Combined prevention programs within criminal justice systems – examples from Malaysia A Kamarulzaman, S Kaur, MN Nazar, M Azahari, C Koh, H AlDarraji, J Fu, J Wickersham, F Altice

Injection Drug Use & HIV Malaysia IDU –Prevalence: 1.33% (15-64 years of age) –Approx. 205,000 IDUs in Malaysia (2009) Heroin –64.5% of users report heroin as their primary drug –69% of all drug-related criminal offences HIV –Prevalence (General): 0.4% [Dec. 2008]; 846,307 / 28,000,000 –Prevalence (IDU): 11.0% –Prevalence (CDDC): 16.8% [range = 8-41%] HIV & IDU –66.0% of all HIV cases associated with IDU –57% of all new infections in 2008 were associated with IDU –25% of all MMT clients are HIV+

Criminal Justice System National response to illicit drug use and IDU –Dangerous Drugs Act of 1952 (revised 1980) –Drug Dependants Act of 1983 (revised 1998) Suspected of being drug dependent can be detained Found in possession of drugs and/or drug paraphernalia Warrantless arrest and mandatory rehabilitation allowed –Police Corrective Order (PCO) Sentence for drug dependence –2 years in CDDC or prison + 2 years in-community supervision –Lack of HAART, OST, evidence-based interventions MMT & NSEP –2005 pilot program –59 government clinics, 9 private clinics, 17,000 registered on MMT –Waitlist for government-provided MMT

Global Rates of Incarceration Imprisonment per CapitaMalaysia 39,758 prisoners –5441 in Puspen –26,294 in jails (5 th ) Ranked 53 rd –Puspen 40 th Driven by war on drugs Mandatory HIV testing –Highest HIV prevalence in SE Asia (6%) Different from USA –Nearly 40% are foreign-borne –Nearly 40% are from rural areas

Project Harapan: Study Design Project Harapan

Project Harapan: Initial Findings Total of 121 participants enrolled –MMT = 38 –MMT + HHRP = 38 –HHRP(M) = 22 –Control = 23 Rate of recidivism by MMT vs. No MMT –MMT = 2.6% –No MMT = 8.8%

Pilot Study: Methadone Dose Matters <80mg mg Log Rank (Mantel-Cox): Χ 2 = (1, 27) 7.60, p <.01 Breslow (Gen Wilcoxon): Χ 2 = (1, 27) 7.45, p <.01 Tarone-Ware: Χ 2 = (1, 27) 7.69, p <.01

HARAPAN-TB Tuberculosis is the leading cause of death in Malaysian prisons (especially HIV coinfection) No standardized TB screening or treatment programs established in the prison setting Patients who are ill are transferred out to government hospitals for treatment

HIV Group Incarceration times: 5 * (range 0-22) Total previous incarceration: 67 months * (range 0-360) Times since HIV diagnosis: 6 years * (range 6m-22years) On HIV treatment: 6% (despite 47% requires ARV) Sharing needles before incarceration: 91% Previous TST: 11% Previous TB disease (undocumented): 11% 1 case was diagnosed with active TB through the survey * Mean

Results HIV +veHIV -veStaff Number Gender89% MaleAll Male87% Male Age37 (23-56)36 (21-62)34 (21-64) Active TB26n/a4 TST +84%91%77% Previous TB11%2%1%

HIV in Drug Treatment & Rehabilitation Centers

HIV Diagnosis, Treatment & Care N= % diagnosed in detention settings Mean number of months since diagnosis: 64.8% 74% have not received HIV- specific medical care since diagnosis - 34% reported ever having a CD4 - Only 18 were told their actual CD4 count J Fu et al IHRC 2011 abstract

HIV Diagnosis, Treatment & Care No access to ARVs in Puspen No/limited medical personnel; completely reliant on external medical facilities for treatment of very sick inmates Only 9% received HIV-specific care during this incarceration 4 forced to discontinue ART Very immunosuppresed - CD4 counts: J Fu et al IHRC 2011 abstract

A COMPREHENSIVE HIV/AIDS PREVENTION AND TREATMENT PROGRAMME IN DRUG REHABILITATION CENTRES IN MALAYSIA NATIONAL ANTI-DRUGS AGENCY (NADA) MINISTRY OF HOME AFFAIRS MALAYSIA

OBJECTIVE 2  In response to the growing drug problem and its complexity and realizing that the existing strategies are not achieving the intended effects / targets, NADA has shifted its approach from INSTITUTIONALISED rehabilitation to an open approach, OPEN ACCESS SERVICES, by setting up THE CURE AND CARE 1 MALAYSIA CLINIC or better known as C&C 1MALAYSIA CLINIC.  This is a paradigm shift for NADA to transform its treatment and rehabilitation services to all its clients in the country. NADA MALAYSIA

National AntiDrugs Agency Methadone Maintenance Program PKAADK11 PUSPEN0 Klinik C&C 0 Jumlah11 PKAADK 184 PUSPEN 0 Klinik C&C 0 Jumlah 184 PKAADK 689 PUSPEN 0 Klinik C&C 0 Jumlah 689 PKAADK 1024 PUSPEN 0 Klinik C&C 0 Jumlah 1024 PKAADK 1275 PUSPEN 21 Klinik C&C 351 Jumlah 1647

NADA MMT PROGRAM Target no of clients Total no registered No remaining on treatment No not on treatment79223 No employed CCSC 8 Klinik C&C 1Malaysia 2 PUSPEN

FASILITI

MEDICAL EVALUATION NADA MALAYSIA

Challenges Condom and needle syringe programs prohibited Lack of a health system within these organisations Organisational competency Community re-entry challenges –Homelessness and shelters (HIV & methadone) –Unemployment –Family and social disruption –Stigma