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Fulltext Extended-Release Naltrexone Improves Viral Suppression Among Incarcerated Persons Living With HIV With Opioid Use Disorders Transitioning to the Community: Results of a Double-Blind, Placebo-Controlled Randomized Trial

Springer SA, Di Paola A, Azar MM, Barbour R, Biondi BE, Desabrais M, et al.

J Acquir Immune Defic Syndr, 2018 05 01;78(1):43-53.
PMID: 29373393 DOI: 10.1097/QAI.0000000000001634

OBJECTIVE: To determine whether extended-release naltrexone (XR-NTX) would improve or maintain viral suppression (VS) among prisoners or jail detainees with HIV and opioid use disorder (OUD) transitioning to the community.
DESIGN: A 4-site, prospective randomized double-blind, placebo-controlled trial was conducted among prison and jail inmates with HIV and OUD transitioning to the community from September 2010 through March 2016.
METHODS: Eligible participants (N = 93) were randomized 2:1 to receive 6 monthly injections of XR-NTX (n = 66) or placebo (n = 27) starting at release and observed for 6 months. The primary outcome was the proportion that maintained or improved VS (<50 copies/mL) from baseline to 6 months.
RESULTS: Participants allocated to XR-NTX significantly improved to VS (<50 copies/mL) from baseline (37.9%) to 6 months (60.6%) (P = 0.002), whereas the placebo group did not (55.6% at baseline to 40.7% at 6 months P = 0.294). There was, however, no statistical significant difference in VS levels at 6 months between XR-NTX (60.6%) vs. placebo (40.7%) (P = 0.087). After controlling for other factors, only allocation to XR-NTX (adjusted odds ratio = 2.90; 95% confidence interval = 1.04 to 8.14, P = 0.043) was associated with the primary outcome. Trajectories in VS from baseline to 6 months differed significantly (P = 0.017) between treatment groups, and the differences in the discordant values were significantly different as well (P = 0.041): the XR-NTX group was more likely than the placebo group to improve VS (30.3% vs. 18.5%), maintain VS (30.3% vs. 27.3), and less likely to lose VS (7.6% vs. 33.3%) by 6 months.
CONCLUSIONS: XR-NTX improves or maintains VS after release to the community for incarcerated people living with HIV with OUD.
Fulltext Exploring intentions to discriminate against patients living with HIV/AIDS among future healthcare providers in Malaysia

Earnshaw VA, Jin H, Wickersham J, Kamarulzaman A, John J, Altice FL

Trop Med Int Health, 2014 Jun;19(6):672-679.
PMID: 24666546 DOI: 10.1111/tmi.12306

OBJECTIVES: Stigma towards people living with HIV/AIDS (PLWHA) is strong in Malaysia. Although stigma has been understudied, it may be a barrier to treating the approximately 81 000 Malaysian PLWHA. The current study explores correlates of intentions to discriminate against PLWHA among medical and dental students, the future healthcare providers of Malaysia.
METHODS: An online, cross-sectional survey of 1296 medical and dental students was conducted in 2012 at seven Malaysian universities; 1165 (89.9%) completed the survey and were analysed. Socio-demographic characteristics, stigma-related constructs and intentions to discriminate against PLWHA were measured. Linear mixed models were conducted, controlling for clustering by university.
RESULTS: The final multivariate model demonstrated that students who intended to discriminate more against PLWHA were female, less advanced in their training, and studying dentistry. They further endorsed more negative attitudes towards PLWHA, internalised greater HIV-related shame, reported more HIV-related fear and disagreed more strongly that PLWHA deserve good care. The final model accounted for 38% of the variance in discrimination intent, with 10% accounted for by socio-demographic characteristics and 28% accounted for by stigma-related constructs.
CONCLUSIONS: It is critical to reduce stigma among medical and dental students to eliminate intentions to discriminate and achieve equitable care for Malaysian PLWHA. Stigma-reduction interventions should be multipronged, addressing attitudes, internalised shame, fear and perceptions of deservingness of care.
KEYWORDS: HIV/AIDS; Malaisie; Malasia; Malaysia; VIH/SIDA; cuidados sanitarios profesionales; discriminación; discrimination; estigma; homosexuality; professional healthcare students; stigma; stigmatisation; substance abuse; étudiants en profession de soins de santé
Fulltext Exploring Malaysian Physicians' Intention to Discriminate Against Gay, Bisexual, and Other Men Who Have Sex with Men Patients

