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Harm reduction in Asia: a successful response to hidden epidemics. The Asian Harm Reduction Network

Crofts N, Costigan G, Narayanan P, Gray J, Dorabjee J, Langkham B, et al.

AIDS, 1998;12 Suppl B:S109-15.
PMID: 9679636
Matched MeSH terms: Substance Abuse, Intravenous/prevention & control*
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.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control*
Drug injecting and HIV infection among the population of drug abusers in Asia

Poshyachinda V

Bull Narc, 1993;45(1):77-90.
PMID: 8305908

Opium has been produced and consumed since the nineteenth century in the areas of Asia currently referred to as the Golden Crescent and the Golden Triangle. In the 1970s and 1980s, most countries from Afghanistan to Japan experienced a heroin epidemic of varying degrees of severity. Opium and heroin abuse appeared to be more severe in countries and areas where those drugs were produced, an exception being Hong Kong, which has had a large population of heroin abusers for more than two decades. Drug injecting was far more common in countries of the Golden Triangle than in those of the Golden Crescent. In Myanmar and Thailand, for example, up to 90 per cent of chronic heroin abusers practised intravenous injection, which appeared to spread to heroin abusers in nearby territories such as the State of Manipur in India. Yunnan province in China, as well as Malaysia and Viet Nam. Amphetamine abuse was more frequent in Japan and the Republic of Korea for a number of years, while illicit production and consumption in the Philippines have recently shown significant increases. The injection of amphetamines was common only in the Republic of Korea. The prevalence of injecting among institutionalized methamphetamine abusers was reported at about 90 per cent. Most countries in Asia first reported cases of infection with the human immunodeficiency virus (HIV) in the mid-1980s. An extremely rapid spead of the epidemic and high prevalence, at rates of from 30 to 90 per cent, of HIV infection among the sample of intravenous heroin abusers were observed in a few countries with a high prevalence of intravenous injecting, such as India (in the State of Manipur), Myanmar and Thailand. The rest had either few reported cases or none at all, even though needle-sharing was found to be common. Great caution should be exercised in interpreting prevalence because of vast differences in methods of assessment. Given the vulnerability of intravenous drug abusers to rapid transmission of HIV infection, the prevention of drug injecting is of paramount importance in arresting the spread of the epidemic. Efforts to contain drug abuse, though difficult, are a principal means of achieving that end.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control
Islam and harm reduction

Kamarulzaman A, Saifuddeen SM

Int J Drug Policy, 2010 Mar;21(2):115-8.
PMID: 20006483 DOI: 10.1016/j.drugpo.2009.11.003

Although drugs are haram and therefore prohibited in Islam, illicit drug use is widespread in many Islamic countries throughout the world. In the last several years increased prevalence of this problem has been observed in many of these countries which has in turn led to increasing injecting drug use driven HIV/AIDS epidemic across the Islamic world. Whilst some countries have recently responded to the threat through the implementation of harm reduction programmes, many others have been slow to respond. In Islam, The Quran and the Prophetic traditions or the Sunnah are the central sources of references for the laws and principles that guide the Muslims' way of life and by which policies and guidelines for responses including that of contemporary social and health problems can be derived. The preservation and protection of the dignity of man, and steering mankind away from harm and destruction are central to the teachings of Islam. When viewed through the Islamic principles of the preservation and protection of the faith, life, intellect, progeny and wealth, harm reduction programmes are permissible and in fact provide a practical solution to a problem that could result in far greater damage to the society at large if left unaddressed.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control*
HIV-related characteristics among female partners of injecting drug users in Kelantan, Malaysia: a descriptive study

