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Fulltext HIV Testing and awareness of HIV status among people who inject drugs in greater Kuala Lumpur, Malaysia

Bazazi AR, Vijay A, Crawford FW, Heimer R, Kamarulzaman A, Altice FL

AIDS Care, 2018 Jan;30(1):59-64.
PMID: 28803503 DOI: 10.1080/09540121.2017.1363852

HIV testing services are the gateway into HIV treatment and are critical for monitoring the epidemic. HIV testing is recommended at least annually in high-risk populations, including people who inject drugs (PWID). In Malaysia, the HIV epidemic is concentrated among PWID, but their adherence to testing recommendations and the proportion of HIV-positive PWID who are aware of their status remain unknown. We recruited 460 PWID in Greater Kuala Lumpur using respondent-driven sampling and conducted HIV testing. We examined past testing behaviors, estimating testing frequency, correlates of testing in the past 12 months, and the proportion of those living with HIV who were aware of their status. Results showed that most PWID living with HIV (90.4%, 95% CI: 83.6%-95.9%) were aware of their status. Among those never previously diagnosed with HIV, few had accessed HIV testing in the past 12 months (14.3%, 95% CI: 11.1%-18.0%). Prison (57.0%) and compulsory drug detention centers (36.1%) were the primary locations where PWID reported ever being HIV tested, and the main correlate of recent testing in regression was recent criminal justice involvement. Although awareness of HIV status may be high among PWID living with HIV in Kuala Lumpur, testing occurs primarily in prisons and compulsory drug detention centers, where it is involuntary and linkage to care is limited. A shift in HIV testing policy is needed to align health and human rights objectives, replacing mandatory testing with voluntary testing in settings where individuals can be rapidly linked to HIV care.
Fulltext Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia

Bazazi AR, Culbert GJ, Wegman MP, Heimer R, Kamarulzaman A, Altice FL

BMC Infect Dis, 2022 Nov 11;22(1):837.
PMID: 36368939 DOI: 10.1186/s12879-022-07804-6

INTRODUCTION: Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison.
METHODS: This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival.
RESULTS: Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4+ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0).
CONCLUSIONS: Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release.
TRIAL REGISTRATION: NCT02396979. Retrospectively registered 24/03/2015.
Fulltext HIV Prevalence Among People Who Inject Drugs in Greater Kuala Lumpur Recruited Using Respondent-Driven Sampling

Bazazi AR, Crawford F, Zelenev A, Heimer R, Kamarulzaman A, Altice FL

AIDS Behav, 2015 Dec;19(12):2347-57.
PMID: 26358544 DOI: 10.1007/s10461-015-1191-y

The HIV epidemic in Malaysia is concentrated among people who inject drugs (PWID). Accurate estimates of HIV prevalence are critical for developing appropriate treatment and prevention interventions for PWID in Malaysia. In 2010, 461 PWID were recruited using respondent-driven sampling in Greater Kuala Lumpur, Malaysia. Participants completed rapid HIV testing and behavioral assessments. Estimates of HIV prevalence were computed for each of the three recruitment sites and the overall sample. HIV prevalence was 15.8 % (95 % CI 12.5-19.2 %) overall but varied widely by location: 37.0 % (28.6-45.4 %) in Kampung Baru, 10.3 % (5.0-15.6 %) in Kajang, and 6.3 % (3.0-9.5 %) in Shah Alam. Recruitment extended to locations far from initial interview sites but was concentrated around discrete geographic regions. We document the high prevalence of HIV among PWID in Greater Kuala Lumpur. Sustained support for community surveillance and HIV prevention interventions is needed to stem the HIV epidemic among PWID in Malaysia.

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