Integrating HIV with Addiction Treatment in Community and Custodial Health Care Services - Adeeba Kamarulzaman - ISAM 2013 Kuala Lumpur

(These are my rough notes that hopefully will give an impression of the depth and breadth of the research and researchers work-W.Hay)
The co existence of HIV in iV drug users is as low as 10% in countries where approaches have been taken to address this early. In Malaysia theres as high as 50%.


With HIV treatment TB is the cause for mortality.
Prevalence of undiagnosed pulmonaryTB among prisones is 12%  - we are instituting a tb screening program at entrance to the prisons.

HIV Epidemiologic Researahc on Outcomes (HERO) study
Longitudinal studying of HIV infection in drug users
Have high mortality.
HIV infected  IV users 7.5/1000
Unaffected IV users 1.5/1000


Modelling of combined and high coverage intervention to prevent HIV infection
Opiate agonist therapies reduce HIV
British Commbia Research Study presented showing benefit of giving retroviral therapy to those who use IV drugs

IDU(intravenous drug users) - of those with HIV only 25% are receiving retroviral therapy
IDU's often present later in the course of their HIV infections
IDU's underrepresented
-Barriers to 'seek,test, treat, and retain'
requires active outreach and overcoming the stigma that surrounds substance abuse and HIV

Addictophobia - exaggerated fear, aversion, distrimation agains drug users
since the beginning of HIV idus have been villified
Apathy - to the suffering
Inattention to adolescent , street youth, women who inject drugs
Criminal Justice System -
Criminal Justice System in Malaysia
- prisoners 40,000 9137/100000
high prevalence of mental ill, mandatory HIV teasing 6% prevalence, methadone introduced in 2009 to 12 prisons, hybrid health care system (Ministry of Health and Justice System)
No form of HIV treatment in compulsory treatment

CDDC survey
2 of 6 HIV positive
80% of all HIV known by both programs
Fair proportion didn't know their HIV status.
Comprehensive care is being provided now in different Malaysian community
Project Harapan has been started to improve situation
Implementaltion Factors
-patient factors -tb related comorbidity, disclosure
-staff factors- clinician concerns, security concerns, repeated educational sessions
Institutional level - we've been fortunate the the 2 director generals for the last 5 years have been fully behind us, we have national task force, integrating criminal justice and public health, anti retroviral treatment not that available.
needle exchange has been done as well,

Managing Addiction through Evidence Based Medical and Psychosocial Interventions, ISAM 2013, Kuala Lumpur

(These are my rough notes from the ISAM 2013 Kuala Lumpur conference. I hope they will share the depth and breadth of material presented. I apologize for any errors and direct you to the sources for greater clarity-W. Hay)
15th Annual International Society of Addiction Medicine Meeting

50 countries represented
Organized by ISAM, University of Malaya, Ministry of Home Affairs, Malaysia; Vice Chancellors Office, University of Malaya; Ministry of Health Malaysia; University of Malaya, Center of Addiction Sciences,; National Anti drug Agency; Department of Prison;Cyberjaya University College of Medical Sciences;Malaysian Culture and Exhibition Bureau; Ministry of Tourism and Culture; Malaysian AIDS Council; Reckitt Benckiser Pharmaceutical;Lundbeck International, Eli-Lilly, MANSA, CCM Pharmaceutical Division, Sunward Pharmaceutical
Opening prayer and praise

Presentation by Dr. Muhammad Muhsin Ahmad Zahari - Chairman of Local Organizing Committee for ISAM's 15th annual meeting 2013 (This is the first time that ISAM annual meeting will be held in the Asia Pacific region

- he is pleased that the media has provided coverage and he is hopeful that this will reduce stigma for those suffering from addiction. He welcomed delegates and expressed his knowledge of the high quality of science and medicine that would be presented. He encouraged delegates to also enjoy Kuala Lumpur and hoped they'd experience the arts.
Then followed the welcome address by Professor Dr Hannu Alho, President of ISAM

He welcomed the delegates. He expressed appreciation for the pre conference training sessions yesterday. He spoke highly of the science at the conference but encouraged networking and the chance for delegates to meet others working in this field in their own countries
The Honorable Deputy Minister of Home Affairs, Malaysia, The Honorable Datuk, Dr Hj Wan Junaidi Tuanku Jaafar

