Substance Abuse and HIV Situation in Malaysia Vicknasingam B Kasinather, PhD Centre for Drug Research Universiti Sains Malaysia

Population: 28 million GDP per capita: $14,275 Industrialized market economy Federal constitutional monarchy Islam is the largest and official religion (61%) Major heroin abuse problem since the 1970s Proximity to Golden Triangle

Drug abuse policies in Malaysia Before 2001, primarily supply-side policies and measures – Oversight by the Internal Security Ministry and the National Anti-Drug Agency Criminalization of drug possession and use, drug testing (e.g., road blocks, areas of high concentration of drug users, workplaces, entertainment venues) and detention of suspected drug users – Drug use, testing positive for drugs, possession of drugs or drug paraphernalia, seeking medical help for drug use problems results in registration in the national database of drug users Many registrants remanded to 2 year detention in rehabilitation centers – Severe criminal penalties Possession of 15 grams (1/2 ounce) of heroin or 200 grams (seven ounces) of marijuana classified by the law as trafficking in drugs Mandatory death sentence for possession of 30 grams of heroin

Number of drug users detected and placed under supervision by the government (2012) No.STATESEK. 6(1)aSEK. 6(1)bSEK. 8(3)aSEK. 8(1)bSEK.9(2)aSEK.9(2)bSEK.38B(1) Prison SEK.38B(2) Fine TOTAL 1.PERLIS KEDAH1,3432, ,914 3.PULAU PINANG7782, ,9381,3116,897 4.PERAK1,5893, ,1776,475 5.SELANGOR1,1032, ,7425,980 6.WPKL ,548 7.NEG SEMBILAN4421, ,464 8.MELAKA ,800 9.JOHOR6241, ,7084, PAHANG8171, ,5713, TERENGGANU ,0404, KELANTAN ,0605, SARAWAK ,049 14SABAH ,512 TOTAL 8,70118, ,17218,26252,925 * Source: Detection and Supervision Unit National Anti Drugs Agency

Recent changes, Malaysia In response to the continuing problems with heroin dependence and the emerging epidemic of HIV/AIDS resulting from injection drug use, Malaysia introduced opiate agonist maintenance treatments (OMT) - Buprenorphine approved in 2002 Currently, approximately 380 general medical practice offices offer agonist maintenance treatments for ~10,000 patients - Methadone approved in 2003 Currently, there are 27,756 active patients in 333 government run MMT centres – Naltrexone registered ?

Recent changes, Malaysia (cont’d) Previously existing programs/measures were retained with plans for slow, gradual elimination or restructuring – Currently, 21 government drug rehabilitation centers are still open (1 center for females) with the total of 5,102 residents/inmates undergoing rehabilitation in 2012 – 42 Cure and Care Service Centres in Malaysia – 1,836 residential and 176,929 non-residential inmates/patients in 2012 – MMT programs were also introduced to prisons beginning with 1 prison in 2008 expanded to 18 MMTs in prisons by 2011

Recent changes, Malaysia (cont’d) NSEP started in 2006 and has reached out to 34,244 IDUs with an average distribution of needle/syringe sets about 116 per IDU in a year (2011) However, the proportions of clients being referred to VCT and MMT are low – ~10% NSEP clients are referred for VCT – ~4% referred and entered MMT Source: Malaysia 2012, Global AIDS Response, Country Progress Report

Overview of the HIV epidemic in Malaysia 2011 IndicatorNumber/ percentage Cumulative no. of reported HIV infections since first detection in ,841 Cumulative no. of reported AIDS since ,686 Cumulative no. of reported deaths related to HIV/AIDS since ,986 Estimated no. PLHIV [EPP 2011]81,000 New HIV infections detected in 20113,479 Notification rate of HIV (per 100,000) in Women reported with HIV in Cumulative no. of women reported with HIV as of December 20119,494 Children aged below 13 with HIV in Cumulative no. of children under 13 with HIV as of December Estimated no. PLHIV eligible for treatment [EPP 2011]37,306 No. PLHIV receiving ART (surveillance data) as of December ,002 Source: Ministry of Health Malaysia

Percentage of new HIV cases by risk factor Risk Factor Injecting drug use470 (60.4%)3,815 (74.7%)1,348 (38.7%) Sexual transmission41 (5.2%)964 (18.8%)1,931 (32.0%) Heterosexual38 (4.8%)902 (17.6%)1,573 (45.2%) Homosexual3 (0.4%)62 (1.2%)358 (10.3%) Source: Ministry of Health (2011)

Amphetamine Type Stimulants (ATS) Methamphetamine seizures in East and Southeast Asia nearly half of world’s total, UNODC says: ‘Significant increase’ in availability, use, arrests and seizures makes meth top illicit drug threat in region, says UNODC (12 Dec 2012) ATS Seizures in Malaysia (2012) ATS Ecstasy Pills98,751772,421 Ecstasy Powder (kg) Yaba Pills364,909521,384 Syabu (kg)1,

Epidemiological Surveys Between 2006 and 2008 USM and Yale researchers conducted a series of surveys among not-in-treatment injection drug users in three cities in Malaysia (Penang, Kuala Lumpur, and Johor Bharu) – 1 st survey: October - November 2006 – 2 nd survey: June - September 2007 – 3 rd survey: January - March 2008 (wave 1) and October March 2009 (wave 2) A total of 732 IDUs were surveyed – 680 males and 53 females Participants were a convenience sample recruited in neighborhoods with known shooting galleries and needle syringe exchange programs Collected information included demographics, drug use history and current patterns of use, self-reported HIV status, behavioral risks, and urine toxicology screens

Timeline of drug use initiation

ATS abuse and HIV status p<0.001

COATS Studies In collaboration with Yale School of Medicine, USM started a research unit in the Medical school to develop medical treatments for Co-occurring Opioid (heroin or morphine) and amphetamine-type stimulants (ATS) dependence (COATS) and to conduct cognitive/neuropsychological and epidemiological studies of ATS and heroin abusers in Malaysia. We are currently conducting several small pilot studies of medications targeting ATS abuse/dependence in Suboxone maintained, opiate dependent individuals

Future Research Needs 1.Epidemiological studies to better understand the behavioral link between ATS use and HIV 2.Development of improved treatment interventions for diverse populations of drug users, and prevention strategies for high risk individuals (e.g., ATS abusers)

Thank you