Malaysian Harm Reduction Successes Underscore Need to Address Ongoing Stigma & State Violence

Malaysia reports impressive harm reduction successes, justifying its selection as host of the International Harm Reduction Conference 2015, but it faces ongoing challenges around stigmatising injecting drug use as well as the continued application of the death penalty for trafficking offenses.

Harm reduction programmes introduced by the Ministry of Health in 2006 to curb the HIV epidemic have been hugely successful in reducing new HIV infections, increasing employment among people who inject opiates, and beginning to reduce stigma.

Currently hosting the 24th International Harm Reduction Conference, Malaysia is described by researcher Katie Stone as probably "one of the best examples in Asia in terms of the adoption and acceptance of harm reduction".

Between 2012 and 2014 the number of needle and syringe exchange programmes (NSP) has rocketed from 297 to 728 according to a report by Harm Reduction International (HRI).

As a result in 2014, 92.8% of people who inject drugs reported using sterile injecting equipment at last injection drug use reports Malaysia’s Ministry of Health. The Ministry of Health found that the number of new HIV infections among injecting drug users dropped from 5,176 in 2002 to 680 in 2014.

In Kelantan, a Northeastern state where the number of new HIV infections was four times higher than the national average between 2005 and 2010, the number of new cases has dropped from 1,239 in 2005 to 227 in 2014.

According to Dr Ahmad Razin, Kelantan’s state health director, the programmes have been successful because reducing stigma towards injecting drug users has contributed to an increase in people who use drugs problematically seeking help at health clinics, reported Malay Mail Online.

Malaysia lists 811 sites offering opioid substitution therapy (OST), the highest number in the region and 137 more than in 2012. By comparison India has similar number of people who inject drugs (between 177,000 and 180,000 vs 170,000 in Malaysia), but only lists 145 sites according to HRI.

Methadone maintenance treatment (MMT), a form of OST, has been found by the World Bank to have averted 1,597 new HIV infections between 2006 and 2013. Alongside this a two-year study of 107 MMT patients found that their employment rate increased from 70.1 percent to 77.6 percent.

Holding the International Harm Reduction Conference 2015 in Kuala Lumpur is no coincidence. It is the first time this major international event for the harm reduction movement has taken place in a Muslim majority country in Southeast Asia. Malaysia’s recent public health improvements are a potent symbol of the value of the harm reduction movement and the successes that investment in these programmes can bring.

Along with Indonesia, Malaysia is the only country in the region providing OST inside prisons, another example of its leading position in terms of harm reduction highlighted by HRI. OST provision in prisons has been expanded with an increase of the number of prisons providing OST from 1 in 2008 to 18 in 2014.

Another example of the country’s shift toward a rights-based approach to drug treatment is the transformation of eight compulsory drug detention centres into voluntary “Cure and Care” clinics reported by the United Nations Programme on HIV and AIDS (UNAIDS).

However, people who use drugs still face multiple obstacles, including being targeted by Malaysian police. A recent survey of Malaysian police officers found the majority seized needles and syringes even when no arrest was made report HRI, increasing the risk of needle-sharing and disease transmission. 

In Malaysia, drug trafficking is punishable by a mandatory death sentence and anyone arrested in possession of certain amounts of drugs is presumed to be trafficking drugs (15+ grams of heroin, 40+ grams of cocaine, 50+ grams of amphetamines and 200+ grams of cannabis).

There is a high level of official secrecy around executions in Malaysia making it difficult to monitor deaths sentences. However half of death sentences in recent years have been for drug trafficking estimates Amnesty International, and as of November 2014 there were 975 inmates on death row.

Minister in the Prime Minister’s Department Datuk Seng Kuan recently admitted “policies are not working; drug mules are being caught when kingpins go free”. He also stated that the Malaysian government was considering reducing the maximum sentence for drug trafficking offenses from mandatory death penalty to life in prison according to Amnesty International.

Besides official policies that harm people who use drugs, specific drug using demographics are posing continuing challenges to harm reduction provision. HIV prevalence rates among Malaysia’s fishing communities are between 4.6 and 14 times higher than the general population. A recent study of 406 fishermen found that unsafe drug injection practices are to blame, highlighting according to addiction specialist Adeeba Kamarulzaman the need to adapt OST to fit the specificities of fishermen's unique work patterns.

Female drugs users still face a higher level of stigmatisation from service providers; their drugs use is seen as contrary to their traditional stereotypes about femininity. As a result their children are often removed from them, according to a report carried out by the Malaysian AIDS Council (MAC). Ending stigmatisation against people who use drugs is vital as it discourages service users from seeking help, reducing the effectiveness of harm reduction services. 

Although Malaysia’s harm reduction successes are clearly an important development which should be applauded, service providers and NGOs still need improved public understanding and support to end stigma against people who use drugs and ensure their fundamental human rights are respected.