Amphetamine-Type Stimulant Use Asia Region in the Southeast Blood-Borne Viruses Andof HIV Other and the Transmission Linkthe Between

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amphetamine-type stimulant use Asia region in the Southeast blood-borne viruses andof HIV other and the transmission linkThe between

25 ANCD research paper 25

The link between paper ANCD research amphetamine-type stimulant use and the transmission of HIV and other blood-borne viruses in the Southeast Asia region

Andrea Fischer, Susan Curruthers, Robert Power, Steve Allsop and Louisa Degenhardt

Macfarlane Burnet Institute for Medical Research and Public Health in partnership with the National Drug Research Institute, Curtin University

A report prepared for the Australian National Council on Drugs, June 2012 © Australian National Council on Drugs 2013 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without the written permission of the publisher.

Published by the Australian National Council on Drugs PO Box 205, Civic Square ACT 2608 Telephone: 02 6166 9600 Fax: 02 6162 2611 Email: [email protected] Website: www.ancd.org.au

National Library of Australia Cataloguing-in-Publication data The link between amphetamine-type stimulant use and the transmission of HIV and other blood-borne viruses in the Southeast Asia region / Andrea Fischer … [et al.] ISBN: 9788770182799 ANCD research paper; 25. Includes bibliographic references. HIV (Viruses) — Southeast Asia — Transmission. HIV infections — Epidemiology — Southeast Asia. Intravenous drug abusers — Diseases — Southeast Asia. Intravenous drug abuse — Southeast Asia. Fischer, Andrea. Macfarlane Burnet Institute for Medical Research and Public Health (Melbourne, Vic.) National Drug Research Institute (Australia). Australian National Council on Drugs. 614.5993095

Editor: Julie Stokes Design: Starkis Design

Acknowledgement: This work has been supported by funding from the Australian Government Department of Health and Ageing. The opinions expressed in this publication are those of the authors and are not necessarily those of the ANCD or the Australian Government.

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Introduction Supply reduction Demand reduction Harm reduction to amphetamine-type stimulants and HIV globally Responses and HIV globally to injecting drug use Reponses in Southeast Asia to injecting drug use Responses to amphetamine-type stimulants in Southeast Asia Responses Manufacturing and trafficking in Southeast Asia in Southeast Manufacturing and trafficking in Southeast Asia Vulnerabilities use and harm in stimulant Specific information on amphetamine-type region the Southeast Asia in Southeast Asia use of amphetamine-type stimulant Patterns sexual risk and Amphetamine-type stimulant use in Southeast Asia HIV prevalence sex with men and HIV in Southeast Asia Men who have and HIV in Southeast Asia Sex workers globally to amphetamine-type stimulants Responding Review of the amphetamine-type stimulants literature stimulants of the amphetamine-type Review stimulants of amphetamine-type Definition and history Effects of amphetamine-type stimulants Injection of amphetamine-type stimulants stimulant use behaviour and amphetamine-type Sexual risk stimulant use and amphetamine-type affected populations Key Overview methods Research review Literature informants Key analysis Delphi Panel Setting the context in Southeast Asia

1 7.1 7.2 7.3 7.4 7.5 7.6 7.7 4.1 4.2 5 5.1 5.2 6 6.1 6.2 7 Executive summary Executive 3 3.1 3.2 3.3 3.4 3.5 1.1 2 2.1 2.2 2.3 4

Acronyms Contents 8 Comparison of amphetamine-type stimulant and opioid use as vectors for HIV and other blood-borne viruses ...... 37 8.1 Literature review ...... 37 8.2 Comparison of data from Southeast Asia ...... 41

9 Summary of information from key informants ...... 42

10 Summary and recommendations ...... 50

11 Bibliography ...... 53

Appendix 1: Search strategy ...... 68

Appendix 2: Country summaries ...... 70 Brunei Darussalam ...... 71 Cambodia ...... 73 China ...... 76 iv Hong Kong ...... 79 Macau ...... 81 Indonesia ...... 83 Lao People’s Democratic Republic ...... 86 Malaysia ...... 88 Myanmar ...... 91 Philippines ...... 94 Singapore ...... 96 Thailand ...... 98 Viet Nam ...... 101

Tables Table 1: Seizures of amphetamine-type stimulant drugs in selected countries in Southeast Asia ...... 12 Table 2: Amphetamine-type stimulant use in Southeast Asian countries . . . . . 18 Table 3: Population prevalence and prevalence of HIV in capital cities among people who inject drugs, sex workers and men who have sex with men . . 24 Table 4: Generic interventions targeting drug injection and HIV/BBV globally . . . 31 Table 5: Interventions in Southeast Asia for people who inject drugs ...... 32 Table 6: Summary of key informant interviews ...... 42 v Acronyms non-governmental organisation non-governmental opioid substitution treatment Republic Democratic People’s people who inject drugs Guideline Network Intercollegiate Scottish Reporting and Trends Synthetics Monitoring Analyses, female sex worker C virus hepatitis human immunodeficiency virus Network Drug Information Drug Abuse Integrated injecting drug use Information, Education, Communication methamphetamine/amphetamine or ‘Ecstasy’ 3,4–Methylenedioxymethamphetamine sex with men men who have of AIDS National Committee for the Control Australian National Council on Drugs National Australian Committee Issues Drug Asia–Pacific treatment anti-retroviral stimulant amphetamine-type blood-borne virus Asia and the Pacific Information Network for Drug Abuse Issues Regional Drug Committee on Asia–Pacific Expert Advisory and Drug Addiction Drugs for Monitoring Centre European acquired immunodeficiency syndrome immunodeficiency acquired SMART IEC MDMA MSM NACCA ATS BBV PWID SIGN NGO OST PDR MA HIV IDADIN IDU EAC EMCDDA FSW HCV ART DAINAP AIDS ANCD APDIC Acronyms vi Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia WHO WDR VAAC UNODC UNICEF UNAIDS STI SW World HealthOrganization World DrugReport Viet NamAdministration ofHIV/AIDSControl United Nations OfficeonDrugs andCrime United Nations Children’s Fund Joint UnitedNations Programme onHIV/AIDS sex worker sexually transmissible infections Executive summary vii - - -

regional level, to address ATS use in terms of HIV prevention and the effectiveness of and these interventions, research. for future recommendations the link between ATS use and the risk of HIV and BBV transmission via injecting or sexual sexual or injecting via transmission BBV and HIV of risk the and use ATS between link the routes of opioid users to the HIV risk compared users ATS among of HIV risk an analysis the interventions currently in place, both internationally and at the Southeast Asian action between people who use ATS and the criminal justice system or law enforcement, particu- in ATS and general in drugs use who people of incarceration of rates high the and Demographic lar. and contextual factors may also interact with ATS use to either increase that evidence some is There behaviour. injecting drug other to relative risk BBV decrease or taking. sexual risk associated of BBV from risk an increased have users ATS specific responses are required. are responses specific inter of rates high the is region the across HIV of risk increased regarding issue specific One that there are varying patterns of use of ATS across the region, indicating that country- ally, the ally, injection of ATS as a substitute for heroin was reported in several countries (Lao PDR, China, Myanmar and Thailand). There are small numbers of people who inject drugs as their drug(s) of choice. (PWID) who identify ATS and ATS, of use increasing the to related concerns stated countries most in informants Key noted also informants Key users. ATS engaging, successfully or targeting, services of lack a reported in key populations such as sex workers and men who have sex with men. Addition men. with sex have who men and workers sex as such populations key in reported with the use of ATS, both as a primary drug of choice and in relation to polydrug use, and use, polydrug to relation in and choice of drug primary a as both ATS, of use the with HIV and BBV both behaviours, risk injecting and sex-related. These suffi- were considered in the region. cient to suggest the need for swift action ATS use who people in behaviour risk investigated have that studies of number limited The in the areas region of shows poor health and indicators of high HIV These risk. have been Epidemiology of use and associated risk behaviours and associated risk Epidemiology of use concerns identified All sources. information three the across agreement significant was There views views with key informants based in or working with the countries of concern; and input a Delphi Panel. from • inter review; literature systematic a sources: information major three comprised review This • • • review focuses on the 11 countries in Southeast Asia (Brunei Darussalam, Cambodia, China Cambodia, Darussalam, (Brunei Asia Southeast in countries 11 the on focuses review (includingareas: key Hong four Kong and Macau),covers and Indonesia, Nam) Viet Lao and People’s DemocraticThailand Republic Singapore, (PDR), Philippines, Myanmar, Malaysia, region. In January 2011, the Australian National Council on Drugs, through its Asia–Pacific Asia–Pacific its through Drugs, on Council National Australian the 2011, January In region. Drug Issues Committee and with funding provided by the Expert Advisory CommitteeThis on concerns. these investigate to review a commissioned Issues, Drug Regional Asia–Pacific There are growing concerns regarding the link between amphetamine-type stimulant (ATS) (ATS) stimulant amphetamine-type between link the regarding concerns growing are There Asian Southeast the in (BBV) viruses blood-borne other and HIV of transmission the and use Executive summary Executive viii Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia contributions from theDelphiprocess toreach thefollowingconclusions: with and informants fromkey input analysiswith and weretriaged availableevidence The mental healthissues; andtheimpactofATS use onthecommunity. usersjusticecriminal the with system; harms,health non-HIV trafficas such and accidents for people who use ATS; social and health harms related to high levels of inter availableoptions reduction harm and treatmenteffective of lack the opportunities); ment employ and schooling (inhibiting people young on ATS of effects the included: analysis Main issues of concern raised by the key informants and reinforced through the Delphi Panel Specific recommendations include: region. the throughout use ATS to responses other and prevention HIV enhance to need a is there suggest opinion, informant key and expert and evidence, available the theless, general,therein and scant is evenis that less Asia specific Southeast Never the region. to is, harm ATS-related reduce and prevent to interventions effective for base evidence The Interventions 1. 1. 5. 4. 3. 2. 4. 3. 2. international literature and existing guidelines, andare adaptedtolocalneed. the of reflective are that dependence ATS for guidelines treatment standard Develop other programs withkeyaffectedpopulations. and activities health sexual existing into messaging reduction harm ATS Incorporate mary ATS users. pri to relation in specifically effectiveness and accessibility their identify to need a is programs, where indicated, to better meet the needs of ATS users. As noted above, there Adapt existing harm reduction services, such as drop-in centres and needle and syringe Invest inHIVprevention strategies thatenhanceaccessforATS users. country-specific dataare required toinforminterventions. However, context. local to interventions tailor to need urgent an is there region, Asia Southeast the across harms associated and ATS of use of patterns varying the Given The extent to which other risk factors have impact is unclear, e.g. poverty and mobility. people. young and (MSM), men with sex have who men workers, sex as such HIV to vulnerable groups among higher appears Use injecting. and use polydrug with ciation ATS users across the region are exposed to multiple HIV risks, particularly high in asso- highlights highrisk andlowserviceaccess. ATS use who people in behaviour risk investigate that studies of number limited The that have relevance inSoutheastAsiancountriesremain undocumented. ute to a differing risk of BBV compared to other drug use. However, the specific factors The injection of ATS is associated with increased BBV risk, and some factors may contrib data onpopulationprevalence intheregion. few are However, there others. in increasing and countries, some in stable is use ATS action of drug - - - Executive summary ix - - - Examine the impact of policy and policy implementation (including legislation) on preva on legislation) (including implementation policy and policy of impact the Examine behaviours. and associated risk lence of use Identify any barriers for ATS users to access existing harm reduction and treatment serv treatment and reduction harm existing access to users ATS for barriers any Identify to these challenges. responses and trial and evaluate ices, may that pharmacotherapies, especially interventions, ATS efficacious emerging, Identify and disseminate to strategies effective assess and region, Asia Southeast the in useful be implement evidence-based approaches. Enhance capacity to identify the contexts of use, particularly demographic and envi ronmental factors that contribute to with ATS risks, a focus on identifying social and other determinants. than riskier are use of contexts and users of groups some that evidence existing on Build Clearer identificationothers. of thesegroups is factors andspecific indicated at-risk at a country level. Assess the prevalence of HIV in people who use ATS, in comparison with people who both drugs. opioids and people who use use and sexual risks. between ATS of associations consistency cross-country Examine BBV to responding and preventing for implications have that harms ATS other Examine mental health problems. impairment; e.g. cognitive risk, Enhance capacity to enable more precise prevalence estimates of ATS use, including information on use of specific substances (e.g. amphetamine or methamphetamine), and harms. associated risks and of administration, route Invest in rapid assessment and response strategies to ATS, which can be employed with employed be can which ATS, to strategies response and assessment rapid in Invest in the region. system an early warning to provide limited resources, 9. 7. 8. 4. 5. 6. 3. 1. 2. Research 10. ics for regional collaboration. This could be facilitated by a forum to allow for sharing of information across the region and in particular across adjoining Theseborders. initiatives Program. SMART Global the as such systems monitoring existing with coordinated be could It is suggested that these recommendations inform the commencement of a regional research research regional a of commencement the inform recommendations these that suggested is It top- and themes country-specific both noting stakeholders, key with negotiated be to plan A key a of was is objective review There dearth this to needs. of identify evidence research that can guide the tailoring of responses to the specific needs of diverse countries in the other from on although cocaine Southeast it use Asia was region, noted that the literature - recommen following The properties. stimulant shared given insights provide could regions here: made are dations 1 Introduction - - use use 1