Mohd Nasarruddin A, Wan Mohammad WM, Nik Hussain NH, Ali SH, Zubir HM

AIDS Care, 2015;27(3):301-6.
PMID: 25471247 DOI: 10.1080/09540121.2014.985182

Kelantan, a northeastern state in Peninsular Malaysia, is one of the states that has been acutely hit by injecting drug user (IDU)-driven HIV epidemic, in addition to having a high number of infected women in Malaysia. This cross-sectional study describes the socio-demographic characteristics, HIV risk factors, risk perception, and adoption of preventive behaviors among female partners of IDUs in Kelantan. Out of 101 women, the majority of them are from low socioeconomic background and have no other risk factors besides heterosexual HIV transmission from their male IDU partners. Although 45.5% have not been tested for HIV and more than half (53.5%) of them did not use condoms during sexual intercourse, only 44.6% of the women perceived themselves to be at risk of being infected with HIV. Most of the women (86.1%) were willing to undergo voluntary counseling and testing (VCT). Female partners of IDUs continue to be vulnerable to HIV due to having sexual contact with IDUs, and also due to their socioeconomic position in the community. To prevent HIV transmission among female partners of IDUs, consolidating HIV prevention efforts from multiple approaches is needed.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control
Drugs and AIDS in Southeast-Asia

Poshyachinda V

Forensic Sci Int, 1993 Nov;62(1-2):15-28.
PMID: 8300028

Opium dependence was indigenous to countries in the Golden Triangle area in south-east Asia (SA). Heroin epidemics developed in most SA countries in the 1960s and early 1970s and remained a significant problem particularly in Myanmar, Thailand and Malaysia until now. In contrast, the island countries in SA seemed quite free from opiate abuse. Intravenous injection (IV) of drugs appeared after the heroin epidemic and currently prevails in countries with a significant opiate abuse problem. IV of opium was particularly common in the highly urbanized cities in Vietnam. Most SA countries started HIV seroscreening in IV drug users (IVDU) around the middle of the 1980s. Rapid epidemic spread of HIV infection was observed in 1988-89 in Thailand and Myanmar. The Highest prevalence of more than 80% was reported from a study of IVDUs in Yangon, Myanmar, followed by Thailand at about 40%. Although HIV infected IVDUs were identified at the same time in Malaysia and later in Singapore and the Philippines, there was no evidence of such a rapid and severe epidemic.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control
Fulltext The complex interplay of social networks, geography and HIV risk among Malaysian Drug Injectors: Results from respondent-driven sampling

Zelenev A, Long E, Bazazi AR, Kamarulzaman A, Altice FL

Int J Drug Policy, 2016 11;37:98-106.
PMID: 27639995 DOI: 10.1016/j.drugpo.2016.08.008

BACKGROUND: HIV is primarily concentrated among people who inject drugs (PWID) in Malaysia, where currently HIV prevention and treatment coverage is inadequate. To improve the targeting of interventions, we examined HIV clustering and the role that social networks and geographical distance play in influencing HIV transmission among PWID.
METHODS: Data were derived from a respondent-driven survey sample (RDS) collected during 2010 of 460 PWID in greater Kuala Lumpur. Analysis focused on socio-demographic, clinical, behavioural, and network information. Spatial probit models were developed based on a distinction between the influence of peers (individuals nominated through a recruitment network) and neighbours (residing a close distance to the individual). The models were expanded to account for the potential influence of the network formation.
RESULTS: Recruitment patterns of HIV-infected PWID clustered both spatially and across the recruitment networks. In addition, HIV-infected PWID were more likely to have peers and neighbours who inject with clean needles were HIV-infected and lived nearby (<5km), more likely to have been previously incarcerated, less likely to use clean needles (26.8% vs 53.0% of the reported injections, p<0.01), and have fewer recent injection partners (2.4 vs 5.4, p<0.01). The association between the HIV status of peers and neighbours remained significantly correlated even after controlling for unobserved variation related to network formation and sero-sorting.
CONCLUSION: The relationship between HIV status across networks and space in Kuala Lumpur underscores the importance of these factors for surveillance and prevention strategies, and this needs to be more closely integrated. RDS can be applied to identify injection network structures, and this provides an important mechanism for improving public health surveillance, accessing high-risk populations, and implementing risk-reduction interventions to slow HIV transmission.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control
Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine

Madden L, Bojko MJ, Farnum S, Mazhnaya A, Fomenko T, Marcus R, et al.

