HIV, Substance Abuse and Criminal Justice in Malaysia
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HIV, Substance Abuse and Criminal Justice in Malaysia
Frederick L. Altice, M.D., M.A.Director of Clinical & Community Research
Professor of Medicine and Public HealthYale University
Academic Icon Professor of MedicineUniversity of Malaya
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Centre of Excellence for Research in AIDS (CERiA)
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CERiACentre of Excellence for Research in AIDS
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Population: 29.2 millionGDP per capita (2011): $16,200Urban: 72%
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Overview of the HIV Epidemic
• Primarily an HIV epidemic among PWIDs• Emerging epidemic among MSM
<5% of PWIDs
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Criminal Justice in Malaysia• Prisoners: 40,000 (137 per 100K)
– High prevalence of mental illness– Mandatory HIV testing: 6% prevalence - 15x – Methadone introduced 2009 12 prisons– Hybrid healthcare system (MoH & Prison oversight)
• Pusat Serenti (CDDCs)– Mandatory HIV testing– HIV prevalence: 10% - 25x – No OST available
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Compulsory Drug Detention Centers
● Expanding throughout many SE Asian countries● Detained without due process and not under the
UN jurisdiction of prisons / jails● 2010: 28 facilities in Malaysia with ~7K detainees● Mandatory 2 year commitment (18 mo. aftercare)● Relapse 70-90% within 1 year post-release● HIV testing is mandatory (10%) with segregation in
6 of 28 facilities● Recent transformation from CDDC to C&C Centers
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CDDC Survey
● 2 of 6 HIV+ CDDCs surveyed ● >80% of all HIV+s approached in both centers● 107 approached 100 recruited (6 sick/1refused)● Baseline characteristics
- 35 years- Malay (91%)- Prior CJ involvement, mean
• Jail (7.6)• Prison (3.0)• CDDCs (2.3)
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CDDC Results
● Substance use disorders- Opioid: 95%- ATS: 40%- Benzos: 29%- 93% addiction severity- Opioid craving: 86%- Relapse expectation: 87%
● Prior OST: 24%● Low prior OST doses
CDDC41%
Prison40%
Non-CJ19%
81%
Site of HIV Diagnosis
• Mean diagnosis: 5.4 years
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HIV: Missed Opportunities for Treatment and Prevention
● Lifetime HIV-related care- Only 26% had “ever” seen a HIV doctor after the initial
diagnosis- 34% had been CD4 tested / 18% were given results
(61% were last tested >2 years ago)- Only 4% were ever on ART (3 at the time of entry)
● Within CDDC HIV-related care- 69% were symptomatic (only 9 seen by a clinician)- 23% were symptomatic for TB- None were prescribed ART
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Cure & Care: Alternative to CDDCs
● Recent “Anti-Drug” Agency Strategy to transform CDDCs 6 “Voluntary” C&C Centers- Marked reduction in staff (mostly security) with
increased medical and treatment staff● Sungai Besi (KL): inpatient (N=120) + outpatient
MMT with low threshold treatment- High numbers of opioid dependent; HIV+ (4.7%)- Latent TB infection: 86.7%
● Kota Bharu (KB): inpatient (N=50) + 120-day outpatient low threshold treatment- High proportion of ATS users (Thai border)
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Preliminary Findings from KB C&C
ATS Opioids BPN0
10
20
30
40
50
60
70
80
90 85
50
15
49
36
5
Past YearDaily (Past 30d)
● Wide range of illicit drugs used
● Polysubstance use common
● Drug of choice- ATS: 53.1%- Opioids: 45.3%
● Marked reductions in drug use after 90 days6.2 8.9
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C&C Centers vs CDDCs
● Slightly younger and earlier in their drug use career and lower previous CJ-involvement
● Regional differences in drug use patterns● Comprehensive EBPs at C&C Centers, including
OST, MET & CBT, skills training, employment linkages, voluntary inpatient unit (120 days max)
● Nascent “Integrated” Care Services Model being introduced that includes onsite medical care- Kerinchi CCNC site
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Comparative Effectiveness StudyC&C vs CDDCs
CDDC(SOC)
C&C(MMT)
Opi
oid
Dep
ende
nce
• Control for baseline differences in addiction severity, depressive symptoms, polysubstance drug use
SA OutcomesTime to opioid relapse
Days of opioid useCJ Outcomes
Days criminal activityArrest/Detention
Health (HIV, OD)Employment
Cost-Effectiveness
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Future Directions for C&C (CDDCs)
● Implementation science of implementing EBPs (e.g. OST) in AADK sites
● Comparative effectiveness studies- Opioid dependence- Poly-substance drug use
● Medication-assisted and behavioral treatment interventions for ATS
● Health services research – healthcare integration
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Correctional Settings: Semi-Permeable Membrane
HIV
ChronicTreatment & Prevention