Ni Z, Shrestha R, Earnshaw VA, Tee YC, Altice FL, Azwa I, et al.

LGBT Health, 2023;10(2):169-175.
PMID: 36251945 DOI: 10.1089/lgbt.2021.0452

Purpose: Gay, bisexual, and other men who have sex with men (MSM) experience high levels of stigma and discrimination. Minimizing the stigma and discrimination is critical to fostering an inclusive environment for care and optimizing health outcomes. This study aimed at exploring the factors related to physicians' intention to discriminate against MSM in Malaysia. Methods: Physicians (N = 542) from two university-affiliated hospitals in Kuala Lumpur, Malaysia, completed an online cross-sectional survey between January and March 2016. Measures included sociodemographic and clinical characteristics, intention to discriminate against MSM, and several stigma-related constructs. Bivariate and multivariable linear regressions were used to evaluate independent correlates of discrimination intent against MSM. Results: Physicians' intention to discriminate against MSM was low (mean [M] = 1.9, standard deviation [SD] = 0.7), but most physicians (70.6%) had a mean score greater than 1.0, indicating that most physicians expressed some degree of intention to discriminate against MSM. A minority of physicians (10.7%), however, had a score of 3.0 or higher, revealing some physicians holding a moderate to high level of discrimination intent toward MSM. The multivariable model demonstrated that physicians who expressed greater prejudice (B = 0.30, p
Fulltext Evaluation of a hepatitis C education intervention with clients enrolled in methadone maintenance and needle/syringe programs in Malaysia

Mukherjee TI, Pillai V, Ali SH, Altice FL, Kamarulzaman A, Wickersham JA

Int J Drug Policy, 2017 09;47:144-152.
PMID: 28652072 DOI: 10.1016/j.drugpo.2017.05.041

BACKGROUND: Approximately 40%-90% of people who inject drugs (PWID) in Malaysia have hepatitis C (HCV). PWID continue to be disproportionately affected by HCV due to their lack of knowledge, perceived risk and interest in HCV treatment. Education interventions may be an effective strategy for increasing HCV knowledge in PWID, and harm reduction services are uniquely positioned to implement and deploy such interventions.
METHODS: We recruited 176 clients from methadone maintenance treatment (MMT: N=110) and needle/syringe programs (NSP: N=66) between November 2015 and August 2016. After baseline knowledge assessments, clients participated in a standardized, 45-min HCV education program and completed post-intervention knowledge assessments to measure change in knowledge and treatment interest.
RESULTS: Participants were mostly male (96.3%), Malay (94.9%), and in their early 40s (mean=42.6years). Following the intervention, overall knowledge scores and treatment interest in MMT clients increased by 68% and 16%, respectively (p<0.001). In contrast, NSP clients showed no significant improvement in overall knowledge or treatment interest, and perceived greater treatment barriers. Multivariate linear regression to assess correlates of HCV knowledge post-intervention revealed that optimal dosage of MMT and having had an HIV test in the past year significantly increased HCV knowledge. Having received a hepatitis B vaccine, however, was not associated with increased HCV knowledge after participating in an education session.
CONCLUSION: Generally, HCV knowledge and screening is low among clients engaged in MMT and NSP services in Malaysia. Integrating a brief, but comprehensive HCV education session within harm reduction services may be a low-cost and effective strategy in improving overall HCV knowledge and risk behaviors in resource-limited settings. In order to be an effective public health approach, however, education interventions must be paired with strategies that improve social, economic and political outcomes for PWID. Doing so may reduce HCV disparities by increasing screening and treatment interest.
Fulltext Evaluating Physicians' Intention to Discriminate Against Patients Living with HIV in Malaysia