to analyse the link between BBV, in particular HIV, and the use of ATS use and the in particular HIV, between BBV, the link to analyse for HIV as a vector to opiate risk comparative risk ATS to analyse and prevention, HIV address that interventions of ATS for viability the assess to needs for the Southeast Asia region. research future to recommend Amphetamine-type stimulants include amphetamine, methamphetamine, crystal Amphetamine-type stimulants include amphetamine, methamphetamine, crystal (Captagon). (Ecstasy) and Fenetylline methamphetamine, 3,4-Methylenedioxymethamphetamine Philippines Singapore Thailand, and Viet Nam. China (including Hong Kong and Macau) China (including Hong Kong Indonesia Republic (PDR) Democratic Lao People’s Malaysia Myanmar Brunei Darussalam Cambodia

3. 1. 2. 4. 1 in Southeast Asia. Other audiences include federal government ministers and departments, and departments, ministers in Southeast Asia. Other audiences government include federal mak- decision and bodies advisory and policy other and ANCD, the of members the APDIC, the region. across ers The primary audience for this review is the EAC, which will use the information to iden tify key issues and priorities for further action to best address potential BBV transmission • • • • • • • • • • • use and sexual risk taking with implications for the sexual transmission of HIV. In response response In HIV. of transmission sexual the for implications with taking risk sexual and use - Issues Committee (APDIC), Drug commis the ANCD, via its to Asia–Pacific these concerns, The with and key interviews stakeholders. literature, and grey sioned of a published review were: goals are: review included in this The countries in the Southeast Asia region Issues (the EAC) regarding a possible link between amphetamine-type stimulants (ATS) stimulants amphetamine-type between link possible a regarding EAC) (the Issues injec the in increase possible a noted ANCD The transmission. (BBV) virus blood-borne and ATS between association an also is there that acknowledging while region, the in ATS of tion In 2009, the Australian National Council on Drugs (ANCD) raised concerns with the federal federal the with concerns raised (ANCD) Drugs on Council National Australian the 2009, In Regional Drug Committee on Asia–Pacific Expert Advisory interdepartmental government’s 1. Introduction 2 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia reported on consumption of the drug (United Nations Office on Drugs and Crime, 2010c). Crime, and Drugs on Office Nations (United drug the of consumption on reported used ATS at least once in the preceding year, and more than 100 countries across the world 2010The 1.1 Overview substance wasnotincludedinthereview, asitis rarely, ifever, injected. Although 3,4–Methylenedioxymethamphetamine to harmreduction servicesamongpeoplewhoinjectdrugs(Hagarty, 2010). 2007); and the Burnet Institute’s Criminology,Australianof Institute& InstituteResearch Drug (National paper background harms other Methamphetamine Injection: a review of the evidence on use and associations with HIV and Pacificthe Nations(United Drugs on Office 2010b); Crime, and reporton (UNODC) Crime Drugs and (Devaney, on NationsOffice United the 2006); Baldwin, & Reid Centre, Drug and Alcohol Point Turning and Institute Burnet the by report research a are: ments tional and national bodies in regard to this issue and these inform this review. These docu- Over the past five years, several significant documents have been compiled by both interna- 2 of particularconcern(UnitedNations Officeon Drugs andCrime,2010c). South Africa and at least nine countries across eastern Europe have been identified as places Mexico, of countries the and Oceania, and Asia Program,2010).Southeast regionsof The and reported manufacturing and trafficking and related seizures remain high (Global SMART that in some countries ATS use has stabilised or even decreased, in others use is increasing, combined (United Nations Office on Drugs and Crime, 2009). While surveillance data show Globally, the number of people who report use of ATS now exceeds that of heroin and cocaine ing from theserisks among ATS users (Colfaxetal.,2010; Degenhardt etal.,2007;2010). strong case to systematically embrace and prioritise strategies to target possible harms aris- well documented or understood, injecting behaviour and sexual risk taking contribute to a always not are use ATS and HIV risks specific of the while that 2010c). noted have Others Crime, and Drugs on Office Nations (United users ATS for treatment suitable of lack the involvementATS,ing of and manufactureorganisedsupply the of and in syndicates crime sor chemicals in the region, general market expansion, increasing injection of ATS, increas- high level of manufacture of ATS across the region, the increase in the diversion continuing of precur- the sub-region, Mekong Greater the in countries neighbouring to Myanmar from ATS of trafficking large-scale the including trends, emerging identified has UNODC Common name: Ecstasy. Region Asia–Pacific the in Responses and Issues Drug Illicit of Analysis Situational Patternsand TrendsAsia and Drugs: Other Amphetamine-Typeand of Stimulants estimated that between 15 and 53 million people worldwide people million 53 and 15 between that estimated Report Drug World (Degenhardt et al., 2007); 2007); al., et (Degenhardt Harm Reduction in Asia: progress towards universal access National Amphetamine-Type Stimulant Strategy: Strategy: Stimulant Amphetamine-Type National 2 (MDMA) is classified as an ATS drug, this The Global Epidemiology of Epidemiology Global The 3 Introduction - - - mated mated However, a However, proportion of ATS users do inject, with an attendant HIV risk. transmission additional an is this and taking risk sexual with associated been has use ATS addition, In factor for HIV transmission. risk especially documented, well always not are behaviours associated and use ATS High-risk including many in the Southeast Asia region. in countries with limited resources, While ATS use has stabilised, use in some countries is increasing. in some countries is use has stabilised, use While ATS The specific link betweenATS use and HIV risk has not been unequivocally identified. • • • 2002; Elford et al., 2004; Fernandez et al., 2007). This body of research has provided sup- has provided body et of et al., research al., 2007). 2004; This 2002; Fernandez Elford porting evidence that the use of ATS in conjunction with sexual encounters increases the behaviours. incidence of risk discussion: this summarise To tial risk for HIV transmission and a domain for intervention (e.g. Colfax et al., 2010). Some (e.g. Colfax et al., 2010). and a domain for intervention for HIV transmission tial risk groups such as men who have sex with men (MSM) have been the focus of an increasing body a of significantresearch, of proportion which has been conducted in North America, Grant, & Patterson Semple, 2010; al., et Degenhardt (e.g. Australia and Kingdom United the populations at high risk for HIV (Degenhardt et al., 2010). Drug use in general, but ATS use use ATS but general, in use Drug 2010). al., et (Degenhardt HIV for risk high at populations in has particular, been associated with sexual taking. risk The strong association has been poten a as connection the consider to recommendations to leading reviews several in noted in Norway, 18 per cent in Australia, and 28 per cent in New Zealand (Degenhardt et al., 2007). al., et (Degenhardt Zealand New in cent per 28 and Australia, in cent per 18 Norway, in The potential association between the use of ATS and HIV needs to take into considera tion possible sexual particularlytransmission, in situations where there is ATS use among only 25 were able to report on the extent of injecting, indicating a risk of HIV transmission. transmission. HIV of risk a indicating injecting, of extent the on report to able were 25 only users of ATS conducted, the of proportion injecting is surveillance Among countries where cent per 12 Thailand, in cent per 9 to Canada in cent per 7 from ranged drug the inject who nated equipment incurs the risk of BBV transmission. In their global review of ATS injecting injecting ATS of review global their In transmission. BBV of risk the incurs equipment nated across ATS of injection and use the summarised (2007) colleagues and Degenhardt HIV, and available, were data ATS some which for countries 190 the Of world. the of regions major all ATS injection and HIV prevalence (UNAIDS, 2010a), the injection of any drug with contami with drug any of injection the 2010a), (UNAIDS, prevalence HIV and injection ATS the globe and, of these, an estimated 3 million were living with HIV (Mathers et al., 2008). al., et (Mathers HIV with living were million 3 estimated an these, of and, globe the concern increasing of issue an is injection orally, consumed are ATS of majority the Although users ATS among injecting of prevalence the on data of lack a However, countries. some in population. of the size of this many countries limits our understanding from between link causal a demonstrate unequivocally to evidence insufficient is there Although uncertainty surrounding the actual size of ATS-using populations. the actual size of ATS-using uncertainty surrounding esti HIV and Use Drug Injecting on Nations United the to Group Reference the 2008 In that there million were between and million 11 21 people who inject drugs (PWID) across recorded in the Philippines at 10 per cent (Degenhardt et al., 2007). However, a lack of national survey data from many resource-poor countries means that there is considerable Although population prevalence figures forATS are generally low (less than 1%), thereis in reported higher New is example, - use For Zealand, Aus country. substantial by variation tralia and the United Kingdom (4%, 3.4% and and 2.8% the respectively) highest use was 4 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia al., 2010) is used in the review. The detailed strategy is described in Appendix 1. In order to Degenhardtet in described (2007, searchstrategycolleagues usedbyThe Degenhardt and was conducted. tionally, a search of the published and grey literature for the period covering 2004 to 2010 As noted above, there were five major documents that informed the literature review. Addi- 2.1 Literature review The research methodologyforthis review consisted ofthree keyactivities: 2. Research methods ants, suchas‘LaoPDR 1’. tified in this report. A simple descriptor is used to identify information provided by inform- In accordance with ethical standards and approval, key informants are not individually iden Indonesia (2),Malaysia (1),Macau(2)andMyanmar (2). (1), Kong Hong (1), PDR Lao (1), China (1), Nam Viet (3), Thailand from informants with face-to-face by local staff from the Burnet Institute. A total of 14 interviews were conducted conducted by telephone, with the exception of Myanmar, where interviews were conducted were interviews 2011.2011 of June May majority 16 3 The and between conducted were agencies providing outreach services or drop-in centres for people who use drugs. Interviews viders, researchers and policy makers. Service providers were sourced from non-government regional contacts, and advice from the Delphi Panel (see below). They represent service pro ants from the countries under review. Informants were identified through existing networks, To complement the literature review, a 2.2 Key informants was extendedtocover theperiod1995–2010. ATSusers,among AIDS literatureand the searchreduceHIV interventions to implemented of overview an provide2010. to order to In 2008 from work published for search to used were strategies Boolean and words search same reviews, the literature existing the to add the Alfred MedicalResearch andEducationPrecinct, Melbourne,Victoria(60/11). of Committee Ethics Research Human providedthe bywas approvalproject this Ethics for 1. 