Substance Use Disorders
Mental Illness
Other
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Pre-Incarceration“Old Environment”
Incarceration“Artificial Environment”
Post-Incarceration“New Environment”
Basic Needs (food, shelter, safety) Drug Treatment Needs
Psychiatric CareMedical Care
Antiretroviral TherapyVocational Training/Education
Re-Integration with Family/Supports
Behavioral Interventions
Time
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A Hierarchical Model for Requisite Transitional Care for HIV+ Prisoners
HIV
Mental Illness
Drug Dependence
Basic Needs (food, shelter, safety, employment)
Case
Manag
emen
tAdh
eren
ce
Inter
venti
ons
Treatment of
SUDs
Treatment
of Mental
Illness
Risk
Reduction
Springer, CID, 2011
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Why Treat With Medication-Assisted Therapies Upon or Before Release
● Substance use disorders are chronic relapsing conditions –associated with retention in care and adherence to ART
● Incarceration is “forced” abstinence, not treatment
● Relapse is high among those who meet pre-incarceration criteria for dependence- 85% within 1 year- Relapse (and overdose mortality) post-release is
highest in first 2 weeks
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Impact of Methadone Treatment
Days in Treatment Entered Treatment (%) Completed 1 Yr (%)0
20
40
60
80
100
120
140
160
180
21.3 25
0
91.3
53.6
17.3
166
70.4
36.7
CounselingC + TransferC + MMT
8 (4%) deaths of the 204 subjects• 6 due to overdose (none on MMT)• 2 cardiovascular
MMT protective of death
Kinlock, J Sub Abuse Treat, 2009
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2010
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Community Re-Entry Challenges Among HIV+ Prisoners
Correlates- Prior incarceration (p=0.07)- High public stigma (p=0.06)
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Correlates of Multiple Re-Entry Challenges
✔
✔
✔
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2011
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Pre-Incarceration Risk Behaviors
● 95% met DSM-IV criteria for opioid dependence● Daily injection (71%)● 30 days pre-incarceration
- 66% shared injection equipment- 37% had unprotected sex
● Polysubstance use- Buprenorphine (28%)- Amphetamines (49%)- Benzodiazepines (28%)
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Attitudes Toward OST
● Perceived OST would be “helpful” (51%)● Useful for relapse prevention (33%)● Major concern expressed: OST would “result in
addiction” and that they were “addiction-free”● BUT 70% wanted to “learn more about OST”● Those with the highest injection risks (p<0.05)
- Perceived OST to be helpful- Useful to prevent relapse post-release- Expressed interest in learning more about OST
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Laying the Foundation
Bull WHO, 2013
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Post-Release Outcomes
Kota Bharu Kajang
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Implementation Factors
● Patient-level- Dose escalation, TB-related comorbidity, disclosure
● Staff-level- Clinician concerns/attitudes- Security concerns/attitudes- Repeated educational sessions
● Institutional-level- Facilitator: Support by the Director General- Barriers: PCOs; release date; lock-downs;
community-based MMT dose reductions
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Impact of Methadone Dose on Post-Release Retention on Treatment
Wickersham et al, Drug Alcohol Depend, 2013
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Adaptation of Behavioral Intervention
2011
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Rec
ruitm
ent
Enr
olm
ent
Cho
ice
R
ando
miz
e
MM
T N
o M
MT
HR
P(+
)H
RP
(+)
HR
P(-
)H
RP
(-)
1° OutcomeHIV risk behaviors
2° OutcomesTime to relapse
Opiate-free urine (%)
Retention in Rx
Time to ART
ART adherence
HIV QoL
Project HARAPAN: Study Design
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Baseline Characteristics (N=271)
Mean age, years 38.4Ethnicity-- Malay 69.8%-- Chinese 18.4%-- Indian 11.8%Pre-Incarceration (30 days)-- Amphetamine use disorder 29.3%-- Alcohol (AUDIT) 18.8%Depression (CES-D≥16) 37.7%
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Retention on Treatment of HIV+ Opioid Dependent Prisoners in Malaysia (N=171)
6 Mo Retention in Rx0
10
20
30
40
50
60
70
80
90
52.4
67.8
78.6 80.3Control HHRP Only MMT Only MMT+HHRP
40.2% 79.5%P<0.01
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Other Outcomes
● Despite pre-incarceration belief that families want re-unite post-release, reality was that many had no place to go (abandonment)
● CD4 data (Median = 413)- CD4 < 350 = 41.8%- CD4 < 200 = 13.7%
● Started ART pre-release – 24.8%● Mortality (N=14)
- Most are TB-related- Resulted in TB screening activities
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McPrisonSentenced Released
McPrison10 Million Sentenced!
10 Million Sentences Served!
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The Path Forward