Tee YC, Earnshaw VA, Altice FL, Jin H, Kamarulzaman A, Wickersham JA

AIDS Behav, 2019 Apr;23(4):1039-1047.
PMID: 30560483 DOI: 10.1007/s10461-018-2362-4

People with HIV (PWH) in Malaysia experience high levels of stigma, which may act as a barrier to accessing healthcare. Stigma against PWH in medical settings is understudied in Malaysia. In the present study, we examine factors associated with physicians' intention to discriminate against PWH in Malaysia. A cross-sectional online survey was emailed to all 1431 physicians at two major university hospitals in Malaysia; 568 (39.6%) participants completed the survey and were included in this analysis. Measures included intention to discriminate against PWH, stigma-related constructs, and socio-demographic characteristics. Multivariate linear regression was used to identify factors associated with intention to discriminate against PWH. Participants were comprised of women (53.5%), Malays (43.1%), and Chinese (35.0%) with nearly 10 years of clinical experience. Most participants were from non-surgical specialties (77.6%). The final multivariate linear regression showed that physicians who expressed greater discriminatory intent against PWH also expressed more negative feelings toward PWH, more HIV-related shame, were more fearful of HIV, and believed that PWH do not deserve good care. Physicians from surgical-based specialties were also significantly more likely to endorse discriminatory intent toward PWH. Stigma and intentions to discriminate against a class of patients, including PWH, can undermine engagement in care, which is central to international HIV prevention and treatment strategies. Interventions that reduce stigma toward PWH among physicians are crucial to ensuring equitable and stigma-free healthcare.
Fulltext Effect of expanding opioid agonist therapies on the HIV epidemic and mortality in Ukraine: a modelling study

Tan J, Altice FL, Madden LM, Zelenev A

Lancet HIV, 2020 02;7(2):e121-e128.
PMID: 31879250 DOI: 10.1016/S2352-3018(19)30373-X

BACKGROUND: As HIV incidence and mortality continue to increase in eastern Europe and central Asia, particularly among people who inject drugs (PWID), it is crucial to effectively scale-up opioid agonist therapy (OAT), such as methadone or buprenorphine maintenance therapy, to optimise HIV outcomes. With low OAT coverage among PWID, we did an optimisation assessment using current OAT procurement and allocation, then modelled the effect of increased OAT scale-up on HIV incidence and mortality for 23 administrative regions of Ukraine.
METHODS: We developed a linear optimisation model to estimate efficiency gains that could be achieved based on current procurement of OAT. We also developed a dynamic, compartmental population model of HIV transmission that included both injection and sexual risk to estimate the effect of OAT scale-up on HIV infections and mortality over a 10-year horizon. The compartmental population model was calibrated to HIV prevalence and incidence among PWID for 23 administrative regions of Ukraine. Sources for regional data included the SyrEx database, the Integrated Biological and Behavioral Survey, the Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health of Ukraine, the Public Health Center of the Ministry of Health of Ukraine, and the Ukrainian Census.
FINDINGS: Under a status-quo scenario (OAT coverage of 2·7% among PWID), the number of new HIV infections among PWID in Ukraine over the next 10 years was projected to increase to 58 820 (95% CI 47 968-65 535), with striking regional differences. With optimum allocation of OAT without additional increases in procurement, OAT coverage could increase from 2·7% to 3·3% by increasing OAT doses to ensure higher retention levels. OAT scale-up to 10% and 20% over 10 years would, respectively, prevent 4368 (95% CI 3134-5243) and 10 864 (7787-13 038) new HIV infections and reduce deaths by 7096 (95% CI 5078-9160) and 17 863 (12 828-23 062), relative to the status quo. OAT expansion to 20% in five regions of Ukraine with the highest HIV burden would account for 56% of new HIV infections and 49% of deaths prevented over 10 years.
INTERPRETATION: To optimise HIV prevention and treatment goals in Ukraine, OAT must be substantially scaled up in all regions. Increased medication procurement is needed, combined with optimisation of OAT dosing. Restricting OAT scale-up to some regions of Ukraine could benefit many PWID, but the regions most affected are not necessarily those with the highest HIV burden.
FUNDING: National Institute on Drug Abuse.
Fulltext Design and implementation of a factorial randomized controlled trial of methadone maintenance therapy and an evidence-based behavioral intervention for incarcerated people living with HIV and opioid dependence in Malaysia

