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This Week in The Lancet

  • Volume 377 1719 (2011)
  • May 21, 2011

Harm reduction schemes in Malaysia and their impact on HIV transmission

By Elliott Davis

King’s College London
elliott.davis(a)kcl.ac.uk

In 2005, the World Health Organisation (WHO) estimated that three quarters of all HIV positive individuals in Malaysia contracted the virus through intravenous drug use. Described by the UN as a “concentrated epidemic”, the result was a country failing in its Millennium Development Goal of reversing the spread of HIV/AIDS. Since 2005, however, the Malaysian government has radically altered its approach to managing intravenous drug use in the country. Its previously tough stance has been softened, while needle exchange and methadone maintenance programmes have been piloted and are now starting to be rolled-out across the country. These schemes remain in their infancy, yet recent evidence suggests they are already starting to have a positive impact on HIV infection rates.

HIV and AIDS continue to represent a significant public health risk across South and South-east Asia. Recent estimates by the WHO suggest that there are now around 3.8 million children and adults living with HIV in the region. This means only sub-Saharan Africa has a greater burden of infection, with an estimated 22.4 million individuals being HIV positive [1].

In several South and South-east Asian countries, HIV prevalence rates exceed 1 per cent of the 15 to 49-year-old population. Cambodia (1.6 per cent), Thailand (1.4 per cent) and Burma (Myanmar, 1.3 per cent) are among those most severely affected [2]. In Malaysia, which is often lauded for the quality of its healthcare service, the HIV prevalence rate is much lower at 0.5 per cent. But while this figure is below that of even the United States (0.6 per cent), the country faces its own serious challenge. This is because three quarters of the estimated 69,000 HIV positive individuals living inMalaysia contracted the virus through intravenous drug use [2-3].

The extent of the problem was brought into sharp focus by a United Nations (UN) report in 2005. Reflecting on the country’s progress towards achieving its Millennium Development Goals (MDGs), the UN stated that: “Malaysia has achieved commendable successes towards all the MDGs except in halting and reversing the spread of HIV/AIDS” [4-5]. Branding the problem a “concentrated epidemic”, the report went on to point out that, although the general population was perceived to be at low risk, infection rates among high-risk groups – specifically intravenous drug users (IDUs), sex workers and prison inmates – were bordering on 20 per cent. This figure is forty times higher than the 0.5 per cent prevalence rate reported for the Malaysian population as a whole [2-5].

With its MDG of reversing the rise in HIV prevalence by 2015 under threat, the Malaysian government acted swiftly in a bid to stem the tide of rising infections, sparking a rapid and dramatic turnaround in the country’s previous drug policy.

Prior to 2005, Malaysia had exercised a zero tolerance approach when it came to drug use, declaring it “public enemy number one” and hailing 2003 as a “year of total war against drugs” [6-7].

This tough stance extended beyond mere rhetoric, with one of the government’s main aims being the creation of a drug free society by 2015 [7]. Previous attempts to introduce needle exchange schemes had been dismissed out of hand [6] and drug rehabilitation programmes were overseen not by the Ministry of Health but by the Internal Affairs Ministry, which had a wider remit for national security [8]. Capitalpunishment remained the maximum penalty for anyone convicted of trafficking [9]. Meanwhile, any individual recording a positive urine test for either opiate or cannabis use was likely to face a mandatory two year sentence in a government-run drug rehabilitation centre, followed by a further two years’ probation [6, 10].

To many commentators, this hard line stance resulted in a disjointed approach to not only HIV management but also to health policy in general. First and foremost, there was good evidence that the programmes in place simply didn’t work – with up to 90 per cent of those attending rehabilitation centres going on to relapse [7]. In addition, government policy marked a dangerous precedent in a country where various studies have suggested that up to 43.9 per cent and 89.9 per cent of IDUs are respectively HIV and hepatitis C positive [10-11].

Encouragingly, the evidence to date already suggests that the change in approach is starting to yield results. The Malaysian government has worked with a number of Non-Government Organisations (NGOs) to introduce harm reduction schemes, namely methadone maintenance and needle-exchange projects.

From an initial pilot scheme of three centres in 2006, the needle exchange programme had extended to cover eight of the country’s 13 states by 2008. In the same year, some 1.8 million needles were distributed to more than 12,000 users. Meanwhile, over 7,000 individuals are now registered with central government-run methadone clinics, with a further 10,000 people receiving opiate replacement therapy through private practices [6].

The introduction of methadone maintenance schemes, in particular, seems to have had a major knock-on effect in terms of health benefits. A number of studies from around the world have already suggested that individuals involved in these schemes are more compliant with anti-retroviral treatment (ART) regimens, resulting in improved healthcare outcomes [12-13]. By 2007, up to 25 per cent of Malaysian ART patients were IDUs, marking a sharp rise from the figure of 7 per cent reported in 2003 [6].

