who are HIV negative. Adhering to treatment prevents one’s health from deteriorating while eliminating sexual and mother to child transmission by lowering the amount of virus in the body. When the amount of virus in the blood becomes undetectable transmitting HIV through sex is not possible”, they advised.
For those who are undergoing treatment for HIV currently, it is heavily encouraged that any dissatisfaction with the current treatment should be brought up at their next appointment. “Together with the clinician, navigate other treatment regiments”, Dr Rapa suggested.
Treatment options for HIV in Malta.
As of the beginning of 2021, Malta has been offering what is referred to as ‘gold standard treatment’ for HIV. Dr Rapa described these treatments as consisting of “a single pill a day rather than a combination of pills”. They emphasised that “patients who are still receiving older treatment regimens should get in touch with their HIV clinician and ask about what other treatments they can get on”
What efforts can be made to reduce the rate of infections locally?
Dr Rapa is an advocate for an updated sexual health policy, stating that “we have been promised an updated sexual health policy for a long time now”; this will have a great impact on the reduction of the rate of HIV spread. In the interim, they suggested that “measures are introduced that can be fully incorporated in the policy once published. One of these measures would be making PrEP available for free. We know that where PrEP has been introduced and made free, the number of new HIV cases dropped dramatically.” Although PrEP is offered in Malta, Dr Rapa protested that “is sold against a prescription for 57 Euros; a price tag too high for the many who may benefit from taking PrEP to reduce the risk of acquiring HIV.”
Other measures that may be introduced, they continued, are to “include provision of free condoms to people at high risk, including young adults of 16 and older.” Dr Rapa insisted that it is of paramount importance that, along with this, there is the provision of “comprehensive sexual health education that is inclusive of the diverse population it is targeting. Anything other than that would not get us far.”
Written by Bettina Zammit