1. Substance Abuse and HIV Situation in Malaysia Vicknasingam B Kasinather, PhD Centre for Drug Research UniversitiSains Malaysia

2. 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

3. 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

4. Number of drug users detected and placed under supervision by the government (2012) * Source: Detection and Supervision Unit National Anti Drugs Agency

5. 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 ?

6. 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

7. Recent changes, Malaysia (cont’d) • NSEP started in 2006 and has reached out to 34,244 IDUswith 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

8. Overview of the HIV epidemic in Malaysia 2011 Source: Ministry of Health Malaysia

10. Percentage of new HIV cases by risk factor Source: Ministry of Health (2011)

11. 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)

13. 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

14. Timeline of drug use initiation

15. ATS abuse and HIV status p<0.001

16. 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

17. Future Research Needs • Epidemiological studies to better understand the behavioral link between ATS use and HIV • Development of improved treatment interventions for diverse populations of drug users, and prevention strategies for high risk individuals (e.g., ATS abusers)

18. Thank you