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Linkage studies have reported high rates of previously unascertained mortality among people living with HIV (PLHIV) who have been lost to follow-up (LTFU). We assessed survival outcomes among PLHIV who were LTFU in Thailand and Malaysia, through linkages to a national death registry or HIV database.Data linkages with the national death registry or national HIV database were conducted in 2020 on all PLHIV who met LTFU criteria while enrolled in care at participating HIV clinical sites. LTFU was defined as having no documented clinical contact in the previous year, excluding transfers and deaths. Survival time was analyzed using the Cox regression, stratified by site.Data linkages were performed for 489 PLHIV who had been LTFU at sites in Malaysia (n = 2) and Thailand (n = 4). There were 151 (31%) deaths after being LTFU; the mortality rate was 4.89 per 100 person-years. Risk factors for mortality after being LTFU were older age [41-50 years: hazard ratio (HR) = 1.99, 95% confidence interval (CI): 1.08 to 3.68; and older than 50 years: HR = 4.93, 95% CI: 2.63 to 9.22; vs. age 30 years or younger]; receiving NRTI + PI (HR = 1.87, 95% CI: 1.22 to 2.85 vs. NRTI + NNRTI); positive hepatitis C antibody (HR = 2.25, 95% CI: 1.40 to 3.62); and having previous AIDS illness (HR = 1.45, 95% CI: 1.03 to 2.05). An improved survival was seen with a higher CD4 count (CD4 351-500 cells/µL: HR = 0.40, 95%CI: 0.21-0.76; and CD4gt;500 cells/µL: HR = 0.43, 95%CI: 0.25-0.75; vs. CD4 ≤200 cells/µL).Almost one-third of PLHIV who were LTFU in this cohort had died while out of care, emphasizing the importance of efforts to reengage PLHIV after they have been LTFU and ensure they have access to ongoing ART.

Background This study estimates prevalence of depression and anxiety among adults living with Human Immunodeficiency Virus (HIV) in University Malaya Medical Centre (UMMC) and determines its associated factors. Methods This cross-sectional study was conducted between August 2020 and January 2021, in the Infectious Disease clinic and ward. One hundred ninety-one patients were recruited via convenience sampling. Patients’ sociodemographic were obtained, followed by Depression, Anxiety, Stress Scale -21 (DASS-21), Multidimensional Scale of Perceived Social Support (MSPSS), and M.I.N.I. international neuropsychiatric interview (M.I.N.I.) The cut off DASS-21 point for depression is ≥5, for anxiety, ≥ 4. Mann-Whitney U and Chi square test were used to analyse the association between variables, and logistic regression to find predictability. Results Of the 191 participants, 89.5% outpatient, mean age 40 years (SD 0.742), 91.1% male, 65.4% single, 71.2% working, 46.1% Malaysian Chinese, 59.8% non- heterosexual, mean 6 years of being HIV positive; mean CD4 count 449/μL; mean viral load 116,690 (median = 20). 85.9% were taking antiretroviral therapy. The prevalence of depression was 35.1% ( n = 67); anxiety was 42.9% ( n = 82). Regression analysis revealed anxiety and stress increased odds of depression by 3.8 times ( p = .001) and 12 times ( p < .001) respectively. Those 40 years old and younger had 2.3 times odds of anxiety ( p = .048). Increased social support from friends increased odds of anxiety by 1.7 times ( p = .018). Depression and stress increased odds of anxiety by 4.4 times ( p = .001) and 3.7 times ( p = .008) respectively. Conclusions Depression and anxiety among people with HIV is often under-recognised. Early identification and treatment of the mental illness is warranted. Screening with DASS-21 is useful to detect depression in patients with HIV.

An estimated 37,000 cisgender and transgender women work as sex workers in Malaysia, a population that has been disproportionately affected by the HIV epidemic. Although Malaysia provides no-cost antiretroviral therapy (ART) to people with HIV, little is known about sex workers' engagement in the HIV care continuum. We analyzed data from 57 HIV-infected cisgender women (n = 33) and transgender women (n = 24) sex workers from a respondent-driven sampling study on HIV prevalence among sex workers in Kuala Lumpur, Malaysia. We examined the proportion of women who were newly diagnosed with HIV, had a baseline CD-4 count test, were initiated and retained on antiretroviral treatment (ART). Overall, only 26.3% had ever been HIV tested and almost 60% were newly diagnosed. Only a small proportion of cisgender (15.2%) and transgender (12.5%) women were currently taking ART. Interventions to enhance sex workers' engagement in the HIV care continuum are urgently needed. Deployment of evidence-based strategies to improve linkage and retention in HIV care should be adapted to address the unique needs of this important key population.