3. 2. Review oftheoutcomesthis analysis using aDelphiPanel approach. literature review andanalysis the supplement only,region to Asia Southeast the in stakeholders key with Interviews cially from theAsianregion espe literature grey including level, local and national global, the at available is that transmission BBV and use ATS between links on literature the of analysis and Review series of interviews was conducted with key inform- - - - 5 Research methods on Drugs and Crime, Regional Centre for East Asia and the Pacific. and Crime, Regional Centre on Drugs Dr Nick Thomson – Field Director, Johns Hopkins University Hopkins Johns – Field Director, Dr Nick Thomson Drugs Who Use Asian Network of People – Chairperson, Mr Jimmy Dorabjee Burnet Institute Fellow, – Senior Principal Robert Power Professor Institute Burnet – Principal Fellow, Higgs Dr Peter Office Nations United Care, and Prevention AIDS and HIV Adviser, – Bergenstrom Anne Dr Professor Steve Allsop – Director, National Drug Research Institute Research National Drug – Director, Allsop Steve Professor Dr Fabio Mesquita, MD, PhD – Senior HIV and AIDS Adviser and Team Leader, World Viet Nam Country Office Health Organization, Malaya of University Research, HIV for Centre Director, – Kamarulzaman Adeeba Professor the full report, and individuals are not quoted directly. are and individuals the full report, The Delphi Panel also provided support in the identification of key informants and grey recommendations. report and ofand thesignificant final input into the drafting literature, across appears Panel Delphi the of input the inputs, separate as these identifying than Rather • • • • • • • • A Delphi Panel method uses the intuitive and available information of participants, who are are who participants, of information available and intuitive the uses method Panel Delphi A results. quantitative as well as qualitative delivers It study. under field the in experts usually In this case, the Delphi Panel reviewed and commented on early drafts of the report and and focus. for changes of emphasis made recommendations comprised: The Delphi Panel 2.3 Delphi Panel analysis 2.3 Delphi Panel 6 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia lant properties of the drug were recognised and use spread. In 1940 methamphetamine methamphetamine 1940 In spread. use and recognised were drug the of properties lant stimu and anorexiant the that time this at was It congestion. nasal of treatment the for stream use of amphetamine occurred in the 1930s, when it was used in Benzedrine inhalers Main asthma. for treatment primary a then ephedrine, for substitute a as substance the as amphetamine,in1897,butitwasnotuntilthe1920sthatscientists tookaninterest in synthesised first Edeleano, chemist, German A and theonce-powdered drugbegins toformintocrystals (Schifanoetal.,2007). cool to productisremovedallowed distillation,the and and fromheat heat of application methamphetamine by dissolving the powdered product in water and alcohol. Following the powderedfrom made is Kelly,methamphetamine Crystallised& 2006). McLaren (McKetin, similar to amphetamine but, at comparable doses, has longer lasting and more structurally potentis effectsMethamphetamine phenethylamine. alpha-methyl name chemical the from derived is ‘amphetamine’ term The Criminology,2007). of Institute Australian & Institute alpha- component, parent the to related chemically are that drugs synthetic of group a are (ATS) stimulants Amphetamine-type 3.1 Definitionandhistory ofamphetamine-typestimulants stimulants literature amphetamine-type 3. Review ofthe 3 alarming conditions. temperature,body pressure,blood concentration,and responsesattention and appetite, to drugs affect neurochemical mechanisms by which the body regulates and controlsThe response. fight’ heart or rate,‘flight epinephrine-induced the resemble ATS of effects acute The in anincrease inlocomotor movements. results dopamine, of release increased the with combination in and, effects anorectic and ephrine following administration of ATS is postulated to be responsible for increased alertness noradrenaline, in the brain (Rothman & Baumann, 2003). The enhanced release of norepin synaptic concentrations of mono-amine neurotransmitters, such as dopamine, sero Amphetamine-type stimulants exert their effects on the central nervous system by increasing 3.2.1 Physiological effects physiological andpsychological effects of ATS is presented below. The physiological and psychological effects of ATS are complex. A summary overview of the 3.2 Effects ofamphetamine-type stimulants prescription ofATS have reduced medicaluse significantly. the on restrictions major then, Since alertness. increase to occupationsvarious to ity, and for the treatment of various ailments, including alcoholism, depression, narcolepsy and obes yearsensuing the vigorouslyin marketed were methamphetamine and amphetamine Both (d- Synonyms include alpha-methylbenzeneethanamine andbeta-phenyl-isopropylamine. phenylisopropylmethylamine hydrochloride) was introduced and marketed as Methedrine. methyl phenethylamine methyl β -phenylispropylamine, commonly known known commonly -phenylispropylamine, 3 (National Drug Research Drug (National tonin and - - - 7 Review of the amphetamine-type stimulants literature - - - psychological impairment (Barr et al., 2006). Prolonged Prolonged 2006). al., et (Barr impairment psychological sexual men and women (Lorvick et al., 2005; Molitor, Truax, Ruiz & Sun, 1998; Raw 1998; Sun, & Ruiz Truax, Molitor, 2005; al., et (Lorvick women and men sexual amphetamine-group substances’ (p.463). Degenhardt and colleagues (2010) also noted that that noted also (2010) colleagues and Degenhardt (p.463). substances’ amphetamine-group the of of route a administration drug not is non- from static, with progressing some users to non-injecting. injecting to injecting, or indeed from of administration injecting routes lished lished groups of PWID, and the type of ATS that are available (Degenhardt et al., 2010). Colfax and colleaguesobserved that(2010) ‘Most use of amphetamine-group substances worldwide not is injection, by but injection of substances amphetamine-group still has an important, but difficult torole accurately quantify, in harms and complicationsrelated to route of administration is likely to be affected by motivations for use, the existence of estab of existence the use, for motivations by affected be to likely is administration of route ing (heating and inhaling vapours), snorting, injecting or, more rarely, ‘shafting’ (anally) or ‘shafting’ rarely, more snorting, injecting ing or, (heating and inhaling vapours), of to exposure carry of routes Different (vaginally). ‘shelving’ risks different administration inher- is drug any of injection The injecting. from risk highest the with BBV, other and HIV behaviours. sharing when accompanied by especially ently risky, predominant the oral, be to thought is world the around use ATS of majority the Although 3.2.3 Routes of administration of amphetamine-type stimulants 3.2.3 Routes of administration smok swallowing, routes: of number a via administered be can stimulants Amphetamine-type States found that regular users of ATS experience psychosis and that symptoms increase 2003). (Cohen, Dickow & Horner, of use duration with greater use, use, particularly if the drug is injected, has also been associated with violent or aggressive ATS-induced contention). without not is association the of nature the (although behaviour psychosis has also been described. A Japanese study found between one-third and two- after weeks two than more some symptoms, psychotic experienced have users ATS of thirds United the in youth street of study Another 2006). al., et (Barr consumed last was drug the is is associated with higher than normal rates of depression, anxiety and attempted suicide, neuro permanent in result may and The short-term psychological effects of ATS are varied and can include effects sought-after effects include can and varied are ATS of effects psychological short-term The by users including euphoria, alertness and increased concentration, an increase inATS use of prolonged self- of self-confidence (Scott et al., 2007). However, esteem and feelings 3.2.2 Psychological effects 3.2.2 Psychological 2009; Thiede et al., 2009; Zhang, Bi, Zhang Iv, & 2007).Hiller, Although the majority of countries, other for relevance have they America, of States United the in were studies these region. including those in the Southeast Asia terms of both the frequency of unprotected intercourse and the number of partners, among among partners, of number the and intercourse unprotected of frequency the both of terms hetero men among and 2004b) Grant, & Patterson Semple, 2002; Reiber, & Domier Washton, son, Patterson, & Strathdee Zians, Semple, 1999; al., et (Molitor (MSM) men with sex have who activity (some the withconsume specifically drugs the intention to sexual increase activity and pleasure), which can potentially increase the of risk exposure to sexually transmissible in of sexual reports increased activity, numerous are There including (STIs), HIV. infections Of particular relevance in relation to HIV transmission is the effect ATS have on the the have effect is libido. ATS to in HIV relation Of transmission particular relevance sexual of frequency increased to leading libido, in increases with associated been have They 8 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 3.3 Injectionofamphetamine-typestimulants borrow used needles (Molitor et al., 1999; Wu et al., 2004). Street-based ATS injectors in in injectors ATS Street-based 2004). al., et Wu 1999; al., et (Molitor needles used borrow Furthermore, compared with heroin injectors, ATS injectors were more likely to both lend and et al.,2009;Semple,Zians, Grant &Patterson, 2005). Bingeing ATS use has been linked with impulsivity and unprotected penetrative sex (Semple to bingeing behaviour where high levels of ATS are used over a period of three to five days. chological problems (Domier, Simon, Rawson, Huber & Ling, 2000). ATS users are also prone psy- of history a have to likely more significantly and ideation suicide experience to likely more depression, reported have to likely more were injectors the non-injectors, to ATS of lower levels of condom use (Molitor et al., 1999). In a USA-based study comparing injectors 2010; Corsi, Kwiatkowski & Booth, 2009; Wu, Pilowsky, Wechsberg & Schlenger, 2004) and a greater number of sexual encounters with both regular and casual partners (Cheng et al., compared to non- example, For inject. not do who users ATS to compared behaviours sexual their and ing indications that people who inject ATS are at higher risk of exposure to strongHIV are there from developed, well their less is inject injection ATS surrounding literaturepublished the environmentaland contextual factors Jarlais,(Des Perlis, Stimson Poznyak,& While 2006). demiological (Riley & O’Hare, 2000) and social research literature that recognises important epi both in established well is HIV and (IDU) use drug injecting between association The and fewservicesare geared totheirspecial needs.’ (WorldHealthOrganization, 2011, p.2.) reductionharm relevant.as services resultThe is ATSof needs the that users are neglected perceive not do thus and users, of networks different to belong often users, opioid with themselves identify not do they because largely services, reduction harm use rarely users ‘ATS that: noted recently (WHO) Organization 2011).Health tion, World the example, For treatment and harm reduction services (Baker, Lee & Jenner, 2004; World Health Organiza - themselves as This issue is worrying because some studies have indicated that people who use ATS perceive concern that ATS injectors have elevated risk behaviours for exposure to HIV and other BBV. tiate between sexual and injecting risk associated with ATS use, there is sufficient cause for Kerr, Fischer, Zhang & Wood, 2009). While many of these studies were not able to differen- some settings are also more likely to be HIV and hepatitis C virus (HCV) seropositive (Miller, less injectors, ATS injectors have been found to have more sexual partners and at risk of HIV than opioid users, and have a more tenuous connection to - - 9 Review of the amphetamine-type stimulants literature - Colfax et al., 2010). HIV risk risk HIV 2010). al., et Colfax regular and/or heavy use of ATS among populations in the Southeast Asia region are limited. are region Asia Southeast the in populations among ATS of use heavy and/or regular tries, in particular those with less well-developed HIV and drug use surveillance, nor to non- to nor surveillance, use drug and HIV well-developed less with those particular in tries, of effects the of studies and populations treatment outside Studies populations. treatment can be stated with any certainty. use ATS of effects the on reporting literature the of majority the that noted be also should It North as such world, the of regions developed in treatment in users ATS of studies on relies to America, may This other western not and generalise coun- Europe necessarily Australia. among ATS users is needed before a causal effect between ATS use and HIV transmission among men who have sex with men was associated with higher of levels HIV infection in San (Buchacz Francisco et al., 2005; Semple et al., 2009), whereas in the Australia mostly et al., 1998). was not (Kippax of ATS use oral behaviours risk investigating research more that suggested further (2007) al. et Degenhardt ies are conducted among study groups already known to be at high risk of HIV and the dif- the and frequency, less with ATS use who groups all to applicable be not may findings to contribute may studied being populations the and HIV of prevalence background fering et (Degenhardt findings al.,For 2007). the example, useinconsistent non-injectingATS of HIV risk behaviours, HIV the behaviours, risk findings of other are investigations often contradictory (Colfax et stud many that note (2007) colleagues and Degenhardt 2007). al., et Degenhardt 2010; al., who have sex with men, adult heterosexuals and young people ( people young and heterosexuals adult men, with sex have who risks partners, multiple with activity sexual and sex penetrative unprotected with associated is et al., 2007). (Fernandez sought-after effects of ATS been associated with also that have increased and use ATS between association independent an found have studies some While between ATS use and increased HIV prevalence (Buchacz et al., 2005; Plankey, Ostrow & Stall, Stall, & Ostrow Plankey, 2005; al., et (Buchacz prevalence HIV increased and use ATS between 2007; Echenberg & 1989; Burcham, Tindall, Berry Jaffe, Darrow, Cooper, & 1987). Penny, men among found been has behaviours risk HIV and use ATS heavy between association An sexual pleasure is one of the more common reasons given for ATS use among some groups. groups. some among use ATS for given reasons HIV. common of more the of one risk is pleasure sexual increased and behaviour sexual ATS-affected linking literature emerging an is There For example, studies from the late 1980s to more recent studies indicate an association As noted earlier, some of the frequently described pharmacological effects of ATS are enhanced enhanced are ATS of effects pharmacological described frequently the of some earlier, noted As of enhancement the Indeed, 2008). Blake, & (Allerton drive sex and mood elevated and libido, 3.4 Sexual risk behaviour and amphetamine-type and amphetamine-type behaviour 3.4 Sexual risk stimulant use 10 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia province to 24.3 per cent in An Giang province (Mai-Nhung, D’Onofrio & Rogers, 2010). In Giang Kien in cent per 0 from ranged prevalence HIV Nam Viet in provinces four across example, For countries. Asian Southeast within and across varies workers sex among HIV per centorabove (UNAIDS,2010b). 20 of rates had workers,15 sex for prevalencedata HIV with countries 54 the Of Malawi. in cent per Australia70.7 in to cent per 0.1 workersvariesbetween prevalencesex among 2010a). (UNAIDS, world the HIV of parts many in epidemics AIDS in factor significant a is sex paid unprotected, that considers UNAIDS epidemic. HIV the of drivers key the of one sex workers is relatively low, while in other areas of the world, sex work is considered to be among HIV of prevalence Zealand, Australia/New and America North Europe, western as regions, such some risk varies.In of level the HIV, though risk for high at are workers Sex 3.5.1 Sexworkers groups andsettings withhigherprevalence rates andrisk ofHIV. some are there contexts, and populations of range diverse a across occurs use ATS While 2005; Mai-Nhungetal.,2010). Liang, & Yin (Chen, non-injectors with compared injected who workers sex female among higher cent per 7.8 was HIV-positive being of likelihood the studies, these In cent. per 1 Nam, 4 per cent of female sex workers also reported IDU; in other provinces, it Viet was northern less behaviour. In than injecting reported workers sex female of cent per 6 Nam Viet southern in recorded, not was injected drug of type the Although undocumented. largely however,remains Asia, Southeast in partners and clients to workers sex female from HIV transmission of the in use ATS 2011). of al., role et The Shannon 2008; al., et (Patterson Mexico and Canada in populations some within HIV to exposurerisk increasedof an with The use of ATS in crystal form among female sex workers has been found to be associated regular partners orspouses wasrare (Mai-Nhungetal.,2010). that they would allow sex without condoms if more money were offered; condom use with stated frequentlyworkerslow,2010). sex was al., and classes et all acrosscondoms of Use (Mai-Nhung counterparts high-class and middle- their than STI an had having report to HIV due to a greater number of clients and longer working hours, and were also more likely of riskgreater at were workers sex low-status found 2010). study al., One et discotheques (Mai-Nhung or bars and nightclubs from operate workers sex high-class and workers; ers; middle-class sex workers in restaurants and bars cater to professionals and government sex workers (usually working in ‘hugging bars’) cater to mostly blue collar workers or labour Patterns of HIV infection also vary by type of sex work. For example, in Viet Nam low- while inotherprovinces itis lessthan2percent(Wangetal.,2010). Yunnan province of China, HIV prevalence among sex workers is approximately 10 per cent, stimulant use 3.5 Key affectedpopulations andamphetamine-type status - Review of the amphetamine-type stimulants literature 11 - the effect of ATS use on sexual behaviours and HIV risk taking or prevalence. No data were were data No prevalence. or taking risk HIV and behaviours sexual on use ATS of effect the located for the Southeast Asia region. in crystal form of (10% the study group) was not associated with unprotected anal inter (Choi et al., 2005). course includes it of little countries, developing in MSM about literature growing a is there Although partners, partners, more anonymous partners, prolonged sexual encounters and reduced inhibitions these show MSM among investigations all Not 2010). al., et Malta 2007; al., et (Fernandez ATS use of MSM, the of among American a and group example, Pacific For characteristics. there there are signs that, among MSM in developed countries, HIV is 3 rising by approximately per cent This per trend has2010). year (Beyrer, been attributed to the use of recreational drugs, including ATS, associated with unprotected anal intercourse, a greater number of 3.5.2 Men who have sex with men with sex have who Men 3.5.2 world the around countries most in exist (MSM) men with sex have who men of Populations and were one of the first populations impactedby Three HIV. decades into the epidemic, noted earlier, the link between ATS use and sexual behaviour suggests that sex workers may may workers sex that suggests behaviour sexual and use ATS between link the earlier, noted ATS. (and inject) if they go on to use be at additional risk More More surveillance data relating to the use of ATS among female sex workers in Southeast Asian countries are needed to assess the specific risk of HIV associated withATS use. As 12 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia An overview ofseizures ofATS drugs intheSoutheastAsiaregion canbeseeninTable 1. meet (UnitedNations OfficeonDrugs andCrime,2010b). operations are located in the Golden Triangle area, where Myanmar, Lao PDR and Thailand manufacturing large-scale 12 to up that suggests Thailand in seized pills ATS of testing remains noted as the major manufacturer of ATS pills in the Southeast Asia region and the Myanmardetermine. to regionisimpossible the ATSmanufacturein the dimensionof the of assessment accurate an that means countries Asian Southeast many in collection data almost 700 (United Nations to risen had number this However,2009 by Asia. Southeast in reported were laboratories tions appears to have been significant. For example, in 1999, approximately 300 clandestine The manufacture of ATS occurs across the Southeast Asia region and the growth in opera- 4.1 Manufacturingandtrafficking inSoutheast Asia in SoutheastAsia 4. Settingthecontext Table 1:Seizures ofamphetamine-typestimulantdrugs inselectedcountriesSoutheastAsia Cambodia China Hong Kong Indonesia Lao PDR Malaysia Myanmar Philippines Singapore Thailand Viet Nam Country Brunei Darussalam 0.32 ATS kg 4.6 2518 43.7 237.8 Nil 1160 124 149.3 3.72 209 3.9 Crystal (Data asat2009:GlobalSMARTProgram, 2010) Office on Drugs and Crime, 2010b). Overall, a lack of systematic Purity % 70–79 75–83 Not reported Not reported Not reported – 75–80 Not reported 71 76 85–90 Not reported (number) ATS pills Not reported 137 249 40 450608 Nil Nil 2.3 M 107 952 23.9 M Nil 1237 26.6 M 5.87 kg 500 000+ Purity % 15–28 Not available – – Not reported Not reported 25 – 6 10–25 Not reported kg ATS powder Not reported Nil Nil Nil Nil Nil nil 339 liquid 831.5 litres Nil Not reported Nil Setting the context in Southeast Asia 13 - - 1; 1;

