Islam & Harm Reduction Adeeba Kamarulzaman Faculty of Medicine, University of Malaya Member, IAS Governing Council

Intervention Outcome Summary of studies Evidence Statement Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness Intervention Outcome Summary of studies Evidence Statement Needle and syringe programmes (NSP) Injecting risk behaviour (IRB) 43 studies Sufficient evidence to support the effectiveness HIV 16 studies Tentative evidence to support the Opiate Substitution Treatment (OST) IRB 35 studies 8 studies McArthur G et al. IJDP Jan 2014

“Mega-Epidemics” Wolfe D. Lancet August 2010

The higher purposes of Islamic law Maqqasid Syariah Preservation of Faith Life Intellect Progeny Wealth

Legal maxims in Islam “A lesser harm may be tolerated in order to eliminate a greater harm” “A particular harm may be tolerated in order to prevent a general one” “Public interest (Maslahah ammah) must be given priority over private concerns” “Harm must be treated and benefits must be brought forth”

Jan 2004 Formation of Harm Reduction Working Group June 2005 MOH approves harm reduction programs June 2005 Formation of National Harm Reduction Task Force Oct 2005 Pilot MMT program implemented Feb 2006 Pilot NSP program implemented April 2006 Cabinet Endorsement for Harm Reduction Program

National Task Force on Harm Reduction Ministry of Health Ministry of Internal Security Police National Antidrugs Agency Prisons Department Malaysian AIDS Council JAKIM Academia

MALAYSIAN HARM REDUCTION PROGRAM 2005-2015 NSP 2006 – 2010 Reduce HIV vulnerability among IDU NSP 2011 – 2015 prevent / reduce infection, improve QoL of PLHIV, and reduce the social and economic impact Up scaling of harm reduction program 2001 - 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jan 29,05 : PM statement on MDG HIV Jan 15 – endorsement of MMT by MTMDK June 3, 05 : MoH annoucement on NSEP June 23,05 : NTFHR Oct, 05 : MMT piloted Review of SOP 2nd Review of SOP Piloted Klinik Kesihatan Angkat Project 3rd Review of SOP NSPEA consultation MMT in prison and NADA NSEP at health clinic Endorsement of up scaling of harm reduction in NSP 2011-2015 Endorsement of up scaling MMT by JRP meeting Harm Reduction program by Global Fund Support activities of harm reduction by HIV/AIDS Alliance funding NSPEA preparatory work Feb 2006 : NSEP piloted April 2006 – Malaysia cabinet Endorsement on HR 2001 - The Declaration of Commitment on HIV/AIDS adopted by United Nation General Assembly Special Session on HIV/AIDS (UNGASS) in 2001, for which Malaysia was a signatory 2002- 2005 : Proposal of harm reduction

NUMBER OF REGISTERED PATIENTS ON OST AND OST CENTERS 2006 – 2014 YEAR 2006 2007 2008 2009 2010 2011 2012 2013 2014 No. of registered patients at Govt Facilities (Cumulative) 1,241 4,018 7,065 10,730 15,869 20,955 27,756 33,444 37,555 No. of registered patient at Private Facilities (Cumulative) NA 12,566 17,976 21,203 23,010 23,257 24,324 31,805 37,261 Total No. of registered patient (Cumulative) 16,584 25,041 31,933 38,879 44,212 52,080 65,249 74,816 Public OST Facilities 17 66 75 162 240 292 333 446 472 Private OST Facilities 306 300 382 365 366 Total OST centers (Govt + GP Setting) 372 381 462 540 674 715 811 838 Source : Disease Control Division, MoH Malaysia

NSP PROGRAM 2006 – 2014   Year 2006 2007 2008 2009 2010 2011 2012 2013 2014 NSP Site : NGO 45 70 114 218 224 221 529 576 540 NSP Site : Health Clinic 6 22 73 76 152 TOTAL 120 240 297 605 728 692 Registered Clients (cumulative) 4,357 6,658 12,230 18,377 24,999 34,244 55,298 72,686 85,693 Needle & Syringe return rate 58.6% 62.2% 63.2% 65.9% 56.4% 63% 58.9% 61.5% 60.0% Source : Ministry of Health, Malaysia

Malaysia Annual Reported HIV Cases 2000-2014 AIDS/STI Section, Ministry of Health Malaysia. 2015

Transformation of Compulsory Drug Detention Centers into Voluntary Treatment & Care Centers

Major Developments since 2010 COMPULSORY REHABILITATION OPEN ACCESS AMBULATORY VOLUNTARY CENTRES 19 CURE & CARE REHABILITATION CENTRES 11 CURE & CARE 1MALAYSIA CLINICS Sangeeth Kaur IAS 2013

C&C – Outcome Study 28663 had received services at C&C or CCSC between 2010 and April 2013 Of 313 interviewed 56.3% - Helped maintain employment 54.3% - Continued education 77.6% - Improved family relations 72.1% - Obtained permanent homes 75.9% - Prevented arrest into prisons

New HIV Infections With Harm Reduction Without Harm Reduction Prevented New HIV Infections 2006-2013 20,903 34,220 39% 2013-2023 3,596 27,118 87% 2006-2050 27,979 134,345 79%

Cost Savings in Direct Health Care By preventing HIV transmissions among PWIDs, the harm reduction programmes allowed the government to accrue savings from direct health care costs Cost-saving in direct health care (mil. RM) 2006 - 2013 2013 - 2023 2006 - 2050 47.06 (30.53 – 58.50) 209.53 (114.10 – 248.26) 909.47 (441.71 – 1182.40) Direct health care cost savings from avoided infection are expected to increase over time due to disease progression for those who are not on treatment require higher intensity health care and higher health care cost for government

People Who Inject Drugs & the Heroin Trade There are 625,000 PWID in MENA Mumtaz G, et al. HIV among people who inject drugs in the Middle East and North Africa: Systematic review and data synthesis. PLoS Medicine, in press.

Emerging HIV Epidemics among People Who Inject Drugs At least one-third of MENA countries are affected by emerging HIV epidemics among PWID Only in the last few years Pakistan one of the worst globally; Libya has the highest prev rate among IDUs Mumtaz G, et al. HIV among people who inject drugs in the Middle East and North Africa: Systematic review and data synthesis. PLoS Medicine, in press.

Cairo Declaration of Human Rights "All men are equal in terms of basic human dignity and basic obligations and responsibilities, without any discrimination on the basis of race, colour, language, belief, sex, religion, political affiliation, social status or other considerations. True religion is the guarantee for enhancing such dignity along the path to human integrity."