Background: Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy; yet, uptake remains low among Malaysian MSM, who have a limited understanding of barriers to PrEP. Methods: We employed the nominal group technique (NGT), a structured mixed-methods strategy to understand the barriers and facilitators to PrEP use among Malaysian MSM, combined with a qualitative focus group. Six virtual focus group sessions, three among MSM (n = 20) and three among stakeholders (n = 16), were conducted using a video-conferencing platform. Rank-ordering of barriers from NGT was recorded, and thematic analysis was conducted for content. Results: Similar barriers were reported by MSM and community stakeholders, with aggregated costs associated with PrEP care (e.g., consultation with a clinician, medication, laboratory testing) being the greatest barrier, followed by limited knowledge and awareness of PrEP. Additionally, the lack of access to PrEP providers, the complex clinical protocol for PrEP initiation and follow-up, and social stigma undermined PrEP delivery. Qualitative discussions identified potential new strategies to overcome these barriers, including expanded outreach efforts to reach hard-to-reach MSM, a ‘one-stop’ delivery model for PrEP services, a patient-centered decision aid to guide PrEP uptake, and easy access to LGBT-friendly PrEP providers. Conclusion: Current barriers may be overcome through governmental subsidy for PrEP and evidence-informed shared decision aids to support both MSM and PrEP providers.

Non-Asian body mass index (BMI) classifications are commonly used as a risk factor for high fasting blood glucose (FBG). We investigated the incidence and factors associated with high FBG among people living with HIV in the Asia-Pacific region, using a World Health Organization BMI classification specific to Asian populations.This study included people living with HIV enrolled in a longitudinal cohort study from 2003 to 2019, receiving antiretroviral therapy (ART), and without prior tuberculosis. BMI at ART initiation was categorized using Asian BMI classifications: underweight (18.5 kg/mA total of 3939 people living with HIV (63% male) were included. In total, 50% had a BMI in the normal weight range, 23% were underweight, 13% were overweight, and 14% were obese. Median age at ART initiation was 34 years (interquartile range 29-41). Overall, 8% had a high FBG, with an incidence rate of 1.14 per 100 person-years. Factors associated with an increased hazard of high FBG included being obese (≥25 kg/mPeople living with HIV with BMI25 kg/m

Background: Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset. Methods: In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min. Findings: We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22–1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68–4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00–89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44–11·20) and less than 60 mL/min (aHR 20·83, 12·83–33·82). Interpretation: RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use. Funding: Unitaid, Bill & Melinda Gates Foundation, WHO.

Objectives We investigated weight changes following antiretroviral therapy (ART) initiation, the development of metabolic syndrome (MetS) and its association with all-cause mortality among Asian adults living with HIV. Methods Participants enrolled in a regional Asian HIV-infected cohort with weight and height measurements at ART initiation were eligible for inclusion in the analysis. Factors associated with weight changes and incident MetS (according to the International Diabetic Federation (IDF) definition) were analysed using linear mixed models and Cox regression, respectively. Competing-risk regression models were used to investigate the association of MetS with all-cause mortality. Results Among 4931 people living with HIV (PLWH), 66% were male. At ART initiation, the median age was 34 [interquartile range (IQR) 29-41] years, and the median (IQR) weight and body mass index (BMI) were 55 (48-63) kg and 20.5 (18.4-22.9) kg/m2 , respectively. At 1, 2 and 3 years of ART, overall mean (± standard deviation) weight gain was 2.2 (±5.3), 3.0 (±6.2) and 3.7 (±6.5) kg, respectively. Participants with baseline CD4 count ≤ 200 cells/µL [weight difference (diff) = 2.2 kg; 95% confidence interval (CI) 1.9-2.5 kg] and baseline HIV RNA ≥ 100 000 HIV-1 RNA copies/mL (diff = 0.6 kg; 95% CI 0.2-1.0 kg), and those starting with integrase strand transfer inhibitor (INSTI)-based ART (diff = 2.1 kg; 95% CI 0.7-3.5 kg vs. nonnucleoside reverse transcriptase inhibitors) had greater weight gain. After exclusion of those with abnormal baseline levels of MetS components, 295/3503 had incident MetS [1.18 (95% CI 1.05-1.32)/100 person-years (PY)]. The mortality rate was 0.7 (95% CI 0.6-0.8)/100 PY. MetS was not significantly associated with all-cause mortality in the adjusted model (P = 0.236). Conclusions Weight gain after ART initiation was significantly higher among those initiating ART with lower CD4 count, higher HIV RNA and an INSTI-based regimen after controlling for baseline BMI. Greater efforts to identify and manage MetS among PLWH are needed.

