Confronting the HIV, Tuberculosis, Addiction, and Incarceration Syndemic in Southeast Asia: Lessons Learned from Malaysia

Abstract

Throughout Southeast Asia, repressive drug laws have resulted in high rates of imprisonment in people who inject drugs 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 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. Although promoted by official policy, evidence-based drug 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, enlarging 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 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.

A Moderated Mediation Model of HIV-Related Stigma, Depression, and Social Support on Health-Related Quality of Life among Incarcerated Malaysian Men with HIV and Opioid Dependence

“…HIV care was initially provided by Ministry of Health clinicians in the prison clinic and later also by study clinicians [51]. All PLH, regardless of study participation, received CD4 and viral load testing and a comprehensive clinical assessment and medical record review.…”

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

“…ART initiation remained contingent on physician discretion, medication stockouts occurred periodically, and high morbidity and mortality among PLH in the prison were observed. 54,81 In 2011, the research team worked with prison staff to establish a dedicated HIV clinic with staffing support from physicians affiliated with University of Malaya and Yale, which led to the expansion of evidence-based HIV care in the prison. 54 Rapid, point-of-care CD4 testing was introduced to the prison clinic.…”

“…54,81 In 2011, the research team worked with prison staff to establish a dedicated HIV clinic with staffing support from physicians affiliated with University of Malaya and Yale, which led to the expansion of evidence-based HIV care in the prison. 54 Rapid, point-of-care CD4 testing was introduced to the prison clinic. Subsequently, all PLH, regardless of study participation, received CD4 and viral load testing and a comprehensive clinical assessment and medical record review.…”

“…54 CD4+ T-lymphocyte count was measured on all participants and viral load was measured on those participants receiving ART. Results were provided to the prison doctors.…”

Promoting Global Health — Prevention and Treatment of Substance Abuse and HIV in Asia

“…Second, Culbert et al reviewed the findings from Malaysia’s largest prison. The authors described the contributions and synergistic effects of HIV, tuberculosis, addiction, and incarceration, and how these factors culminated to a “perfect storm” of events that challenge both public and personal health, and they offered insights into innovative strategies to control these converging epidemics (Culbert et al, 2016). Third, Wingo et al reviewed the literature on novelty seeking from both human and animal studies at behavioral and molecular levels, which led to the conclusion that the novelty-seeking trait can be valuable for predicting individual vulnerability to drug addiction and for generating successful treatment for patients with drug abuse disorders (Wingo et al, 2015).…”