HIV, Substance Abuse and Criminal Justice in Malaysia

1. 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 Health Yale University Academic Icon Professor of Medicine University of Malaya

2. Centre of Excellence for Research in AIDS (CERiA)

3. CERiACentre of Excellence for Research in AIDS

4. Population: 29.2 million GDP per capita (2011): $16,200 Urban: 72%

5. Overview of the HIV Epidemic <5% of PWIDs • Primarily an HIV epidemic among PWIDs • Emerging epidemic among MSM

6. 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) • PusatSerenti (CDDCs) • Mandatory HIV testing • HIV prevalence: 10% - 25x  • No OST available

7. 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

9. 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)

10. CDDC Results Site of HIV Diagnosis • 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 • Mean diagnosis: 5.4 years

11. 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

12. 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)

13. Preliminary Findings from KB C&C • 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 days 6.2 8.9

14. 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

15. Comparative Effectiveness StudyC&C vs CDDCs • Control for baseline differences in addiction severity, depressive symptoms, polysubstance drug use SA Outcomes Time to opioid relapse Days of opioid use CJ Outcomes Days criminal activity Arrest/Detention Health (HIV, OD) Employment Cost-Effectiveness CDDC(SOC) Opioid Dependence C&C (MMT)

16. 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

17. Correctional Settings: Semi-Permeable Membrane Chronic Treatment & Prevention Mental Illness HIV Other Substance Use Disorders

18. Pre-Incarceration “Old Environment” Incarceration “Artificial Environment” Post-Incarceration “New Environment” Behavioral Interventions Re-Integration with Family/Supports Vocational Training/Education Antiretroviral Therapy Medical Care Psychiatric Care Drug Treatment Needs Basic Needs (food, shelter, safety) Time 

20. A Hierarchical Model for Requisite Transitional Care for HIV+ Prisoners Risk Reduction Treatment of Mental Illness Adherence Interventions Treatment of SUDs Case Management Springer, CID, 2011

21. 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

22. Impact of Methadone Treatment 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

23. 2010

24. Community Re-Entry Challenges Among HIV+ Prisoners • Correlates • Prior incarceration (p=0.07) • High public stigma (p=0.06)

25. Correlates of Multiple Re-Entry Challenges ✔ ✔ ✔

26. 2011

27. 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%)

28. 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

29. Laying the Foundation Bull WHO, 2013

30. Post-Release Outcomes Kota Bharu Kajang

31. 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

32. Impact of Methadone Dose on Post-Release Retention on Treatment Wickersham et al, Drug Alcohol Depend, 2013

33. Adaptation of Behavioral Intervention 2011

34. MMT Recruitment Choice Randomize No MMT Project HARAPAN: Study Design 1° Outcome HIV risk behaviors 2° Outcomes Time to relapse Opiate-free urine (%) Retention in Rx Time to ARTART adherence HIV QoL HRP(+) HRP(-) Enrolment HRP(+) HRP(-)

35. Baseline Characteristics (N=271)

36. Retention on Treatment of HIV+ Opioid Dependent Prisoners in Malaysia (N=171) 40.2% 79.5% P<0.01

37. 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

38. McPrison 10 Million Sentenced! 10 Million Sentences Served! McPrison Sentenced Released

39. The Path Forward