BACKGROUND HIV disproportionately affects men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, including in health care settings, mobile health (mHealth) platforms have the potential to open new frontiers in HIV prevention. OBJECTIVE We developed an innovative, clinic-integrated smartphone app called JomPrEP, which provides a virtual platform for Malaysian MSM to engage in HIV prevention services. In collaboration with the local clinics in Malaysia, JomPrEP offers a range of HIV prevention (ie, HIV testing and pre-exposure prophylaxis [PrEP]) and other support services (eg, referral to mental health support) without having to interface face to face with clinicians. This study evaluated the usability and acceptability of JomPrEP to deliver HIV prevention services for MSM in Malaysia. METHODS In total, 50 PrEP-naive MSM without HIV in Greater Kuala Lumpur, Malaysia, were recruited between March and April 2022. Participants used JomPrEP for a month and completed a postuse survey. The usability of the app and its features were assessed using self-report and objective measures (eg, app analytics, clinic dashboard). Acceptability was evaluated using the System Usability Scale (SUS). RESULTS The participants’ mean age was 27.9 (SD 5.3) years. Participants used JomPrEP for an average of 8 (SD 5.0) times during 30 days of testing, with each session lasting an average of 28 (SD 38.9) minutes. Of the 50 participants, 42 (84%) ordered an HIV self-testing (HIVST) kit using the app, of whom 18 (42%) ordered an HIVST more than once. Almost all participants (46/50, 92%) initiated PrEP using the app (same-day PrEP initiation: 30/46, 65%); of these, 16/46 (35%) participants chose PrEP e-consultation via the app (vs in-person consultation). Regarding PrEP dispensing, 18/46 (39%) participants chose to receive their PrEP via mail delivery (vs pharmacy pickup). The app was rated as having high acceptability with a mean score of 73.8 (SD 10.1) on the SUS. CONCLUSIONS JomPrEP was found to be a highly feasible and acceptable tool for MSM in Malaysia to access HIV prevention services quickly and conveniently. A broader, randomized controlled trial is warranted to evaluate its efficacy on HIV prevention outcomes among MSM in Malaysia. CLINICALTRIAL ClinicalTrials.gov NCT05052411; https://clinicaltrials.gov/ct2/show/NCT05052411 INTERNATIONAL REGISTERED REPORT RR2-10.2196/43318

Photovoice is an action-oriented qualitative method involving photography and story-telling. Although photovoice yields a powerful form of data that can be leveraged for research, intervention, and advocacy, it has arguably been underutilized within HIV research. Online, asynchronous photovoice methods represent a promising alternative to traditional in-person methods, yet their acceptability and feasibility with key populations and people living with HIV (PLWH) have yet to be explored. The current study describes the methods and evaluation of an online, asynchronous photovoice project conducted with 34 members of key populations and PLWH in Malaysia in 2021. A HIPAA-compliant website incorporating a series of instructional videos was created to facilitate participant engagement and data collection. Quantitative and qualitative indicators suggest that participants found the project to be highly acceptable and feasible. Online, asynchronous photovoice methods hold potential for increasing the scale of this powerful and versatile qualitative research method with key populations and PLWH.La fotovoz es un método cualitativo orientado a la acción que usa fotografía y narración de historias. Aunque la fotovoz produce una poderosa forma de datos que se puede utilizar para la investigación, la intervención y la promoción, podría decirse que ha sido poca aplicada en la investigación del VIH. Los métodos de fotovoz asincrónicos en línea representan una alternativa prometedora a los métodos en persona tradicionales, pero aún no se ha explorado su aceptabilidad y viabilidad con los grupos de población clave y las personas que viven con el VIH (PLWH por sus siglas en inglés). El estudio actual describe los métodos y la evaluación de un proyecto de fotovoz asincrónico en línea realizado con 34 miembros de grupos de población clave y PLWH en Malasia en 2021. Se creó un sitio web compatible con HIPAA que incorpora una serie de videos instructivos para facilitar la participación y la recopilación de datos. Los indicadores cuantitativos y cualitativos sugieren que los participantes encontraron el proyecto altamente aceptable y realizable. La fotovoz asincrónica en línea es un poderoso y versátil método cualitativo de investigación la cual tiene potencial para usarse más con los grupos de población clave y PLWH.

PURPOSE: Gay, bisexual, and other men who have sex with men (MSM) experience high levels of stigma and discrimination. Minimizing the stigma and discrimination is critical to fostering an inclusive environment for care and optimizing health outcomes. This study aimed at exploring the factors related to physicians' intention to discriminate against MSM in Malaysia. METHODS: Physicians (N = 542) from two university-affiliated hospitals in Kuala Lumpur, Malaysia, completed an online cross-sectional survey between January and March 2016. Measures included sociodemographic and clinical characteristics, intention to discriminate against MSM, and several stigma-related constructs. Bivariate and multivariable linear regressions were used to evaluate independent correlates of discrimination intent against MSM. RESULTS: Physicians' intention to discriminate against MSM was low (mean [M] = 1.9, standard deviation [SD] = 0.7), but most physicians (70.6%) had a mean score greater than 1.0, indicating that most physicians expressed some degree of intention to discriminate against MSM. A minority of physicians (10.7%), however, had a score of 3.0 or higher, revealing some physicians holding a moderate to high level of discrimination intent toward MSM. The multivariable model demonstrated that physicians who expressed greater prejudice (B = 0.30, p

