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

Centre of Excellence for Research in AIDS (CERiA)

CERiACentre of Excellence for Research in AIDS

Population: 29.2 millionGDP per capita (2011): $16,200Urban: 72%

Overview of the HIV Epidemic

• Primarily an HIV epidemic among PWIDs• Emerging epidemic among MSM

<5% of PWIDs

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

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

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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)

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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

Correctional Settings: Semi-Permeable Membrane

HIV

ChronicTreatment & Prevention

Substance Use Disorders

Mental Illness

Other

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

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

✔

✔

✔

26

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

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

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

McPrisonSentenced Released

McPrison10 Million Sentenced!

10 Million Sentences Served!

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The Path Forward