to poverty and political disenfranchisement. to poverty inadvertent results of law enforcement and interdiction operations, resulting in changes resulting operations, and interdiction of law enforcement results inadvertent routes coastal and cross-border overland in increases especially routes, trafficking drug to use and in drug trafficking new populations which then involve and factors, leading to all the above programs, the impact of development leading elites, political ruling among power of maintenance the in role its and corruption migration, and resultant cash-rich migrant labour populations living away from their homes their from away living populations labour migrant cash-rich resultant and migration, rich between gaps increased with growth, such of benefits the of distribution inequitable economy ability to participate in the formal and differential and poor, drug for flows human both creating migration, external resultant with upheaval, political without access to the formal economy populations and disenfranchised trafficking rapid economic growth, with a burgeoning middle-class youth population and with internal internal with and population youth middle-class burgeoning a with growth, economic rapid tion between occasional drug use and drug dependence). For example, in Cambodia, China, China, Cambodia, in example, For dependence). drug and use drug occasional between tion Lao Thailand PDR, and Indonesia, Viet Myanmar, Nam, people who use drugs are arrested staff military by managed frequently are settings Such centres. compulsory to removed and is unclear in Cambodia, Malaysia, Myanmar and Thailand. In other countries, criminal penal criminal countries, other In Thailand. and Myanmar Malaysia, Cambodia, in unclear is seeking support from and harsh Some health have services. users ties appear to discourage distinc little with (often settings closed in detention compulsory including laws, control drug Although many Southeast Asian countries are now supportive of harm reduction as a response response a as reduction harm of supportive now are countries Asian Southeast many Although to reducing drug-related harm, it syringes remains in theand early stages, needles with and legislative of cultural distribution the of legality the example, For conflicts. and ambiguities (Blickman, This displacement2011). theoryThailand was 2; also mentionedMyanmar 1; by key Myanmar informants 1; from informant] [key (China Thailand and Myanmar China, Thailand 2; Thailand 3). 2011). The Transnational Institute paper also argued that may paper argued there be Institute also another effect of a The Transnational 2011). campaign the with ‘displacement’, region: the in measures reduction supply largely on focus (methamphetamines) substitutes of use the of rise the to leading (heroin) drug one against is is supported by others (Lyttleton, with associated 2004), is use as heroin is or the Opium view use. drug that regarding ATS fashion use and is change influenced generational by a older generations, while ATS use is associated with youth, fun and recreation (Blickman, Such changes have contributed to a context that has influenced both drug notes use Institute patterns Transnational the from briefing a example, For transmission. HIV of risk and that ATS use ‘fits better with the new competitive and cultures of industrious rising Asian view This p.3). 2011, (Blickman, pace’ work and habits work in changes the and economies • • • • • • An analysis of the situation in Asia and the Pacific conducted inof 2006the identifiedsituation in a number Asia and the Pacific An analysis of vulnerabilities linked to illicit drug use in the Southeast Asia region 2006). which Baldwin, & renderReid the (Devaney, complex more use ATS with associated risk of assessment below: listed These are 4.2 Vulnerabilities in Southeast Asia in Southeast 4.2 Vulnerabilities 14 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia cluded that most centres lacked not only drug treatment services, but also HIV preventionalsoHIV treatmentservices,but drug only not centreslacked most that cluded con- Organization,2009) Health (World Nam Viet Malaysiausersand China, Cambodia, in transmissiondrug the compulsorytreatmentcentresfor in HIV.assessmentof cated of An impli- issettings closed usersin drug of detention the settings,and these interventions in Thismatters,situation because riskat people are readilyto able not evidence-based access Thailand (Thomson, 2010). and Cambodia PDR, Lao in reported are centres withdrawal drug compulsory and prisons both users in ATS of rates High 2009). al., et (Phimphachanh setting closed a in detained been had cent per 15 PDR, Lao in usersATS Among treatment. drug compulsory rienced expe- had cent per 23.9 prison,and in been had cent per 85.4 that Thailand, Bangkok, in injectors 117ATS of frequent survey a in (2010) reported Sripramong services. treatment compulsory and enforcement law of attention the to come to likely be to appear users comparativeanalyses,ATSformal of way the in little isthere Although services.reduction countries,resourcebecausefactors,Some of political or remainupgrade reluctant harm to (World HealthOrganization, 2009). 100and 60 relapsebetween usepeople that fromdrug of exit to cent centreson per such estimates Organization Health World The 2009). Program, Development Reduction Harm (International release for criteria no and appeal, for process no process, judicial no or tle lit- istherecountries,interventions. these dependence In drug in training no or little with higher levels ofrisk taking. to contribute possibly and services, health much-needed to access their and campaigns prevention HIV in participation their impede potentially which discrimination, and stigma significant to subjected are men with sex have who men and workers sex mean laws Such nation. Prostitution is illegal in many Southeast Asian countries, but tends to be tolerated. Asia, only China and the Philippines have any systems in place to address associated discrimi same-sex activity are harsh. Although homosexuality is legal in other countries in Southeast in engaging Myanmar,for and penalties MalaysiaDarussalam,whereSingapore, Brunei in illegal remains use, ATS to linked behaviour high-risk potential another Homosexuality, Health Organization, 2009). (World detainees to given not are results test the but centres, treatment government-run into entry on compulsory is HIV for testing Malaysia, In HIV-positive. areprisons state in users drug of cent per 15–40 estimated an Indonesia in and 2009) Organization, Health usersdrug of compulsoryin treatmentdrug centres are reported HIV-positivebe to (World cent per 17 China, in concern: of are data existing scarce, are centres these in users drug Office on Drugs and Crime, 2006). Although accurate data on the prevalence of HIV among Nations (United findings similar reported region the across settings prison and custodial of assessment An 2008). Amon, & reused(Cohen sharedfrequentlyand are needles where detention, in continues also use drug Injecting 2008). Amon, & (Cohen inmates between despite there being reports of unprotected sex between male staff and female inmates, and Nam, Viet or China Cambodia, in available centres.not wereCondomsmost in availability and care services. HIV prevention education materials are either not available or have limited - Amphetamine-type stimulant use and harm in the Southeast Asia region 15 . - provides data on illicit drug rely supply, World World Drug Report