Bazazi AR, Wickersham JA, Wegman MP, Culbert GJ, Pillai V, Shrestha R, et al.

Contemp Clin Trials, 2017 08;59:1-12.
PMID: 28479216 DOI: 10.1016/j.cct.2017.05.006

Incarcerated people living with HIV and opioid dependence face enormous challenges to accessing evidence-based treatment during incarceration and after release into the community, placing them at risk of poor HIV treatment outcomes, relapse to opioid use and accompanying HIV transmission risk behaviors. Here we describe in detail the design and implementation of Project Harapan, a prospective clinical trial conducted among people living with HIV and opioid dependence who transitioned from prison to the community in Malaysia from 2010 to 2014. This trial involved 2 interventions: within-prison initiation of methadone maintenance therapy and an evidence-based behavioral intervention adapted to the Malaysian context (the Holistic Health Recovery Program for Malaysia, HHRP-M). Individuals were recruited and received the interventions while incarcerated and were followed for 12months after release to assess post-release HIV transmission risk behaviors and a range of other health-related outcomes. Project Harapan was designed as a fully randomized 2×2 factorial trial where individuals would be allocated in equal proportions to methadone maintenance therapy and HHRP-M, methadone maintenance therapy alone, HHRP-M alone, or control. Partway through study implementation, allocation to methadone maintenance therapy was changed from randomization to participant choice; randomization to HHRP-M continued throughout. We describe the justification for this study; the development and implementation of these interventions; changes to the protocol; and screening, enrollment, treatment receipt, and retention of study participants. Logistical, ethical, and analytic issues associated with the implementation of this study are discussed.
Fulltext Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis

Morozova O, Crawford FW, Cohen T, Paltiel AD, Altice FL

Addiction, 2020 Mar;115(3):437-450.
PMID: 31478285 DOI: 10.1111/add.14797

BACKGROUND AND AIMS: Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment.
DESIGN, SETTING AND PARTICIPANTS: Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD.
MEASUREMENTS: Incremental cost per quality-adjusted life-year gained in the simulated population.
FINDINGS: An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand.
CONCLUSIONS: It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.
Fulltext Correlates of viral suppression among HIV-infected men who have sex with men and transgender women in Lima, Peru

Rich KM, Valencia Huamaní J, Kiani SN, Cabello R, Elish P, Florez Arce J, et al.

AIDS Care, 2018 Nov;30(11):1341-1350.
PMID: 29843518 DOI: 10.1080/09540121.2018.1476657

In Peru, HIV is concentrated among men who have sex with men (MSM) and transgender women (TGW). Between June 2015 and August 2016, 591 HIV-positive MSM and TGW were recruited at five clinical care sites in Lima, Peru. We found that 82.4% of the participants had achieved viral suppression (VS; VL
Correlates of newly diagnosed HIV infection among cisgender women sex workers and transgender women sex workers in Greater Kuala Lumpur, Malaysia

Wang M, Lim SH, Gibson BA, Azwa I, Guadamuz TE, Altice FL, et al.