BACKGROUND Men who have sex with men (MSM) are disproportionately affected by the HIV epidemic in Malaysia and globally. Cross-cutting prevention strategies like mHealth, particularly smartphone apps, hold great promise for HIV prevention efforts among Malaysian MSM, especially when linked to HIV testing and pre-exposure prophylaxis (PrEP). OBJECTIVE This study aimed to adapt an existing app to create and test a clinic-integrated app (“JomPrEP”), a virtual platform to deliver HIV testing and PrEP services for MSM in Malaysia. METHODS The JomPrEP project involves developing and testing an app-based platform for HIV prevention among Malaysian MSM and will be conducted in two phases. In Phase I (Development Phase), we will adapt an existing mHealth app (“HealthMindr”) to create a new clinic-integrated app called “JomPrEP” to deliver holistic HIV prevention services (e.g., HIV testing, PrEP, support services for mental health and substance use) among MSM in Malaysia. During Phase II (Testing Phase), we will utilize a Type I Hybrid Implementation Science trial design to test the efficacy of JomPrEP while gathering information on implementation factors to guide future scale-up in real-world settings. RESULTS As of September 2022, we have completed Phase I of the proposed study. Based on a series of formative work completed during Phase I, we developed a fully functional, clinic-integrated JomPrEP app, which provides a virtual platform for MSM in Malaysia to facilitate their engagement in HIV prevention in a fast and convenient manner. Based on participant feedback provided during Phase I, we are currently optimizing JomPrEP and the research protocols for a large-scale efficacy trial (Phase II), which will commence in January 2023. CONCLUSIONS Scant HIV prevention resources coupled with entrenched stigma, discrimination, and criminalization of same-sex sexual behavior and substance use hamper access to HIV prevention services in Malaysia. If found efficacious, JomPrEP can be easily adapted for a range of health outcomes and healthcare delivery services for MSM, including adaptation to other low- and middle-income countries (LMICs). CLINICALTRIAL NCT05325476

BACKGROUND The use of smartphone apps can improve the HIV prevention cascade for key populations, such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, mHealth app-based strategies have the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about ethical concerns unique to the development and implementation of app-based HIV prevention programs. OBJECTIVE This paper aims to fill this gap by characterizing the attitudes and concerns of Malaysian MSM regarding HIV prevention mobile apps, particularly on ethical aspects surrounding their use. METHODS We conducted online focus group discussions (FGDs) with 23 MSM between August and September 2021. Using in-depth semi-structured interviews, participants were asked about the risks and ethical issues they perceived to be associated with using mobile apps for HIV prevention. Each session was digitally recorded and transcribed. Transcripts were inductively coded using Dedoose software and analyzed to identify and interpret emerging themes. RESULTS Although participants had a high willingness to use app-based strategies for HIV prevention efforts, they raised several ethical concerns related to their use. Prominent concerns raised by participants included privacy and confidentiality concerns, including fear of third-party access to personal health information (e.g., friends or family, government agencies), issues around personal health data storage and management, equity and equitable access, informed consent, and regulation. CONCLUSIONS Study findings highlighted the role of ethical concerns related to the use of app-based HIV prevention programs. Given the ever-growing nature of such technological platforms that are intermixed with a complex ethical-legal landscape, mHealth platforms must be safe and secure to minimize unintended harms, safeguard user privacy and confidentiality, and obtain public trust and uptake. CLINICALTRIAL

Viral load (VL) testing is still challenging to monitor treatment responses of antiretroviral therapy (ART) for HIV treatment programme in Asia. We assessed the association between routine VL testing and virological failure (VF) and determine factors associated with switching to second-line regimen.Among 21 sites from the TREAT Asia HIV Observational Database (TAHOD), people living with HIV (PLHIV) aged ≥18 years initiating ART from 2003 to 2021 were included. We calculated the average number of VL tests per patient per year between the date of ART initiation and the most recent visit. If the median average number of VL tests was ≥ 0.80 per patient per year, the site was classified as a routine VL site. A site with a median0.80 was classified into the non-routine VL sites. VF was defined as VL ≥1000 copies/ml during first-line therapy. Factors associated with VF were analysed using generalized estimating equations with Poisson distribution.Of 6277 PLHIV starting ART after 2003, 3030 (48%) were from 11 routine VL testing sites and 3247 (52%) were from 10 non-routine VL testing sites. The median follow-up was 9 years (IQR 5-13). The median age was 35 (30-42) years; 68% were male and 5729 (91%) started non-nucleoside reverse-transcriptase inhibitor-based regimen. The median pre-ART CD4 count in PLHIV from routine VL sites was lower compared to non-routine VL sites (144 vs. 156 cells/mmPLHIV from non-routine VL sites had a higher incidence of persistent VF and a low switching regimen rate, reflecting possible under-utilized VL testing.