pore and Macau) in 2009. However, it is likely that the true extent of manufacture manufacture of extent true the that likely is it However, 2009. in Macau) and pore

Although progress has been made, lack of reporting of detailed and consolidated data on on data consolidated and detailed of reporting of lack made, been has progress Although region. the in countries many in challenge a remains use and trafficking production, ATS and Crime, 2010b) Office on Drugs (United Nations are are under-resourced and unable to keep pace with the increasing numbers of users of these drugs. Furthermore, the treatment available in compulsory detention manu- The centresuse. ATS is addresses specifically none and abstinence-based exclusively almost PDR, (Lao locations three but all in reported was ATS of manufacture attempted or facture Singa as under-reported, the is low with amounts the of relatively inconsistent seized are ATS number of manufacturing facilities detected. ATS ATS now rank in the top three drugs of use in all countries in East and Southeast Asia and upward trends in the use of methamphetamine are reported in most countries in the the now have in ATS used drugs area. traditional more displaced the such region as and cannabis. heroin Despite the rising numbers of ATS in users countries, several few treatment services are (and other of synthetic ATS drugs) and services often for drug users available treatment • • The summary section of the SMART program report made the following observations about about observations following the made report program SMART the of section summary The in Southeast Asia: ATS • contained in the report are based on information obtained from drug control agencies and agencies control drug from obtained information on based are report the in contained relevant agencies in Southeast Asian countries; collected via the Drug Abuse Information Report Annual UNODC from supplemented and (DAINAP); Pacific the and Asia for Network Questionnaires. section. in this of information reported form the basis These two reports Patterns and Trends of Amphetamine-type Stimulants and other Drugs in Asia and the Pacific the and Asia in Drugs other and Stimulants Amphetamine-type of Trends and Patterns relevant and States Member targeted of capacity the ‘enhance to aims Program SMART The order in information, drug synthetic use and report analyse, manage, generate, to authorities data The programs’. and policies evidence-based and sound scientifically effective, design to achieve the stated goal. The ing on member states to the provide data required through the completion of the Annual on report a released also Program SMART Global UNODC’s 2010, In Questionnaire. Reports In 2009, member states committed to ‘the elimination or significantreduction in the global illicit drug supply and demand by (United2019’ Nations Office on Drugs and Crime, At the same 2010c). time UNODC stressed that data collection was critical in the effort to 5.1 Patterns of amphetamine-type stimulant use in stimulant use of amphetamine-type 5.1 Patterns Southeast Asia the Southeast Asia region Asia the Southeast stimulant use and harm in and use stimulant on amphetamine-type amphetamine-type on 5. Specific information information 5. Specific 16 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 2010); 24percentinBangkok;and11 percentinChiangMai(Yongvanitjit etal.,2010). needles or unsafe sex, and relatively high levels of HIV: 22 per cent in Bangkok (Sripramong, previous six months. Both studies found high levels of risky behaviour, such as the sharing of colleagues (2010) found 65 per cent of PWID surveyed (n=317) reported injecting ATS in the month (n=1055). Recruiting through a community harm reduction centre, Sripramong and 63 per cent of ATS users in Bangkok and 32 per cent in Chiang Mai injected ATS in the last common among surveyed people who use drugs. Yongvanitjit and colleagues (2010) report Thailand (Yongvanitjit et al., 2010; Sripramong, 2010), the injection of ATS fromwas studies found recent tomore beIn 2007). al., et (Wattana ATS injecting report injectors lifetime of half almost Bangkok capital the injectorsATS,in of inject while cent per 9 Thailand, In Office onDrugs andCrime,2010b). streetof dwellerscent reportATSNationsper injecting (United 12 Cambodia, in injecting; via drug the use users ATS all of cent 11 per indicates China from surveillance National There is scant information regarding injecting of ATS by users in the Southeast Asia region. (United Nations OfficeonDrugs andCrime,2010b). in methamphetamine use in pill form in China, Lao PDR, Malaysia, Myanmar and Viet Nam increasingtrendalsoreportan Experts China. in drug the of form secondary the and land Thai- and Cambodia PDR, Lao in used drug primary the is form pill in Methamphetamine is widespread across several groups, with estimates of 50 per cent of people who use drugs gulangan AIDS & Indonesia HIV Prevention and Care Project, 2007). In Cambodia, ATS use there are small pockets where ATS use is a result of substitution for heroin (Komisi Penang- ATS users are ‘middle-class’ recreational users (Indonesia 1; Indonesia 2). Also in Indonesia, Indonesia, In 1). recreational(Malaysia mainly isuse Malaysia, In 1). (Thailand opium and heroin or opium users who are using ATS as a substitute for poor quality or unavailabletwo main groups of heroinusers: young recreational users who use ATS as the drug of choice, and use,occupational to ATSisfromlargelyor 1). useThailand changing being ‘functional’ in Kong, ATS use is limited, with the use of ketamine being far more of a concern (Hong Kong Hong In 1). (China ATS userssubstituting opium and heroin seen has measures reduction supply in increase an south, the to areas border the along China, mainland In 1). (Macau among young people and specific professions, such as croupiers in casinos and sex workers focused is use Macau, In 1). PDR (Lao users’ urban recreational ‘young, as characterised picture of regional variation in regards to the use of ATS. In Lao PDR, ATS users area mainly presents and area, this in literature the supplements informants key from Information available dataontheuse andinjectionofATS inSoutheastAsiancountries. the presents 2 Table injected. drug(s) the specify not does IDU on data surveillance Asian ATSof werefromcountries Asian Southeast available,Southeast the not other of much as injection on Data concern. primary of drugs the remain opium and heroin Malaysia, and Singapore Nam, Myanmar, Viet China, generally, in increasing is ATS of use the Although Amphetamine-type stimulant use and harm in the Southeast Asia region 17 - - and a cross-over between heroin users and ATS use warrant concern regarding the transmis the regarding concern warrant use ATS and users heroin between cross-over a and sion of HIV and other BBVs. populations, populations, but are most often not enumerated. There are growing reports of the use of ATS by heroin injectors. It is not documented by which routes this group is administering ATS of injecting some of indicators the data, limited with Even injection). via or (orally ATS informants. However, data regarding the routes of administration of ATS are scant. Where this this Where scant. are ATS of administration of routes the regarding data However, informants. at differing rates. study groups across reported is information has been collected, injecting these in reported also are sex, unsafe and sharing needle especially behaviours, risk HIV Other country under Some review. studies have noted routes of initiation to drug use (Phimph people who injected drugs. achanh et al., 2009), but did not include key many to concern’ ‘of is use that indicate Asia Southeast in use ATS of reports summary, In Our literature review also included searching for studies related to initiation to the injection injection the to initiation to related studies for searching included also review literature Our of ATS. noHowever, studies or reports were identified documenting this process for any MDMA use was noted in interview data from Thailand, Hong Kong, Viet Nam and Indonesia Indonesia and Nam Viet Kong, Hong Thailand, from data interview in noted was use MDMA (Thailand 1; Hong Kong 1; Viet Nam 1; Indonesia 2). This is consistent with key regional 2010). (Global SMART Program, reports ATS ATS for yet informants heroin when report a heroin availability is low, growing number of (Myanmar 1; ATS users recreational Myanmar 2). This trend is also noted in recent official 2010a). and Crime, Office on Drugs (United Nations reports - prac this on data of lack a reported informants key all ATS, of injecting the to regard With exception the (with countries their in ATS of injecting of pockets large noted few and tice, of Thailand). in Cambodia using ATS (Cambodia 1). In Viet Nam, ATS use is predominantly concentrated concentrated predominantly is use ATS Nam, Viet In 1). (Cambodia ATS using Cambodia in substitute users heroin traditional Myanmar, In 1). Nam (Viet users recreational young among 18 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Kong Hong Malaysia China Lao PDR Brunei Cambodia Indonesia Darussalam Country Table 2:Amphetamine-typestimulantuse inSoutheastAsian countries 11 596 170 000 PWID estimated registered users 1.3 million users dependent ATS 35 000–40000 1000–8000 # (DAINAP) 3.3–3.6 million registered users* • drug users Number of 2009 2009 2010 collection of data Year Crystal Cannabis Heroin Crystal Pills Heroin Opium Cannabis MA pills Cannabis MA pills Crystal XTC Crystal Cannabis drugs Top 3 Rank – Cannabis MA Crystal • 2009 2010 2009 2010 2009 Year 2010 27 70 • Drug Agency) (Nat’l Anti since 2008 18% increase % ATS use • 8–9* • • Injecting crystal Smoking crystal administration route of Predominant MA Smoking crystal • in 2009 injecting reports of No 2009 Year 2010 2009 2010 (UNODC, 2010c) Yunnan province by landthrough from Myanmar pills trafficked in country;ATS manufactured Crystal ATS to Thailand route from Myanmar into Lao PDR on Diversion of ATS Pills from Myanmar by air Trafficked from Iran Indonesia Manufactured in Source country trafficked toBD to Malaysia and Philippines shipped Myanmar Some crystal from Pills from Myanmar Meth/amphetamine • data but no reported PWID • increasing ? • injected % ATS •  •  •  • pills Trend •  •     crystal Trend  • (<25 years) young people use among increasing Trend towards (<25 years) young people use among increasing Trend towards Comments (<25 years) young people use among increasing Trend towards

19 Amphetamine-type stimulant use and harm in the Southeast Asia region Asia Southeast the in harm and use stimulant Amphetamine-type 20 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia * # • Source: UnitedNations OfficeonDrugs andCrime,2010b Thailand Viet Nam Myanmar Singapore Philippines Country Global SMARTProgram, 2009 Drug Use, 2010) Range reported by UNAIDS(Reference Group totheUnited Nations onHIVandInjecting No informationavailable (Khon Kaen IPWID: 40 300 Estimated • registered users 146 731 • • Thailand (Kobori Karen innorth 9.9% among University, 2010) 2010) Drug Board (Dangerous 1.7 million et al.,2009) drug users Number of

2009 2009 collection of data Year Crystal MA pills Heroin MA pills Opium Heroin MA Inhalants Heroin Inhalants Cannabis phetamine Metham drugs Top 3 Rank – Inhalants Cannabis Crystal 2009 2009 Year 2009 drug users 4% ofall • drug arrests 19% ofall • % ATS use common polydrug use drug users; 62% ofall not reported Injecting MA reported Injecting not Smoking pills smoking Primarily been reported Injecting has smoking Primarily administration route of Predominant Snorting 2010 UNGASS 2010 Year 2010 from Myanmar and China from India,Thailand precursors imported in country; ATS pills produced Thailand Malaysia and Trafficked from Myanmar primarily through Pills andcrystal Source country from China some trafficked country; Manufactured in   •  injected % ATS      pills Trend • crystal Trend Comments