Int J STD AIDS, 2021 06;32(7):609-619.
PMID: 33752518 DOI: 10.1177/0956462420970417

Globally, cisgender women sex workers (CWSWs) and transgender women sex workers (TWSWs) experience increased vulnerabilities to HIV infection. Unfortunately, there is limited data on the drivers of HIV infection in these two understudied populations, particularly in Southeast Asia. To better understand factors associated with HIV infection, we evaluated correlates of newly diagnosed HIV infection in these two populations in Greater Kuala Lumpur, Malaysia. A total of 469 women (CWSW: n = 283; TWSW: n = 186) were included in this study. Most participants who tested HIV+ were unaware of their infection (59.6%; n = 34/57). Separate binary and multivariable logistic regressions were conducted to identify correlates of newly diagnosed HIV in CWSWs and TWSWs. Among CWSWs, Chlamydia trachomatis (aOR = 5.66; p = 0.007) and lifetime use of ecstasy/MDMA (aOR = 5.34; p = 0.03) were associated with newly diagnosed HIV, while condomless vaginal sex with clients was associated with lower likelihood of HIV infection (aOR = 0.98; p = 0.01). Among TWSWs, being single (aOR = 6.76; p = 0.03), using mobile application to solicit clients (aOR = 25.33; p = 0.006), and having C. trachomatis infection (aOR = 88.22, p = 0.02) were associated with newly diagnosed HIV. Expansion of HIV/sexually transmitted infection screening is needed to increase detection of HIV and linkage to care for sex workers. Interventions to reduce HIV infection among CWSWs and TWSWs should be tailored to these populations' unique vulnerabilities.
Fulltext Correlates of Recent HIV Testing Among Transgender Women in Greater Kuala Lumpur, Malaysia

Rutledge R, Morozova O, Gibson BA, Altice FL, Kamarulzaman A, Wickersham JA

LGBT Health, 2018 11 27;5(8):484-493.
PMID: 30481120 DOI: 10.1089/lgbt.2018.0021

PURPOSE: In Malaysia, an estimated 9.7%-12.4% of transgender women (TW) are HIV positive, with higher estimates among those engaged in sex work. According to the 90-90-90 Joint United Nations Programme on HIV/AIDS strategy, HIV testing is the first crucial step in curbing the HIV epidemic. This study examines correlates of recent HIV testing among TW in Greater Kuala Lumpur, Malaysia.
METHODS: TW (N = 199) in Greater Kuala Lumpur completed a survey on healthcare access and utilization, including HIV testing history. Bivariate logistic regression and penalized multivariate logistic regression were used to explore correlates of HIV testing in the last 12 months.
RESULTS: Overall, 41.7% of TW reported having ever been tested for HIV. Among participants who were HIV negative or not sure of their HIV status (n = 187), only 18.7% (n = 35) had been tested for HIV in the last 12 months. The multivariate analysis indicated that having a primary care provider (PCP), being 26-40 years of age, and having higher mental health functioning were positively associated with recent HIV testing. Active amphetamine use and previous depression diagnosis were also associated with recent HIV testing.
CONCLUSION: HIV testing is the first step in linking individuals to prevention and treatment interventions. Our findings suggest that having a PCP can improve engagement in HIV testing. Moreover, PCPs can serve as a valuable link to HIV treatment and prevention services. Current interventions that target social and behavioral risk factors for HIV, on their own, may be insufficient at engaging all HIV-vulnerable TW.
Fulltext Confronting the HIV, Tuberculosis, Addiction, and Incarceration Syndemic in Southeast Asia: Lessons Learned from Malaysia

Culbert GJ, Pillai V, Bick J, Al-Darraji HA, Wickersham JA, Wegman MP, et al.