Background Pre-exposure prophylaxis (PrEP) is a valuable HIV prevention strategy, particularly among men who have sex with men (MSM); however, PrEP uptake is below the threshold needed to curb the HIV epidemic among this group, especially in settings like Malaysia, where same-sex sexual behavior is illegal. Methods A sample of 355 participants completed an online survey between June and July 2020, recruited through geosocial networking apps for MSM and social networking websites (e.g. Facebook). We used descriptive and multivariable analyses to examine correlates of PrEP use within this population. Results The sample was predominantly Malay (53.5%), had monthly incomes greater than RM 3000 (USD 730) (52.7%), and a tertiary level of education (84.5%). About 80% of participants heard of PrEP prior to the survey, with significantly less (18.3%) having ever taken PrEP. In the adjusted multivariable logistic model, using drugs before or during sexual intercourse (“chemsex”) (AOR: 3.37; 95% CI: 1.44–7.89), being diagnosed with a sexually transmitted infection in the last 12 months (AOR: 2.08; 95% CI: 1.13–3.85), HIV testing in the previous 6 months (AOR: 3.23; 95% CI: 1.74–5.99), and disclosure of sexual orientation (AOR: 1.85; 95% CI: 1.02–3.34) were associated with having taken PrEP in the past. Conclusions This study revealed that PrEP use among Malaysian MSM is relatively low, despite high awareness, and is associated with healthcare engagement and high-risk behaviors. These results highlight the need to tailor outreach activities for individuals at increased risk for HIV and those disengaged with the health system.

Globally, cisgender women sex workers (CWSWs) and transgender women sex workers (TWSWs) experience increased vulnerabilities to HIV infection. Unfortunately, there is limited data on the drivers of HIV infection in these two understudied populations, particularly in Southeast Asia. To better understand factors associated with HIV infection, we evaluated correlates of newly diagnosed HIV infection in these two populations in Greater Kuala Lumpur, Malaysia. A total of 469 women (CWSW: n = 283; TWSW: n = 186) were included in this study. Most participants who tested HIV+ were unaware of their infection (59.6%; n = 34/57). Separate binary and multivariable logistic regressions were conducted to identify correlates of newly diagnosed HIV in CWSWs and TWSWs. Among CWSWs, Chlamydia trachomatis (aOR = 5.66; p = 0.007) and lifetime use of ecstasy/MDMA (aOR = 5.34; p = 0.03) were associated with newly diagnosed HIV, while condomless vaginal sex with clients was associated with lower likelihood of HIV infection (aOR = 0.98; p = 0.01). Among TWSWs, being single (aOR = 6.76; p = 0.03), using mobile application to solicit clients (aOR = 25.33; p = 0.006), and having C. trachomatis infection (aOR = 88.22, p = 0.02) were associated with newly diagnosed HIV. Expansion of HIV/sexually transmitted infection screening is needed to increase detection of HIV and linkage to care for sex workers. Interventions to reduce HIV infection among CWSWs and TWSWs should be tailored to these populations’ unique vulnerabilities.

Background By the end of 2017, an estimated 83% of people living with HIV in Malaysia knew their serostatus. However, the Ministry of Health reported a high proportion of those newly diagnosed had low CD4 counts 18 years who fit the description of late presentation (World Health Organization defined as CD4 cell count

BACKGROUND The use of smartphone apps can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, app-based strategies have the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about ethical concerns unique to the development and implementation of app-based HIV prevention programs. OBJECTIVE This study aims to understand and characterize the attitudes and concerns of Malaysian MSM regarding HIV prevention mobile apps, particularly focusing on ethical aspects surrounding their use. METHODS We conducted online focus group discussions with 23 MSM between August and September 2021. Using in-depth semistructured interviews, participants were asked about their perceived risks, benefits, and ethical issues associated with using mobile apps for HIV prevention. Each session was digitally recorded and transcribed. Transcripts were inductively coded using Dedoose software and analyzed to identify and interpret emerging themes. RESULTS Overall, participants indicated a preference for using app-based strategies for HIV prevention efforts. Emerging themes on benefits related to app use for HIV prevention included convenience, anonymity (ability to remain anonymous while seeking care), less stigmatizing access to services (ability to avoid the burden and stigma of visiting an HIV clinic in person), readily accessible multimedia resources (eg, text, graphics, videos), and self-management portals (eg, medication adherence, appointment reminders). Prominent concerns raised by participants included privacy and confidentiality concerns, issues around personal health data storage and management, and fear of the Malaysian government accessing data. CONCLUSIONS The findings from this study indicate that app-based strategies for HIV prevention efforts are acceptable among Malaysian MSM. The results further highlighted the role of ethical concerns and the associated risks and benefits related to the use of app-based HIV prevention programs. Given the ever-evolving nature of such technological platforms and the complex ethical and legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.