21 Amphetamine-type stimulant use and harm in the Southeast Asia region Asia Southeast the in harm and use stimulant Amphetamine-type 22 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 5.2 Amphetamine-typestimulantuse andsexualrisk In a prospective study of young women who engaged in sex work in Cambodia, Couture Cambodia, in work sex in engaged who women young of study prospective a In such asmore young menandwomenhavingpremarital sex(Phimphachanhetal.,2009). users,ATS in norms sexual changing showedalso study This 2009). al., et (Phimphachanh variable was HIV of knowledge HIV,and for tested been had cent per 5 than low. Fewer was use condom and active sexually were majority The (>99%). pillssmoking be to found were participants all almost and years, 16 was pills) Yaba of form the (in ATS of use first of age average the found (n=440) PDR Lao in people young among use ATS of study A partners wasreported (Celentanoetal.,2008a). drawingfrom ATS depression,and increased and multiple unprotectedwith activity sexual Celentano et al. (2008b). Celentano and colleagues also found an association between with findingsSimilar 2008). riskal., condom sexual et to and relating use were also reported by wereusedpreventthey primarily to and reportedpregnancy;statusnot (Sherman HIV was 20%) than (less low was group this among condoms of use The 2008). al., et (Sherman found a minority considered the drug increased the duration and frequency of sexual events years4.5 average of an for ATSsmoked had who Thailand in youth of study qualitative A the SoutheastAsiaregion. smalla Only havestudies of number investigated risksexual of influence the under in ATS among non-ATS users. ciated with low condom usage, higher numbers of partners and longer duration of sex than is an elevated risk of sexual transmission of HIV in people who use ATS in the region, asso- Consistent with other international studies, as described earlier, these studies suggest there (Couture etal.,2012). an STI. The authors concluded that ATS use is an important emerging risk exposure for HIV have to likely more times five were and use, alcohol levelsof partners,higher sexual more use(2012)not ATS,colleagues did ATSand who userscomparedthose that, to found had - HIV prevalence in Southeast Asia 23 - - 3. However, it should be noted it should 3. However,

ing practices, such as sharing needles and syringes, sharing other injecting paraphernalia and Among syringes. pre-loaded using PWID in Southeast Asian HIV countries, prevalence between ranging countries other in prevalence with cent, per 52.4 at Indonesia in highest is 0.2 per cent in the Philippines, to 36 per cent in Myanmar and 38.7 per cent in Thailand. in Table shown is sentinel surveillance from HIV prevalence that most sentinel surveys do not identify which drug is injected. do not identify which drug is that most sentinel surveys injecting drug use, although one study in China, which surveyed 1200 MSM across This three 2002. in IDU reported MSM of cent per 6.1 found 2006), and 2004 (2002, periods time by only 0.2 per reported by 2006 when injecting was had significantly dropped proportion (Zhang et al., 2007). The type of drug injected was not reported cent in that year. who inject (PWID) at drugs People are if continued they high inject- engage risk in unsafe In a systematic review of HIV among MSM in middle- and low-income countries, the authors authors the countries, low-income and middle- in MSM among HIV of review systematic a In established within occurs risk MSM ‘where one being as Asia Southeast of parts characterised investigate MSM of studies Few 2010). al., et (Beyrer use’ drug injecting by driven epidemics dence data are scarce. Information from Thailand indicates that incident density was 5.7 per per 5.7 was density incident that indicates Thailand from Information scarce. are data dence (2005) 2.5 of incidence estimated an China in and 2009) al., et Griensven (van year per 100 (Li, Zhang & Li, 2008). was recorded per year and 3.62 (2006) per 100 While prevalence data are made available through epidemiological and sentinel surveys, inci surveys, sentinel and epidemiological through available made are data prevalence While cent between 2004 (n=68) and 2007 (n=174) and although the number declined slightly in 2008 than (n=156), 35 more per cent of HIV cases among in MSM are Hong (van Kong In in Singapore 2008, 40 per & cent de of Griensven Lind 2010). all Wijngaarden, van HIV between cent per 500 increased diagnoses new of number the and MSM among were cases 2010). Wijngaarden, & de Lind van Griensven (van 2002 (38 cases) and 2008 (185 cases) across Asia were 18 per cent more likely to have HIV than non-MSM (Beyrer et al., 2010). HIV than non-MSM (Beyrer likely to have 18 per cent more Asia were across Substantial increases in HIV prevalence among MSM have occurred over the past decade. For instance, in Hong Kong, the number of infections among MSM increased by 250 per to HIV across the globe. Among MSM, HIV prevalence is highest in Myanmar (29%) and low and (29%) Myanmar in highest is prevalence HIV MSM, Among globe. the across HIV to 2.6 between ranging countries other in prevalence with cent, per 1 at Philippines the in est MSM study, 2007 a In 2010b). (UNAIDS, Nam Viet in cent per 16.7 and Singapore in cent per 6.1 Men who have sex with men and HIV in Southeast Asia sex with men have 6.1 Men who exposure of risk increased at are (MSM) men with sex have who men discussed, previously As presented in Table 3. An understanding of the use of ATS among 3. in of of in these An the the ATS Table populations understanding use presented to assessing HIV risk. critical is region The most recent HIV population prevalence data as well as that of key populations are HIV in most countries in Southeast Asia can be described as a concentrated epidemic, with with epidemic, concentrated a as described be can Asia Southeast in countries most in HIV of the higher HIV prevalence among considerably key affected such populations as people sex and with men men female who than sex have in workers the general who inject drugs, 2010b). population (UNAIDS, Southeast Asia in Southeast 6. HIV prevalence prevalence 6. HIV 24 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia # Prevalence among populationaged 15–49years + Source: * Source: UNAIDSReporton theGlobalAIDSEpidemic2010 (UNAIDS,2010b) Macau Viet Nam Thailand Singapore Philippines Myanmar Malaysia Lao PDR Hong Kong + Indonesia China Cambodia Brunei Darussalam country Southeast Asian HIV/AIDS Situation in Hong Kong: factsheet Table 3:Population prevalence andprevalence ofHIVincapitalcitiesamong people whoinjectdrugs, sexworkers andmenwhohave sexwithmen No data 0.4% 1.3% 0.1% <0.1% 0.6% 0.5% 0.2% 0.2% 0.1% 0.5% 11 cases2009 56 cases1986–2009; National prevalence *# , (Hong Kong Centre for Health Promotion, 2010) 0.3–0.5 1.0–1.6 0.1–0.1 <0.1 – 0.5–0.7 0.4–0.6 0.2–0.4 0.1–0.3 0.1–0.1 0.4–0.8 • Range (220 000 –350000) 280 000 (420 000 –660000) 530 000 (2100 –4400) 3400 (6100 –13 000) 8700 (200 000 –290000) 240 000 (83 000 –120000) 100 000 (6000 –13 000) 8500 (200 000–460 310 000 4832 (390 000 –1.1million) 700 000 (42 000 –90000) 63 000 • people livingwithHIV Estimated numberof 29 (2008) 18.4 (2009) 38.7 (2009) • 0.2 (2009) 36.3 (2008) 22.1 among sex workers andfemale migrants Thought tobehighamongMSM,somePWID, 52.4 (2007) 9.3 (2009) (Cambodia NCHADS, 2008) 35% ofreferrals from NGOs 24% PWIDinrehab 24.4 (2007) No knowncases Injecting drugusers (%) HIV amongPWID,SWandMSM 3.2 (2009) 2.8 (2009) • 0.2 (2009) 18.1 (2008) • • 7.8 (2007) 0.6 (2009) • • Sex workers (%) 16.7 (2010) 13.5 (2009) 2.6 (2009) 1.0 (2009) 28.8 (2008) 3.9 (2009) • 5.2 (2007) 50.0 (2009) 4.5 (2005) • sex withmen(%) Men whohave

25 HIV prevalence in Southeast Asia Southeast in prevalence HIV 26 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia between this population and the general population, thus providing no evidence about about evidence no providing thus population, general the and population this between made was 2011). comparison Jiang, No & Yuan (Chang, HIV-positive were cent per 26.1 12.4 per cent tested positive for methamphetamines. Of those who tested positive for ATS, In China, urine testing of methadone maintenance treatment clients (n=1514) indicated that services (e.g. HCV testing) and a relatively high rate of HIV at 22 health per some to cent access (Sripramong, low system, justice criminal 2010). the to exposure high (42%), sex tected behaviours of frequent ATS injectors included high rates of needle sharing (31%)characteristics and The and drug. the unproinjected these of cent per 65 months,and six last the in ATS used had cent per 63 Thailand, Bangkok, in 317PWID of survey unpublished an In ity withoutacondomwassimilarforbothgroups (Martinetal.,2010). 16%), but the proportion of PWID having sex with multiple casual partners or sexual activ- 2010). Needle sharing among ATS injectors was higher than among heroin injectors (26% vs any drug declined from 94 per cent at baseline to 48.5 per cent at 36 months (Martin et al., in Bangkok in which PWID were surveyed seven times over a 36-month period, injection of study Thai a months).In 36 at 2.8% and baseline at (1.1% drug exclusivethe of injection ity reported the injection of ATS (16% at baseline to 15% at 36 months); few reported the among ATS users ranged from 4 to 36 per cent (Anh Tuan et al., 2007). A consistent minor rates of HIV among ATS users. A study in four provinces of Viet Nam found HIV prevalence show countries Asian Southeast some in use amphetamine of studies of number small A Macau, norecent estimates ofHIVamongfemalesexworkers were available. population mobility (Anh Tuan et al., 2007). In Brunei Darussalam, Lao PDR, Singapore and et al., 2007). HIV infection was associated with irregular condom use, a history of IDU and Tuan (Anh cent per 16.5 and respectively24.3 positive, HIV be to workers karaoke-based than likely morewere workers street-based Nam, Viet in workers sex Among engaged. are HIV among sex workers varies considerably depending on the type of sex work in which they and prolonged sexualactivity. (2011) reported ATS use in young women engaging in sex work, coupled with unprotected use by female sex workers and their clients (World Health Organization, 2009). Maher et al. use. A 2006 study in Cambodia found high levels of both injecting and non-injecting drug drug groups,concurrent some among and, use inconsistentcondom to riskdue increased isisit Indonesia in while Tablecent, (see per cent 18 per 7.8 Female3). workerssex are at it Myanmar in instance, For countries. Asian Southeast many in high relatively still is but MSM, among than lower somewhat is HIV of prevalence the workers, sex female Among 6.2 Sexworkers andHIVinSoutheast Asia relative risk. - - Responding to amphetamine-type stimulants globally 27 - -