J Neuroimmune Pharmacol, 2016 09;11(3):446-55.
PMID: 27216260 DOI: 10.1007/s11481-016-9676-7

Throughout Southeast Asia, repressive drug laws have resulted in high rates of imprisonment in people who inject drugs (PWID) and people living with HIV (PLH), greatly magnifying the harm associated with HIV, tuberculosis, and addiction. We review findings from Malaysia's largest prison to describe the negative synergistic effects of HIV, tuberculosis, addiction, and incarceration that contribute to a 'perfect storm' of events challenging public and personal health and offer insights into innovative strategies to control these converging epidemics. The majority of PLH who are imprisoned in Malaysia are opioid dependent PWID. Although promoted by official policy, evidence-based addiction treatment is largely unavailable, contributing to rapid relapse and/or overdose after release. Similarly, HIV treatment in prisons and compulsory drug treatment centers is sometimes inadequate or absent. The prevalence of active tuberculosis is high, particularly in PLH, and over 80 % of prisoners and prison personnel are latently infected. Mandatory HIV testing and subsequent segregation of HIV-infected prisoners increases the likelihood of tuberculosis acquisition and progression to active disease, amplifying the reservoir of infection for other prisoners. We discuss strategies to control these intersecting epidemics including screening linked to standardized treatment protocols for all three conditions, and effective transitional programs for released prisoners. For example, recently introduced evidence-based interventions in prisons like antiretroviral therapy (ART) to treat HIV, isoniazid preventive therapy to treat latent tuberculosis infection, and methadone maintenance to treat opioid dependence, have markedly improved clinical care and reduced morbidity and mortality. Since introduction of these interventions in September 2012, all-cause and HIV-related mortality have decreased by 50.0 % and 75.7 %, respectively. We discuss the further deployment of these interventions in Malaysian prisons.
Fulltext Clinic-Integrated Smartphone App (JomPrEP) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Mixed Methods Evaluation of Usability and Acceptability

Shrestha R, Altice FL, Khati A, Azwa I, Gautam K, Gupta S, et al.

JMIR Mhealth Uhealth, 2023 Feb 16;11:e44468.
PMID: 36795465 DOI: 10.2196/44468

BACKGROUND: HIV disproportionately affects men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, including in health care settings, mobile health (mHealth) platforms have the potential to open new frontiers in HIV prevention.
OBJECTIVE: We developed an innovative, clinic-integrated smartphone app called JomPrEP, which provides a virtual platform for Malaysian MSM to engage in HIV prevention services. In collaboration with the local clinics in Malaysia, JomPrEP offers a range of HIV prevention (ie, HIV testing and pre-exposure prophylaxis [PrEP]) and other support services (eg, referral to mental health support) without having to interface face to face with clinicians. This study evaluated the usability and acceptability of JomPrEP to deliver HIV prevention services for MSM in Malaysia.
METHODS: In total, 50 PrEP-naive MSM without HIV in Greater Kuala Lumpur, Malaysia, were recruited between March and April 2022. Participants used JomPrEP for a month and completed a postuse survey. The usability of the app and its features were assessed using self-report and objective measures (eg, app analytics, clinic dashboard). Acceptability was evaluated using the System Usability Scale (SUS).
RESULTS: The participants' mean age was 27.9 (SD 5.3) years. Participants used JomPrEP for an average of 8 (SD 5.0) times during 30 days of testing, with each session lasting an average of 28 (SD 38.9) minutes. Of the 50 participants, 42 (84%) ordered an HIV self-testing (HIVST) kit using the app, of whom 18 (42%) ordered an HIVST more than once. Almost all participants (46/50, 92%) initiated PrEP using the app (same-day PrEP initiation: 30/46, 65%); of these, 16/46 (35%) participants chose PrEP e-consultation via the app (vs in-person consultation). Regarding PrEP dispensing, 18/46 (39%) participants chose to receive their PrEP via mail delivery (vs pharmacy pickup). The app was rated as having high acceptability with a mean score of 73.8 (SD 10.1) on the SUS.
CONCLUSIONS: JomPrEP was found to be a highly feasible and acceptable tool for MSM in Malaysia to access HIV prevention services quickly and conveniently. A broader, randomized controlled trial is warranted to evaluate its efficacy on HIV prevention outcomes among MSM in Malaysia.
TRIAL REGISTRATION: ClinicalTrials.gov NCT05052411; https://clinicaltrials.gov/ct2/show/NCT05052411.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/43318.
Fulltext Clinic-Integrated Mobile Health Intervention ("JomPrEP" App) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Protocol for an Intervention Development and Multiphase Trial

Shrestha R, Wickersham JA, Khati A, Azwa I, Ni Z, Kamarulzaman A, et al.