Although harm reduction programmes remain a relatively new invention in Malaysia, the progress made so far has been heralded as a step in the right direction. Research from UNICEF suggests that the number of new HIV infections occurring in the country each day has fallen from 17 to ten between 2004 and 2009. There has also been a noticeable drop in the number of these infections associated with intravenous drug use, from the previous 75 per cent to 57 per cent [14] (see Figure 1).

tableFigure 1: HIV infection rates in Malaysia [2, 14]

Yet there remain problems. A recent article in The Lancet pointed out that IDUs continue to drive the epidemic in Malaysia. Around 1.3 per cent of the population are believed to be IDUs. And although HIV testing is now almost universal amongst these individuals (at close to 100 per cent), just 5.1 per cent said they used a condom during their last sexual encounter. Less than 30 per cent, meanwhile, reported using sterile equipment [15].

Compare these figures with the Ukraine, which is frequently cited as the country in the world with the most significant IDU-driven HIV epidemic, and the extent of the task still facing the Malaysian government becomes clear. Although only 27.6 per cent of Ukrainian IDUs had been tested for HIV in the past 12 months, over 80 per cent use sterile equipment and almost 60 per cent used a condom the last time they had sex [15-16].

The importance of these statistics cannot be over-stated. One recent survey of 526 IDUs not involved in drug treatment programmes across five cities in Peninsula Malaysia reported that 68.6 per cent of those questioned continued to share equipment and that 34 per cent were regularly involved in paid sex. Presciently, the study also identified the sharing of injecting equipment and having multiple sexual partners as the two most significant risk factors for HIV infection [11].

There have also been reports that, initially at least, local anti-drug legislation was slow to catch up with the new approach. Writing in 2007, one group of researchers reported that some pilot methadone maintenance and needle exchange projects had been raided by police with attendees beingarrested [7].

Though there is much work still to do in Malaysia, the results achieved so far do suggest that introducing simple measures like needle exchange programmes and methadone maintenance therapy can have a significant impact on HIV infection rates.

As a result of the initial success of these schemes there appears to be increasing goodwill towards them. Last year alone, the number of government-run health clinics operating needle exchange programmes increased from seven to 12, with RM43.1 million (£9.3 million) being invested in the scheme over a five-year programme. In the coming years, the president of the Malaysian AIDS Council has set a target of granting access to these schemes to a minimum of 60 per cent of IDUs [17].

Time will tell how successful these measures are long-term. However, it could well be that Malaysia emerges as a model of just how effective harm reduction measures can be in curbing the spread of HIV/AIDS in developing nations.

References

1. Joint United Nations Programme on HIV/AIDS and World Health Organisation (2009). AIDS epidemic update: December 2009. Geneva, UNAIDS.
2. United Nations Children’s Fund (2007). The state of the world’s children 2008. New York, UNICEF.
3. World Health Organisation (2007). Country cooperation strategy at a glance: Malaysia [online]. Available:http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_mys_en.pdf [accessed 30 March 2010].
4. United Nations Country Team: Malaysia (2005). Achieving the millennium development goals: successes and challenges. Kuala Lumpur, United Nations Development Programme.
5. United Nations General Assembly (2005). Monitoring the declaration of commitment of HIV/AIDS. New York, United Nations.
6. Kamarulzaman A. (2009). Impact of HIV prevention programs on drug users in Malaysia. Journal of Acquired Immune Deficiency Syndrome 52(S1):17-19.
7. Reid G, Kamarulzaman A, Sran SK. (2007). Malaysia and harm reduction: The challenges and responses. The International Journey of Drug Policy18(2): 136-140.
8. Scorzelli JF. (1992). Has Malaysia’s antidrug effort been effective? Journal of Substance Abuse Treatment 9(2): 171-176.
9. Mazlan M, Schottenfield RS, Chawarski MC. (2006). New challenges and opportunities in managing substance abuse in Malaysia. Drug and Alcohol Review 25(5): 473-478.
10. Chawarski MC, Mazlan M, Schottenfeld RS. (2006). Heroin dependence and HIV infection in Malaysia. Drug and Alcohol Dependence 82(S1): 39-42.
11. Vicknasingam B, Narayanan S, Navaratnam V. (2009). The relative risk of HIV among IDUs not in treatment in Malaysia. AIDS Care 21(8): 984-991.
12. Palepu A, Tyndall MW, Joy R, Kerr T, Wood E, Press N, Hogg RS, Montaner JS. (2006). Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug and Alcohol Dependence 84(2): 188-194.
13. Roux P, Carrieri MP, Villes V, Dellamonica P, Poizot-Martin I, Ravaux I, Spire B; MANIF2000 cohort study group. (2008). The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence from the MANIF2000 cohort study. Addiction 103(11): 1828-1836.
14. United Nations Children’s Fund (2009). HIV and AIDS in Malaysia: Fact sheet. Kuala Lumpur, UNICEF Malaysia Communications.
15. Arasteh K, Jarlais DCD. (2008). Injecting drug use, HIV, and what to do about it. The Lancet 372: 1709-1710.
16. United Nations Regional Task Force on Injecting Drug Use and HIV/AIDS for Asia and the Pacific. (2009). Malaysia country advocacy brief: injecting drug use and HIV. Geneva, UNAIDS.
17. Edwards A. (2009). Needle syringe exchange programme injects hope. The Star, May 2009.

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