BACKGROUND In Malaysia, HIV disproportionately affects gay, bisexual, and other men who have sex with men (GBMSM). Homosexuality and substance use are criminalized in Malaysia, making GBMSM bear multilevels of social stigma and discrimination, including in health care. Mobile health (mHealth), particularly smartphone apps, is a promising and cost-effective strategy for reaching stigmatized and hard-to-reach populations like GBMSM and linking them to HIV prevention services (eg, HIV testing and pre-exposure prophylaxis [PrEP]), particularly in the context of COVID-19. OBJECTIVE This study aimed to adapt the HealthMindr app (Emory University), which was developed with GBMSM in the United States, to improve HIV testing and PrEP uptake for GBMSM in Malaysia. METHODS We conducted online focus group discussions (FGDs) between August and September 2021 with 20 GBMSM and 16 community stakeholders (eg, doctors, nurses, pharmacists, and nongovernmental organization staff). Participants were asked questions regarding their preferences for functions and features in mHealth apps among GBMSM and suggestions for adapting the HealthMindr app to the Malaysian context. Each session was digitally recorded and transcribed. Transcripts were inductively coded using Dedoose software (University of California, Los Angeles) and analyzed to identify and interpret emerging themes. RESULTS The FGDs with GBMSM revealed preferences for interfacing with apps to access HIV testing, PrEP, and counseling services. Stakeholders showed strong interest in using the app-based platform to deliver integrated care (eg, HIV and mental health). The key themes mostly focused on adaptation and refinement for the Malaysian context and were related to cultural and stylistic preferences (design and user interface), engagement strategies (reward systems, marketing campaigns, and reminders), and recommendations for new functions (enhanced communication options via chat and discussion forums) in a one-stop hub for all HIV prevention needs (HIV self-testing, PrEP, and postexposure prophylaxis) that minimize privacy and confidentiality risks. CONCLUSIONS Our data suggest that a tailored HIV-prevention app would be acceptable for GBMSM in Malaysia. The findings provided detailed recommendations for the successful adaptation and refinement of the existing platform for optimal use in the Malaysian context.

BACKGROUND The growth in mobile technology access, utilization, and services holds great promise for facilitating HIV prevention efforts in Malaysia. Despite these promising trends, there is a dearth of evidence on the use of mobile health (mHealth) platforms to address the HIV prevention needs of Malaysian men who have sex with men (MSM). OBJECTIVE The goal of this study was to gain insights into (1) the access and utilization of communication technology (eg, landline phone, internet, and cell phone), (2) the acceptability of mHealth-based interventions for HIV prevention services, and (3) preferences regarding the format and frequency of mHealth interventions among Malaysian MSM. METHODS A cross-sectional survey of 376 Malaysian MSM was conducted between July 2018 and March 2020. Participants were recruited using respondent-driven sampling in the Greater Kuala Lumpur region, Malaysia. Participants completed a self-administered assessment of participant demographics, HIV risk-related behaviors, access to and frequency of the use of communication technology, and the acceptability of mHealth for HIV prevention. RESULTS Almost all participants owned or had access to a smartphone with internet access (97.9%) and accessed the internet daily (99.2%), mainly on a smartphone (88.8%). Using a 5-point scale, participants on average used smartphones primarily for social networking (mean 4.5, SD 0.8), followed by sending or receiving emails (mean 4.0, SD 1.0) and searching for health-related information (mean 3.5, SD 0.9). Further, the results indicated the high acceptance of mHealth for HIV prevention, that is, receiving HIV prevention information (91.8%), receiving reminders to take medications (89.4%), tracking sexual activity (81.4%), tracking drug use (74.7%), and monitoring drug cravings (74.5%), with the most preferred method being the smartphone app for all activities. CONCLUSIONS The findings from this study provide support for developing and deploying mHealth strategies for HIV prevention in MSM by using a smartphone app, which are crucial for a key population with suboptimal engagement in HIV prevention and treatment.

BACKGROUND We validated the Data collection on Adverse events of anti-HIV Drugs (D:A:D) full-risk and short-risk score models for chronic kidney disease (CKD) in the Asian HIV cohorts. SETTINGS A validation study among people living with HIV (PLHIV) aged ≥18 years among the cohorts in the Asia-Pacific region. METHODS PLHIV with a baseline estimated glomerular filtration rate > 60 mL/min/1.73 m were included for validation of the D:A:D CKD full version and short version without cardiovascular risk factors. Those with

Background: While global research on the implementation of HIV self-testing (HIVST) has increased exponentially, few studies have assessed information on HIVST uptake factors (i.e., willingness, preferences) in transgender women (TW) and none in the Malaysian context. We therefore sought to assess willingness to use HIVST among this understudied key population. Methods: A cross-sectional survey was conducted among 361 HIV-negative Malaysian TW in 2017. Participants were recruited using flyers, announcements through social media, and direct referral from staff members of the community-based organizations serving the TW communities. Multivariable logistic regression was used to identify correlates of willingness to use HIVST. Results: Nearly half of the participants (47.6%) reported that they would be willing to use HIVST. Multivariable analysis showed that willingness to use HIVST was positively associated with having experienced sexual assault in childhood (adjusted odds ratio [aOR]=3.239, p