JMIR Res Protoc, 2022 Dec 21;11(12):e43318.
PMID: 36542425 DOI: 10.2196/43318

BACKGROUND: Men who have sex with men (MSM) are disproportionately affected by the HIV epidemic in Malaysia and globally. Cross-cutting prevention strategies such as mobile health (mHealth), particularly smartphone apps, hold great promise for HIV prevention efforts among Malaysian MSM, especially when linked to HIV testing and pre-exposure prophylaxis (PrEP).
OBJECTIVE: This study aims to adapt an existing app to create and test a clinic-integrated app (JomPrEP), a virtual platform to deliver HIV testing and PrEP services for MSM in Malaysia.
METHODS: The JomPrEP project involves developing and testing an app-based platform for HIV prevention among Malaysian MSM and will be conducted in 2 phases. In phase I (development phase), we will adapt an existing mHealth app (HealthMindr) to create a new clinic-integrated app called "JomPrEP" to deliver holistic HIV prevention services (eg, HIV testing, PrEP, support services for mental health and substance use) among MSM in Malaysia. During phase II (testing phase), we will use a type I hybrid implementation science trial design to test the efficacy of JomPrEP while gathering information on implementation factors to guide future scale-up in real-world settings.
RESULTS: As of September 2022, we have completed phase I of the proposed study. Based on a series of formative work completed during phase I, we developed a fully functional, clinic-integrated JomPrEP app, which provides a virtual platform for MSM in Malaysia to facilitate their engagement in HIV prevention in a fast and convenient manner. Based on participant feedback provided during phase I, we are currently optimizing JomPrEP and the research protocols for a large-scale efficacy trial (phase II), which will commence in January 2023.
CONCLUSIONS: Scant HIV prevention resources coupled with entrenched stigma, discrimination, and criminalization of same-sex sexual behavior and substance use hamper access to HIV prevention services in Malaysia. If found efficacious, JomPrEP can be easily adapted for a range of health outcomes and health care delivery services for MSM, including adaptation to other low- and middle-income countries.
TRIAL REGISTRATION: ClinicalTrials.gov NCT05325476; https://clinicaltrials.gov/ct2/show/NCT05325476.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43318.
Fulltext Challenges in managing HIV in people who use drugs

Kamarulzaman A, Altice FL

Curr. Opin. Infect. Dis., 2015 Feb;28(1):10-6.
PMID: 25490106 DOI: 10.1097/QCO.0000000000000125

HIV management in people who use drugs (PWUD) is typically complex and challenging due to the presence of multiple medical and psychiatric comorbidities as well as social, physical, economic and legal factors that often disrupt the HIV continuum of care. In this review, we describe the individual, health systems and societal barriers to HIV treatment access and care retention for PWUD. In addition, the clinical management of HIV-infected PWUD is often complicated by the presence of multiple infectious and noninfectious comorbidities.
Case series of buprenorphine injectors in Kuala Lumpur, Malaysia

Bruce RD, Govindasamy S, Sylla L, Haddad MS, Kamarulzaman A, Altice FL

Am J Drug Alcohol Abuse, 2008;34(4):511-7.
PMID: 18584580 DOI: 10.1080/00952990802122259

