Substance Abuse and HIV Situation in Malaysia

Vicknasingam B Kasinather, PhDCentre for Drug ResearchUniversiti 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. STATE SEK. 6(1)a SEK. 6(1)b SEK. 8(3)a SEK. 8(1)b SEK.9(2)a SEK.9(2)b SEK.38B(1) Prison

SEK.38B(2) Fine

TOTAL

1. PERLIS 63 170 0 1 0 0 115 515 864

2. KEDAH 1,343 2,044 6 25 0 0 595 901 4,914

3. PULAU PINANG 778 2,855 4 10 0 1 1,938 1,311 6,897

4. PERAK 1,589 3,161 16 16 0 2 514 1,177 6,475

5. SELANGOR 1,103 2,434 22 52 0 2 625 1,742 5,980

6. WPKL 441 924 13 8 0 2 559 601 2,548

7. NEG SEMBILAN 442 1,197 3 6 0 3 82 731 2,464

8. MELAKA 281 757 4 7 1 0 78 672 1,800

9. JOHOR 624 1,732 1 22 1 9 625 1,708 4,722

10. PAHANG 817 1,130 29 50 0 0 361 1,571 3,958

11. TERENGGANU 193 339 49 37 0 32 818 3,040 4,508

12. KELANTAN 678 914 54 55 0 2 471 3,060 5,234

13. SARAWAK 261 258 88 8 1 2 0 431 1,049

14 SABAH 88 89 126 17 0 0 391 802 1,512

TOTAL 8,701 18,004 414 314 3 55 7,172 18,262 52,925

* 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

Indicator Number/ percentage

Cumulative no. of reported HIV infections since first detection in 1986 94,841

Cumulative no. of reported AIDS since 1986 17,686

Cumulative no. of reported deaths related to HIV/AIDS since 1986 14,986

Estimated no. PLHIV [EPP 2011] 81,000

New HIV infections detected in 2011 3,479

Notification rate of HIV (per 100,000) in 2011 12.18

Women reported with HIV in 2011 735

Cumulative no. of women reported with HIV as of December 2011 9,494

Children aged below 13 with HIV in 2011 65

Cumulative no. of children under 13 with HIV as of December 2011 974

Estimated no. PLHIV eligible for treatment [EPP 2011] 37,306

No. PLHIV receiving ART (surveillance data) as of December 2011 14,002

Source: Ministry of Health Malaysia

Percentage of new HIV cases by risk factor

Risk Factor 1990 2000 2011

Injecting drug use 470 (60.4%) 3,815 (74.7%) 1,348 (38.7%)

Sexual transmission 41 (5.2%) 964 (18.8%) 1,931 (32.0%)

Heterosexual 38 (4.8%) 902 (17.6%) 1,573 (45.2%)

Homosexual 3 (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 2011 2012

Ecstasy Pills 98,751 772,421

Ecstasy Powder (kg) 26.53 464.61

Yaba Pills 364,909 521,384

Syabu (kg) 1,235.58 851.82

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)– 1st survey: October - November 2006– 2nd survey: June - September 2007– 3rd survey: January - March 2008 (wave 1) and

October 2008 - 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

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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