Combined prevention programs within criminal justice systems –

examples from Malaysia

A Kamarulzaman, S Kaur, MN Nazar, M Azahari, C Koh, H AlDarraji, J Fu, J Wickersham, F Altice

Global Rates of Incarceration

Imprisonment per Capita Malaysia

• 39,758 prisoners– 5441 in Puspen– 26,294 in jails (5th)

• Ranked 53rd

– Puspen 40th

• Driven by war on drugs• Mandatory HIV testing

– Highest HIV prevalence in SE Asia (6%)

• Different from USA– Nearly 40% are foreign-borne– Nearly 40% are from rural areas

Project Harapan: Study Design

Project Harapan

Project Harapan: Initial Findings

• Total of 121 participants enrolled– MMT = 38– MMT + HHRP = 38– HHRP(M) = 22– Control = 23

• Rate of recidivism by MMT vs. No MMT– MMT = 2.6% – No MMT = 8.8%

Pilot Study: Methadone Dose Matters

<80mg

100-120mgLog Rank (Mantel-Cox):Χ2 = (1, 27) 7.60, p < .01

Breslow (Gen Wilcoxon):Χ2 = (1, 27) 7.45, p < .01

Tarone-Ware:Χ2 = (1, 27) 7.69, p < .01

HARAPAN-TB

• Tuberculosis is the leading cause of death in Malaysian prisons (especially HIV coinfection)

• No standardized TB screening or treatment programs established in the prison setting

• Patients who are ill are transferred out to government hospitals for treatment

HIV Group

• Incarceration times: 5 * (range 0-22)• Total previous incarceration: 67 months * (range 0-360)• Times since HIV diagnosis: 6 years * (range 6m-22years)• On HIV treatment: 6% (despite 47% requires ARV)• Sharing needles before incarceration: 91%• Previous TST: 11%• Previous TB disease (undocumented): 11%• 1 case was diagnosed with active TB through the survey

* Mean

ResultsHIV +ve HIV -ve Staff

Number 140 151 441

Gender 89% Male All Male 87% Male

Age 37 (23-56) 36 (21-62) 34 (21-64)

Active TB 26 n/a 4

TST + 84% 91% 77%

Previous TB 11% 2% 1%

HIV in Drug Treatment & Rehabilitation Centers

HIV Diagnosis, Treatment & Care• N= 100• 78% diagnosed in detention

settings • Mean number of months since

diagnosis: 64.8%• 74% have not received HIV-

specific medical care since diagnosis- 34% reported ever having a CD4 - Only 18 were told their actual CD4 count

J Fu et al IHRC 2011 abstract

HIV Diagnosis, Treatment & Care

• No access to ARVs in Puspen• No/limited medical personnel; completely reliant on

external medical facilities for treatment of very sick inmates

• Only 9% received HIV-specific care during this incarceration 4 forced to discontinue ART

• Very immunosuppresed - CD4 counts: 15 - 140

J Fu et al IHRC 2011 abstract

A COMPREHENSIVE HIV/AIDS PREVENTION AND TREATMENT

PROGRAMME IN DRUG REHABILITATION CENTRES IN

MALAYSIA 

NATIONAL ANTI-DRUGS AGENCY (NADA)

MINISTRY OF HOME AFFAIRS

MALAYSIA

OBJECTIVE In response to the growing drug problem and its

complexity and realizing that the existing strategies are not achieving the intended effects / targets, NADA has shifted its approach from INSTITUTIONALISED rehabilitation to an open approach, OPEN ACCESS SERVICES, by setting up THE CURE AND CARE 1 MALAYSIA CLINIC or better known as C&C 1MALAYSIA CLINIC.

This is a paradigm shift for NADA to transform its treatment and rehabilitation services to all its clients in the country.

NADA MALAYSIA

2011200920082007 2010

National AntiDrugs AgencyMethadone Maintenance Program

2007 - 20011

PKAADK 11

PUSPEN 0

Klinik C&C

0

Jumlah 11

PKAADK 184

PUSPEN 0

Klinik C&C

0

Jumlah 184

PKAADK 689

PUSPEN 0

Klinik C&C

0

Jumlah 689

PKAADK 1024

PUSPEN 0

Klinik C&C

0

Jumlah 1024

PKAADK 1275

PUSPEN 21

Klinik C&C

351

Jumlah 1647

NADA MMT PROGRAM

2010 2011Target no of clients 1325 4825

Total no registered 1183 1647

No remaining on treatment

784 1275

No not on treatment 79 223

No employed 632 936

33 CCSC 8 Klinik C&C 1Malaysia 2 PUSPEN

FASILITI

MEDICAL EVALUATION

NADA MALAYSIA

Challenges• Condom and needle syringe programs prohibited• Lack of a health system within these

organisations• Organisational competency• Community re-entry challenges

– Homelessness and shelters (HIV & methadone)– Unemployment– Family and social disruption– Stigma