Diversion of buprenorphine has been described in settings where it is legally prescribed and has become an increasing concern in Malaysia; it resulted in banning of buprenorphine in Singapore where unsubstantiated case reports suggested that buprenorphine injection was associated with particularly poor outcomes. We therefore conducted a case series of qualitative interviews with buprenorphine injectors in Kuala Lumpur, Malaysia to examine further the issues surrounding buprenorphine injection as well as the abuse of midazolam in combination with buprenorphine. Interviews with 19 men do not suggest significant adverse health consequences from buprenorphine injection alone and injectors have adapted diverted buprenorphine as a treatment modality. A subset of these injectors, however, combined buprenorphine and midazolam for euphoric effects with resultant symptoms of a possible pharmacological interaction. Prospective cohort studies, rather than hospital-derived samples, are needed to better understand the safety of buprenorphine injection.
Fulltext Barriers and Facilitators to Implementing Project ECHO in Malaysia During the COVID-19 Pandemic

Walters SM, Li WP, Saifi R, Azwa I, Syed Omar SF, Collier ZK, et al.

J Int Assoc Provid AIDS Care, 2022;21:23259582221128512.
PMID: 36177542 DOI: 10.1177/23259582221128512

Objective: In Malaysia, HIV is concentrated among key populations who experience barriers to care due to stigma and healthcare discrimination. The COVID-19 pandemic has increased barriers to healthcare. Project ECHO (Extension for Community Healthcare Outcomes) is a transformative tele-education strategy that could improve HIV prevention and treatment. Methods: Practicing physicians who were aged 18 years or older and had internet access participated in asynchronous online focus groups. Results: Barriers to Project ECHO were conflicting priorities, time constraints, and technology. Facilitators included content and format, dedicated time, asynchronized flexible programming, incentives, and ensuring technology was available. Conclusion: Project ECHO is a promising intervention that can increase physicians' knowledge and skill set in specialty medicine during the COVID-19 pandemic. Interventionists in Malaysia in particular, but also in general, should consider these barriers and facilitators when developing Project ECHO as they may aid in developing a more robust program and increase participation.
Balancing access and safety in prescribing opioid agonist therapy to prevent HIV transmission

Bachireddy C, Weisberg DF, Altice FL

Addiction, 2015 Dec;110(12):1869-71.
PMID: 26464200 DOI: 10.1111/add.13055
Fulltext Attitudes toward opioid substitution therapy and pre-incarceration HIV transmission behaviors among HIV-infected prisoners in Malaysia: implications for secondary prevention

Bachireddy C, Bazazi AR, Kavasery R, Govindasamy S, Kamarulzaman A, Altice FL

Drug Alcohol Depend, 2011 Jul 1;116(1-3):151-7.
PMID: 21232882 DOI: 10.1016/j.drugalcdep.2010.12.001

Pre-incarceration HIV transmission behaviors and current attitudes toward opioid substitution therapy (OST) among HIV-infected male prisoners in Malaysia have important implications for secondary HIV prevention efforts.
Fulltext Attitudes toward medication-assisted treatment among fishermen in Kuantan, Malaysia, who inject drugs

Brown SE, Wickersham JA, Pelletier AR, Marcus RM, Erenrich R, Kamarulzaman A, et al.

J Ethn Subst Abuse, 2016 07 12;16(3):363-379.
PMID: 27404914 DOI: 10.1080/15332640.2016.1196632

Fishermen who inject drugs represent an understudied group at high risk for HIV in Malaysia. This study describes fishing, drug use, and attitudes toward medication-assisted treatment (MAT) for opioid use disorders. Thirty-four male ethnic Malay fishermen completed semistructured interviews analyzed by content analysis. Analysis revealed four themes surrounding opioids, which they called ubat ("medicine"): (a) the fishing lifestyle facilitating substance use, (b) previous unsuccessful attempts to quit, (c) categorizing substances as haram or halal, and (d) attitudes toward MAT. Fishermen's environment permits substance use, including injecting drugs on boats. Fishermen expressed more positive attitudes toward methadone and negative attitudes toward buprenorphine.

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