Int J Drug Policy, 2017 11;49:48-53.
PMID: 28957756 DOI: 10.1016/j.drugpo.2017.07.025

BACKGROUND: Opioid agonist therapies (OAT) like methadone and buprenorphine maintenance treatment remain markedly under-scaled in Ukraine despite adequate funding. Clinicians and administrators were assembled as part of an implementation science strategy to scale-up OAT using the Network for Improvement of Addiction Treatment (NIATx) approach.
METHODS: Nominal Group Technique (NGT), a key ingredient of the NIATx toolkit, was directed by three trained coaches within a learning collaborative of 18 OAT clinicians and administrators to identify barriers to increase OAT capacity at the regional "oblast" level, develop solutions, and prioritize local change projects. NGT findings were supplemented from detailed notes collected during the NGT discussion.
RESULTS: The top three identified barriers included: (1) Strict regulations and inflexible policies dictating distribution and dispensing of OAT; (2) No systematic approach to assessing OAT needs on regional or local level; and (3) Limited funding and financing mechanisms combined with a lack of local/regional control over funding for OAT treatment services.
CONCLUSIONS: NGT provides a rapid strategy for individuals at multiple levels to work collaboratively to identify and address structural barriers to OAT scale-up. This technique creates a transparent process to address and prioritize complex issues. Targeting these priorities allowed leaders at the regional and national level to advocate collectively for approaches to minimize obstacles and create policies to improve OAT services.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control
The transition to harm reduction: understanding the role of non-governmental organisations in Malaysia

Narayanan S, Vicknasingam B, Robson NM

Int J Drug Policy, 2011 Jul;22(4):311-7.
PMID: 21300533 DOI: 10.1016/j.drugpo.2011.01.002

The transition of drug policy from prohibition to harm reduction has never been easy. The deeply entrenched belief in prohibition shared by policy makers and religious leaders provided little room for alternatives, and change came only slowly. The non-governmental organisations (NGOs) in Malaysia played a pivotal role in effecting such a change. Understanding how they did so may be instructive for other similarly placed countries.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control
Fulltext Lack of reduction in buprenorphine injection after introduction of co-formulated buprenorphine/naloxone to the Malaysian market

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

Am J Drug Alcohol Abuse, 2009;35(2):68-72.
PMID: 19212931 DOI: 10.1080/00952990802585406

Diversion of buprenorphine (BPN) has been described in settings where it is legally prescribed and has resulted in increasing concern. To address this concern, co-formulation of buprenorphine/naloxone (BPN/NLX) replaced buprenorphine alone in Malaysia in December 2006.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control*
Malaysia and harm reduction: the challenges and responses

Reid G, Kamarulzaman A, Sran SK

Int J Drug Policy, 2007 Mar;18(2):136-40.
PMID: 17689356

In Malaysia the response to illicit drug use has been largely punitive with the current goal of the Malaysian government being to achieve a drug-free society by 2015. This paper outlines the results of a desk-based situation assessment conducted over a 3-week period in 2004. Additional events, examined in 2005, were also included to describe more recent policy developments and examine how these came about. Despite punitive drug policy there has been a substantial rise in the number of drug users in the country. Over two-thirds of HIV/AIDS cases are among injecting drug users (IDUs) and there has been an exponential rise in the number of cases reported. Further, data suggest high risk drug use practices are widespread. Harm reduction initiatives have only recently been introduced in Malaysia. The successful piloting of substitution therapies, in particular methadone and buprenorphine, is cause for genuine hope for the rapid development of such interventions. In 2005 the government announced it will allow methadone maintenance programmes to operate beyond the pilot phase and needle and syringe exchange programmes will be established to serve the needs of IDUs.

Matched MeSH terms: Substance Abuse, Intravenous/prevention & control*