Transcript Document

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
100-120mg
Log Rank (Mantel-Cox):
2
Χ = (1, 27) 7.60, p < .01
Breslow (Gen Wilcoxon):
2
Χ = (1, 27) 7.45, p < .01
<80mg
Tarone-Ware:
2
Χ = (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
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•
•
•
•
•
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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
Results
HIV +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 HIVspecific 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
National AntiDrugs Agency
Methadone Maintenance Program
2007 - 20011
2007
2008
2009
PKAADK
PUSPEN
11
0
PKAADK
PUSPEN
184
0
PKAADK
PUSPEN
Klinik
C&C
Jumlah
0
Klinik
C&C
Jumlah
0
Klinik C&C 0
184
Jumlah
11
689
0
689
2010
2011
PKAADK
PUSPEN
1024
0
PKAADK
PUSPEN
1275
21
Klinik
C&C
Jumlah
0
Klinik
C&C
Jumlah
351
1024
1647
NADA MMT PROGRAM
 33 CCSC
 8 Klinik C&C 1Malaysia
 2 PUSPEN
2010
2011
Target no of clients
1325
4825
Total no registered
1183
1647
No remaining on
treatment
No not on treatment
784
1275
79
223
No employed
632
936
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