Background: Chemsex is the use of illicit drugs—particularly methamphetamine, gamma hydroxybutyrate (GHB), and gamma-butyrolactone (GBL)—to enhance sexual activity. Chemsex, which occurs primarily among communities of men who have sex with men (MSM), is associated with greater HIV risk behaviors, including multiple sex partners, group sex, condomless sex, and injection drug use. Despite evidence showing chemsex engagement among Malaysian MSM, there is a paucity of research on chemsex among MSM in Malaysia. Methods: This cross-sectional study was conducted through an online survey (August to September 2021) among 870 Malaysian MSM. Participants were recruited through targeted advertisements on social networks. We collected information regarding participants’ recent (

Background The use of smartphone apps can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, app-based strategies have the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about ethical concerns unique to the development and implementation of app-based HIV prevention programs. Objective This study aims to understand and characterize the attitudes and concerns of Malaysian MSM regarding HIV prevention mobile apps, particularly focusing on ethical aspects surrounding their use. Methods We conducted online focus group discussions with 23 MSM between August and September 2021. Using in-depth semistructured interviews, participants were asked about their perceived risks, benefits, and ethical issues associated with using mobile apps for HIV prevention. Each session was digitally recorded and transcribed. Transcripts were inductively coded using Dedoose software and analyzed to identify and interpret emerging themes. Results Overall, participants indicated a preference for using app-based strategies for HIV prevention efforts. Emerging themes on benefits related to app use for HIV prevention included convenience, anonymity (ability to remain anonymous while seeking care), less stigmatizing access to services (ability to avoid the burden and stigma of visiting an HIV clinic in person), readily accessible multimedia resources (eg, text, graphics, videos), and self-management portals (eg, medication adherence, appointment reminders). Prominent concerns raised by participants included privacy and confidentiality concerns, issues around personal health data storage and management, and fear of the Malaysian government accessing data. Conclusions The findings from this study indicate that app-based strategies for HIV prevention efforts are acceptable among Malaysian MSM. The results further highlighted the role of ethical concerns and the associated risks and benefits related to the use of app-based HIV prevention programs. Given the ever-evolving nature of such technological platforms and the complex ethical and legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.

Background In Malaysia, HIV disproportionately affects gay, bisexual, and other men who have sex with men (GBMSM). Homosexuality and substance use are criminalized in Malaysia, making GBMSM bear multilevels of social stigma and discrimination, including in health care. Mobile health (mHealth), particularly smartphone apps, is a promising and cost-effective strategy for reaching stigmatized and hard-to-reach populations like GBMSM and linking them to HIV prevention services (eg, HIV testing and pre-exposure prophylaxis [PrEP]), particularly in the context of COVID-19. Objective This study aimed to adapt the HealthMindr app (Emory University), which was developed with GBMSM in the United States, to improve HIV testing and PrEP uptake for GBMSM in Malaysia. Methods We conducted online focus group discussions (FGDs) between August and September 2021 with 20 GBMSM and 16 community stakeholders (eg, doctors, nurses, pharmacists, and nongovernmental organization staff). Participants were asked questions regarding their preferences for functions and features in mHealth apps among GBMSM and suggestions for adapting the HealthMindr app to the Malaysian context. Each session was digitally recorded and transcribed. Transcripts were inductively coded using Dedoose software (University of California, Los Angeles) and analyzed to identify and interpret emerging themes. Results The FGDs with GBMSM revealed preferences for interfacing with apps to access HIV testing, PrEP, and counseling services. Stakeholders showed strong interest in using the app-based platform to deliver integrated care (eg, HIV and mental health). The key themes mostly focused on adaptation and refinement for the Malaysian context and were related to cultural and stylistic preferences (design and user interface), engagement strategies (reward systems, marketing campaigns, and reminders), and recommendations for new functions (enhanced communication options via chat and discussion forums) in a one-stop hub for all HIV prevention needs (HIV self-testing, PrEP, and postexposure prophylaxis) that minimize privacy and confidentiality risks. Conclusions Our data suggest that a tailored HIV-prevention app would be acceptable for GBMSM in Malaysia. The findings provided detailed recommendations for the successful adaptation and refinement of the existing platform for optimal use in the Malaysian context. Conflicts of Interest None declared.