He opened by thanking the organizers and welcoming the delegates. He spoke to the range of addiction from illicit drugs, to alcohol, and behavioural addictions like gambling.  He spoke of the governments introducing key programs to address the problems systematically.  He gave a brief history of the work done in Malaysia.  He described hospital resources, the recognition of addiction disease, and the need to identify the addicted person and do assessment to provide treatment. He described events from 1975 , the move from compulsory treatment to more voluntary treatments.  He addressed the improvements in recidivism.  He expressed the concern the government has for treatment of addiction and addressing addiction because it affects so negatively those young people.  He described learning that 'cold turkey' simply didn't cure all the problems of addictions. He said that there was a growth in awareness that drug addiction resulted in a risk of relapse and a need to address multiple factors in their lives and recognize the effect addiction has on families.  He noted the recognition of drug addiction ,spending more money and time with the addiction, having more withdrawal, and using more for longer.  He felt there was a need to aim for at a drug free nation. He said that with the advent of HIV there was a recognition that to protect from HIV and spread with IV needles there was a need to adopt a harm reduction approach.  HIV in IV drug users has dropped 29% from 72.4% in the Methadone Programs showing their success and the success of education.  There is improvement in employment in those in medication assisted treatment, those in methadone programs is as high as 76% after 2 years in the program. Retention rates in the programs can be as high as 62%.  2/3s remain in the program.  All this is proof of medication assisted approach.  2003 - Cochrane research showed people in medication assisted research are retained in programs. This allows comprehensive strategies to be used.  He stated it was important to have doctors trained in addiction medicine. He described the work of the National Anti Drug Agency of Malaysia in treatment and rehabilitation. He described the contributions of public and private sections. He expressed the importance of psychosocial interventions.  They include case management, programs, programs of education to reduce risks. The government encourages close cooperation between government and non government organizations. They recognize the realities.  He described the need for one stop clinical settings that would provide assessments and treatment as well as services for psychosocial for addicted persons. There is a need for accessibility. Other venues need to be considered to, outreach to target groups, helping at diverse places.  He expressed the governments concern for the need for addiction experts and addiction agencies to have support.
Government has been concerned with training programs , and community based research, especially supporting private and public services, identifying and preventing new addictions.  The quality and outcome should be to reintegrate the drug dependent into society.  Restoring social skills is supported. Treatment and rehabilitation of persons with drug addiction should be done in the community, not keeping them in isolated institutions.  He described the various local programs in communities and the prison setting programs.
In closing he welcomed all delegates to Malaysia and hoped they would enjoy their stay and appreciate all that Malaysia has to offer.  With that he said he took great pleasure in officially opening the 2013 ISAM conference.
At that a large gong was struck three times!




 

Kuala Lumpur - Merdeka Square

Merdeka Square is also called Independence Square.  There's a great flag pole with the Malaysian Flag atop it.  Helen Oon in the Globetrotter Guide to Malaysia says it's the tallest flagpole in the world.  It was written in 2011.  The flagpole is 328 feet. When I was in Azerbaijan they said their flagpole was the tallest. Wikipedia today says the Tajikistan, at 541 feet is the tallest and the Azerbaijan flagpole at 436 feet is second tallest. By comparison 328 feet doesn't seem to cut it.  It's still pretty tall.

1957 the Union Jack came down and the Malaysian flag went up.  The field here was for cricket and rugby matches for the colonialists who attended the mock tudor fronted building, the Selangor Club.  I walked by this and could appreciated the 'exclusivity' and sense of superiority membership would give.  It reminded me just a bit of the Bombay Bicycle Club. It's all about who you know, isn't it?  The right sort of people?
The 
The Sultan Abdul Samad Building, moorish looking,  was built in 1897 by the architect A C Norman.  It has a central clock tower and three copper onion domes. AC Norman also designed St Mary's Church nearby.  I walked through the art gallery which houses a replica of the city of KL. There's also a model of the down town in detail and ARCH wooden cut outs and pictures.  I was able to watch the artisans at work there.





In the taxi on the way to Merdeka square the driver pointed out the beautiful old train station.
t

Singapore to Kuala Lumpur by Train

I boarded at the Woodlands Station in Singapore.  We all passed through Singapore departure, producing passport and exit portion of visa.  We all then passed through Malaysia customs.  Before going to the train waiting room,  I put my bag through a scanner. Everywhere there were signs forbidding recording or photography in the train station.
The train arrived on time and we boarded on time.  The train was very clean and modern. I brought my suitcase and backpack on with me, storing the suitcase in the overhead while keeping the back pack at my feet.  The chairs were comfortable and reclined.  There was a dining car behind us.  The clean washroom was in the car in front of us.
The gentleman who joined me in the window seat turned out to be an Indonesian psychiatrist.  We talked most of the trip and had lunch together in the dining car. He and his wife have a labradoodle.  We shared the frustrations we had working as psychiatrists, with too few resources and complex cases with long waiting lists. In addition to being a clinician he was an academic and had just published a paper in one of the world's most prestigious medical and psychiatric journals. I was humbled.
A catholic, we talked about God and the benefits of spirituality to our patients and the intolerance that we experienced with our atheist colleagues who unknowingly persecute the religious under the guise of their secularity.  This was a fascinating discussion and a surprise to both of us since we had just met.  He told me that the Malaysian patients appreciated and were comforted by those who participated in their religious traditions and weren't that particular as to which one their doctor followed, just so long as he appreciated the importance of faith and tradition.  I told him about the ignorance and intolerance of Canada's Quebec.  This was something he thought might happen in Australia but wouldn't be tolerated in Malaysia.
The train progressed through large tracts of jungle.
A couple of times we passed or were passed by a freight train.  The passenger train was all shiny whereas the freight trains were definitely more worn.
"Those are the palm plantations, mostly for harvesting palm oil," he told me as the train passed rows and rows of palm trees obviously well spaced and cultivated.
We saw all manner of habitat along the way, from poor and primitive to rich and ornate.  The only animals I saw were the big horned cattle and oxen's.
At one stop, he told me how he'd loved as a young man to come to this particular village and sit having coffee by the train. The coffee shop had grown so famous over time that it was eventually franchised.  It was very quaint. The train passed through several little villages and towns before going through a larger city before reaching Kuala Lumpur.
Being able to walk about the train with a few seats here and there vacant, I moved about taking pictures with my Nikon D5000 or my Gopro Hero 3.
My colleague had travelled on different trains around the world. He hoped some day to take the train through the Canadian Rockies and Laurentians.  We both waxed poetic about train travel as we sat in the dining car, he eating a noodle dish, while I had a chicken burger.  In the afternoon near the end of our trip we had rain.
"That's pretty standard this time of the year. It tends to be sunny in the morning and rain in the afternoon. It's always fairly humid and warm."
This was certainly a lovely train. Not quite the Orient Express, I understand, but very much a great way to travel Malaysia.