1. Current Substance Abuse Disorders and HIV Situation in Malaysia B. Vicknasingam (1), Singh, D (1), Suppiah, B (1), Schottenfeld, R (2) and Chawarski, M (2) 1) Centre for Drug Research, Universiti Sains Malaysia 2) Yale School of Medicine, New Haven, CT

2. Population: 30 million GDP per capita: $23,100 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

3. Introduction -From 1980s to around 2003 Malaysia’s drug policy was based solely on a prohibitionist approach. - Non-medical institutional rehabilitation approach was the main modality for rehabilitating people who use drugs (PWUD). -High relapse rates within the first six months of release were reported -Malaysia’s failure to reverse an increasing trend of HIV infection in the United Nations Millennium Development Goal (MDG) prompted the Malaysian government to re-examine its approach towards people who use drugs.

4. Introduction (cont’d) -The introduction of harm reduction programs in Malaysia also opened the doors for the public health sector to be involved in providing treatment for people who use drugs in Malaysia. -However, a dual track drug policy is still being practised in Malaysia. PWUD can still be mandated to undergo rehabilitation. NADA, the primary agency managing prevention, treatment and rehabilitation efforts in the country, has significant enforcement powers and plays a contradictory role in the response to drug use in Malaysia.

5. Arrest under section 3(1) Drug Dependents Act (Treatment and Rehabilitation) 1983, related to opiate and cannabis drug use from 2006 – 2013 Source: Royal Malaysia Police (2013)

6. Arrest under section 15(1)(a) Dangerous Drug Act 1952 (DDA) related to Amphetamine Type Stimulant (ATS) and Ketamine Drug use from 2006 – 2013 Source: Royal Malaysia Police (2013)

7. Timeline of drug use initiation (Chawarski et al., 2012)

8. ATS abuse and HIV status p<0.001 (Chawarski et al 2012)

9. Source: National Anti Drug Agency (2013) Number of People who use drugs (PWUD) detected by the National Anti Drug Agency (NADA) from year 2000 -2013

10. Drug Seizures (2011 – 2014) Year2011201220132014 HeroinKgKg445.13362.67638.61381.40 CannabisKg796.05751.80539.30578.19 Crystal methamphetamine Kg830.29608.671245.63761.71 Liquid methamphetamine Kg122.6027.9676.691,260.09 KetamineKg106.75118.07139.23216.61 Amphetamine powder Kg26.53457.36674.6253.69 EcstasyPills47,761634,573335,984117,702 YabaPills364,879521,384524,966557,336 Erimin 5Pills87,0125,175,069177,916467,133 Royal Malaysia Police 2015

11. NoName of CCRCCapacityNumber of clients 1SERDANG300280 2KG. SELAMAT300310 3BATU KURAU300317 4PERLOP300295 5SERENDAH250257 6GAMBANG300270 7BENTA250272 8KARAK300236 9RAUB300277 10JELEBU300313 11MUAR300298 12TIANG DUA300246 13PAPAR250197 14KUCHING15093 15BACHOK250132 16JELI300319 17BKT. CHABANG300299 18KOTA TINGGI300183 JUMLAH5,0504,594 Number of PWUD receiving treatment in Cure and Care Rehabilitation Centre (CCRC) - 2013

12. NoStateNo of CCSCResidentsNon residents 1Perlis13431 2Kedah3139785 3Pulau Pinang529320,113 4Perak526415,901 5WP Kuala Lumpur623145,057 6Selangor628627,646 7Negeri Sembilan513626,120 8Melaka17530 9Johor818614,525 10Pahang41574,384 11Kelantan12574 12Terengganu3190886 13Sabah240316 14Sarawak423193 JUMLAH542,011156,561 Number of PWUD receiving treatment in Cure and Care Service Centre (CCSC) - 2013

13. Methadone Maintenance Therapy (MMT) Facilities (June 2014) Source : Ministry of Health (MoH) Malaysia Type of Facility Number of MMT Facility (Cumulative by Years) 20062007200820092010201120122013 2014 (June) Hospital 8252735404849 53 Health Clinic 232 77134168203 293295 Govt G.P 79914212421 2223 NADA 00324253241 59 Prison 0041218 Others 0000221 11 Total Govt176675162240292333 446449 TOTAL GOVT + GP : 814 (June 2014) No. GP providing OST services : 365 (source : MoH Malaysia)

14. Coverage: MMT patients (June 2014) Source : MoH Malaysia 20062007200820092010201120122013 2014 (June) No. of registered patient (Annual) 1,2412,7773,0473,6655,1395,0866,8015,6882,189 No. of registered patient (Cumulative) 1,2414,0187,06510,73015,86920,95527,75633,44435,633 No. of Active Patient (by end of the year) 9323,2425,0247,45510,66414,63118,40120,30720,705 Retention Rate 75%81%71%69%70% 70.1%71.3%84.1% TOTAL REGISTERED Patients at government and and private GP = 67,438 (June 2014) Cummulative number of patients on OST in private GP : 31,805

15. Needle and Syringe Exchange (NSEP) – Facilities and Coverage Source : MoH Malaysia Year 20062007200820092010201120122013 2014 (June) NSEP Site : NGO 4570114218224221529 576545 NSEP Site : Health Clinic 006227376 152 TOTAL4570120240297 605728697 Registered Client (cumulative) 4,3576,65812,23018,37724,999 34,24455,29872,68677,179 Needle & Syringe return rate 58.6%62.2%63.2%65.9%56.4%63%58.9%61.5%62.2% * Regular client (at least once a month ): 39,163

16. Overview of the HIV epidemic in Malaysia 2013 IndicatorNumber/ percentage Cumulative no. of reported HIV infections since first detection in 1986101,672 Cumulative no. of reported AIDS since 198620,235 Cumulative no. of reported deaths related to HIV/AIDS since 198616,340 Estimated no. PLHIV [EPP 2014]86,324 Total number of PLHIV [surveillance date]85,332 New HIV infections detected in 20133,393 Notification rate of HIV (per 100,000) in 201311.42 Women reported with HIV in 2013728 Cumulative no. of women reported with HIV as of December 201310,956 Children aged below 13 with HIV in 201350 Cumulative no. of children under 13 with HIV as of December 20131,076 Estimated no. PLHIV eligible for treatment [EPP 2014]38,418 No. PLHIV receiving ART (surveillance data) as of December 201317,369 Estimated adult (15-49 years) HIV prevalence [EPP 2014]73,005 [0.44%] Source: Ministry of Health Malaysia

17. PERCENTAGE OF NEW HIV CASES BY RISK FACTOR Source: Minstry of Health (2013)

18. Conclusion - Need for a more consistent drug policy where treatment is the main priority. - There is an increase in ATS use in the country. Methadone and buprenorphine patients are also beginning to use ATS. -Sexual transmission is the main transmission mode of HIV. We need more sexual risk behaviors studies to understand this problem. -After several years of implementing treatment programs for PWUDs, it is imperative that the government not only increase the coverage of the program but to also start improving the quality of their programs. For example, only 17% and 12% of NSEP clients have been referred to voluntary counseling and testing (VCT) and MMT respectively (Global AIDS Response Progress Report, 2014). -The term Medication Assisted Treatment (MAT) should be used for methadone and buprenorphine treatment programs. Currently, the Malaysian government views this as part of the harm reduction program.

19. Thank you