BACKGROUND The use of mobile health (mHealth), including smartphone apps, can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, the mHealth platform has the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about privacy and confidentiality concerns unique to the development and implementation of app-based HIV prevention programs. OBJECTIVE Given the lack of empirical data in this area, we aim to understand the privacy and confidentiality concerns associated with participation in a hypothetical app-based research study for HIV prevention efforts. METHODS A cross-sectional, web-based survey was conducted between June and July 2020 among 355 Malaysian MSM. The survey included demographic and sexual health questions and a series of short videos describing a hypothetical app-based HIV prevention program, followed by questions related to privacy and confidentiality concerns in each step of the app-based program (ie, recruitment, clinical interaction, risk assessment, and weekly reminder). Multivariable logistic regression models were used to identify the correlates of willingness to use such an app-based program. RESULTS Most of the participants (266/355, 74.9%) indicated their willingness to participate in a hypothetical mHealth app–based HIV prevention program. Participants expressed concerns about privacy, confidentiality, data security, and risks and benefits of participating in all stages of the app-based HIV research process. Multivariate analyses indicated that participants who had a higher degree of perceived participation benefits (adjusted odds ratio [aOR] 1.873; 95% CI 1.274-2.755; P=.001) were more willing to participate. In contrast, participants who had increased concerns about app-based clinical interaction and e-prescription (aOR 0.610; 95% CI 0.445-0.838; P=.002) and those who had a higher degree of perceived risks of participating (aOR 0.731; 95% CI 0.594-0.899; P=.003) were less willing to participate. CONCLUSIONS Overall, our results indicate that mHealth app–based HIV prevention programs are acceptable for future research on Malaysian MSM. The findings further highlighted the role of privacy and confidentiality, as well as the associated risks and benefits associated with participation in such a program. Given the ever-evolving nature of such technological platforms and the complex ethical–legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.

Introduction: Transgender women (TW) face one of the highest HIV burdens worldwide. In Malaysia, 12.4% of TW are HIV infected, ∼30-fold higher than in the Malaysian adult population. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy, however, little is known about TW's willingness to use PrEP or their preferences for receiving PrEP. This study examined the correlates of Malaysian TW's willingness to use PrEP and their attitudes and preferences related to delivery of PrEP and PrEP-related care. Methods: Between June and August 2017, 361 TW in Malaysia completed an online survey about their knowledge of and willingness to use PrEP for HIV prevention. Results: Only 20.2% of participants had ever previously heard of PrEP and none were currently taking PrEP. The majority (82.5%) expressed high willingness to take PrEP and most participants met the World Health Organization (WHO) indication for PrEP (82.3%). In the multivariate model, lifetime hormone use, prior postexposure prophylaxis use, and having completed a high school education were associated with higher willingness to use PrEP, while injection drug use, older age, and Chinese ethnicity were associated with lower PrEP willingness. Conclusion: TW in Malaysia are highly willing to use PrEP for HIV prevention. Differences in willingness to use PrEP identified by education, ethnicity, substance abuse, and age suggest different strategies may be needed to scale-up PrEP for this diverse community of TW.

INTRODUCTION The majority of patients with Human Immunodeficiency Virus (HIV) will have cutaneous manifestation during their disease course. We report the spectrum of cutaneous manifestations and clinicopathological concordance in the diagnosis of skin diseases in patients with HIV. METHODS A retrospective review of all cutaneous manifestations of HIV-infected patients with skin biopsy-proven histopathological confirmation, treated in the University of Malaya Medical Centre, from 2016 till 2018, was performed. Clinical characteristics and histopathological correlation of these patients were reviewed. RESULTS A total of 38 cases were included where the median age was 40.5 (interquartile range (IQR) 13.3). The median duration of HIV diagnosis to the development of skin disease was 3 years (IQR 7.8). Majority of our patients were male (89.5%, n = 34), and the commonest mode of transmission is men who have sex with men (36.8%, n = 14). Most patients (92.1%, n = 35) had Acquired Immunodeficiency Syndrome when they presented with skin diseases, predominantly non-infectious types (51.4%, n = 19). Commonest skin diseases include eczema (n = 7) and pruritic papular eruption of HIV (n = 6). Papules and plaques were the commonest morphology for both infectious and non-infectious skin diseases. Duration of HIV diagnosis (P = 0.018) and non-compliance to Highly Active Antiretroviral Therapy (HAART) (P = 0.014) were significantly associated with the development of non-infectious skin diseases. Overall, clinicopathological concordance was 84.2% in our centre. CONCLUSION A wide spectrum of cutaneous diseases can occur in HIV patients depending on the degree of immunosuppression. skin biopsy along with appropriate stains, and microbiological cultures are important in helping clinicians clinch the right diagnosis.

Background: Previous World Health Organization (WHO) guidance on tenofovir disoproxil fumarate (TDF)-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards. Creatinine screening may represent barriers to PrEP implementation and uptake. We systematically reviewed published literature on renal toxicity among PrEP users and conducted an individual patient data meta-analysis (IPDMA) on kidney function among PrEP users in a global data set. Methods: Meta-analyses were conducted on published data to estimate pooled relative risks of grade 1+ and 2+ kidney-related adverse events among PrEP users. The IPDMA included data on PrEP users from 19 PrEP programmes. Estimated creatinine clearance at baseline and change in creatinine clearance after PrEP initiation were described by age, gender, and comorbidities. Random-effects regressions estimated risk in decline in creatinine clearance to