Evaluations of Evaluations the effectiveness of school-based drug education in delaying or preventing alcohol or drug use also vary, but most experts agree that skills-based interventions are and also in content, which tends to mirror the drug policy of the country in question. 2008; Davis et al., 2008). the However, evidence for the effectiveness of such campaigns and some have (Wakefield, Loken & Hornik, 2010) less robust is illicit drug use in reducing Erceg-Hurn, 2008; Kalton, & Piesse Orwin, Jacobsohn, (Hornik, effect measurable no shown use. ATS evidence about the impact on little in the way of specific is 2008). There delivery of mode and construct their in greatly vary programs education drug School-based there is strong evidence that campaigns targeting smoking have been successful in reducing reducing in successful been have smoking targeting campaigns that evidence strong is there some among rates smoking reducing and adolescents by tobacco of smoking of uptake the sections of the community (Wakefield, Loken & Bala, Hornik, Strzeszynski & 2010; Cahill, a relatively small cost per individual reached (Terry-McElrath, Emery, Szczypka & Johnston, Johnston, & Szczypka Emery, (Terry-McElrath, reached individual per cost small relatively a alcohol, including behaviours of variety a modify to attempts in used been have and 2011) example, For 2010). Hornik, & Loken (Wakefield, use drug illicit and drink-driving smoking, Demand reduction responses include mass media education, school-based intervention includ intervention school-based education, media mass include responses reduction Demand have campaigns media Mass education. peer and interventions workplace education, drug ing for audience wide a reaching of capable are they that basis the on popular particularly been 7.2 Demand reduction Demand reduction include responses prevention approaches that target prevention of use dependent use. to address include drug treatment also They of use. or delay in the onset munity is yet to be demonstrated in the long term. There were short-term effects following effects short-term were There term. long the in demonstrated be to yet is munity - admis hospital in reductions including States, United the in drugs precursor of control the sions for ATS-related events and decreases in ATS-related arrests. thereHowever, is little longer periods of time had (Cunningham an & effect Liu, over evidence that the responses 2010). et al., 2007; 2003; 2005; Degenhardt such as the United Kingdom. The success of the supply controls described inabove reducing consumption in the com of pseudoephedrine and ephedrine containing products that an individual is permitted to purchase in a certain time period, and rules apply to the storage of such preparations in order to prevent theft. Other supply reduction activities, such as the re-regulation of ATS to a class that attracts higher penalties for possession, have been introduced in countries of the precursor ephedrine and equipment used in the manufacture of ATS in 1983, followed followed 1983, in ATS of manufacture the in used equipment and ephedrine precursor the of 2003). Liu, & (Cunningham 1989 in pseudoephedrine and ephedrine bulk of control the by amount the on restrictions now are There 2005. in introduced was control recent most The drugs. Supply reduction responses focus on the control of manufacture, by restricting access access restricting by manufacture, of control the on focus responses reduction Supply drugs. and to chemicals, by penalising precursor the possession, supply and manufacture of ATS. possession the regulated first policy suppression major a States, United the in example, For 7.1 Supply reduction for, demand and of, supply reducing on focuses globally ATS of use illicit the of control The stimulants globally stimulants amphetamine-type amphetamine-type 7. Responding to to 7. Responding 28 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia There are some developments in this domain. For example, Shearer (2008) and Shearer et al. is arange ofpharmacotherapy options, includingsubstitution therapies. therewhere dependence opioid of management the with contrastsThis maintenance. and therapeutic relationship, and limited pharmacotherapies to assist in withdrawal management specific psychological heroin), (e.g. users drug other supporting to geared are services that perception a risk, of 2004). There are many potential factors that contribute to this, including a lower al., perception et Baker (e.g. connection tenuous a have or treatment access not do either usersATS However,most 2008). Rawson, & (Lee ATS for relevance have drugs, other with used are In general, it is accepted that many of the counselling treatments, or ‘talking therapies’, that of bothshort-term outcomesandfuture employer costs(Guyll,Spoth&Crowley, 2011). terms in cost-effective, be to found also was and cent per 4 almost by use amphetamine amine among adolescents in the United States was found to be effective in reducing meth- userecentrelatedprogramA and evaluationa harm. of targetinguse methamphet the of There is little in the way of evidence about prevention initiatives that specifically target ATS community- and family of inclusion the by enhanced is education school-based of effectiveness the 2008; Stead, Stradling, MacNeil et al., 2010; McBride 2004). There is growing evidence that al., programsVersinoet Vigna-Taglianti,(Faggiano,knowledge-based than effectivemore services forATS users. This technicalbriefincludesfive recommendations: brief which summarises the international literature and provides a set of key harm reduction situation in all Southeast Asian countries under review. Most recently, WHO issued a technical Globally,usewho drugsreductionpeople isinjectors,harm for focusedopioid on is as the 7.3 Harmreduction engagement andretention forATS users are addressed. treatment to barriers impact, have to treatment for order in that, critical is It dependence. opioid and alcohol for options treatment behind well lag practice clinical and science the medications, such as buproprion and serotonin medications (Shoptaw et al., 2008). However, other and modafinil of use the with useATSpromising(2001, in reductiona report 2009) 1. • • • • Outreach andpeereducation(providing culturally sensitive, clearmessages) including thefollowingmessages: lighting the risks of injecting and acquiring BBV from sharing contaminated equipment, users,high ATS to relevant and accurate consistent, and integrated be should These Use less ATS and less often (drink water, eat fruit, improve diet, get adequate rest, em Use a condomevery time you have sex. Do notinjectorelse switchfrom injectinguse tooral —ifinjecting,donotshare. from ATS). Avoid using ATS with other psychoactive substances (e.g. alcohol to help ‘come down’ ploy strategies to help control drug intake, monitor own behaviours, do not use alone). based interventions (Spoth,Clair, Shin&Redmond,2006). effects (e.g. agitation, paranoia) that might interfere with building a interferebuilding paranoia)might with agitation, that (e.g. effects - - Responding to amphetamine-type stimulants globally 29 - - - European European Targeted interventions for specific groups ofusers (e.g. injectors and non-injectors, minorities) women and youth, needles and syringes) (condoms, of equipment to help behaviour change Provision and families users to ATS advice and brief counselling Low-threshold facilities to health and welfare networks and referral links Establishing piece syringes) and structural factors (e.g. by increasing the availability of sterile syringes or or syringes sterile of availability the increasing by (e.g. factors structural and syringes) piece ( injecting). public to alternative an as environments injecting hygienic providing p.19) 2010, and Drug Addiction, for Drugs Monitoring Centre To prevent and reduce harms related to amphetamines injecting, a combination of inter of combination a injecting, amphetamines to related harms reduce and prevent To ventions may be required, aiming at reducing personal behaviours, changingrisk social network norms (about risk boundaries or equipment sharing) through peer education, two- of instead one-piece of use the promoting by (e.g. process injecting the addressing 2. 3. 4. 5. (World Health Organization, Western Pacific Region, 2011: Technical Brief 2). Technical Region, 2011: Western Pacific (World Health Organization, ATS injectors, and the need to provide treatment for HIV-infected ATS users and programs and programs users for HIV-infected ATS treatment and the need to provide injectors, ATS to address stigma and with discrimination. Consistent these points, a recent review by the that: a conclusion led to and Drug Addiction for Drugs Monitoring Centre European recent reviews, and commentary from key informants, have specifically emphasised the need need the emphasised specifically have informants, key from commentary and reviews, recent con for testing, and counselling HIV voluntary and provision condom education, include to with them, as both key to elements address of and strategies those in sumers relationships among treatment and prevention HIV of importance the to point also They risk. HIV and ATS There There is clearly an absence of a strong evidence base to guide action. the However, more with sufficient investment of time or resources to address them’. This comment, This that there with sufficient of investment time toresources them’. or address is a need for multifaceted approaches, as no single strategy is likely to be able to address risk problems, health physical and health mental as (such concern of issues potential the all key informants. by etc), was echoed taking behaviours, methamphetamine, requiring novel and sophisticated responses, which have not yet been met met been yet not have which responses, sophisticated and novel requiring methamphetamine, lications (Colfax et al., 2010; Degenhardt et al., 2007; 2010). Degenhardt (Colfax et al., 2010; lications sub group amphetamine of use address ‘to that suggest p.463) (2010, colleagues and Colfax might policy) and community group, individual, (e.g. approaches of combination a stances of HIV infection’. the risk be needed, including those that address p.347) Degenhardt and further colleagues suggested (2010, that ‘complex issues surround There There is no globally to coordinated response ATS and and HIV, a limited evidence base to pub- of number a in detail in discussed are responses recommended although action, guide 7.4 Responses to amphetamine-type stimulants stimulants to amphetamine-type 7.4 Responses and HIV globally 30 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 7.5 Reponses toinjectingdruguse andHIVglobally The statement further recommended that the comprehensive package of nine interventions interventions toaddress injectingdruguse andHIV. Theseare: reduction harm of set core the as considered be should Guide Technical the in outlined Statement, whichstatedinitssummaryofrecommendations: Reference Group to the United Nations on HIV and Injecting Drug Use released a Consensus2010,2010a). the In Organization, Health (World users drug injecting for care and ment prevention,treatHIV universal- to for targetsaccess set to countries for guide technical a In 2009, WHO, in collaboration with UNODC, UNAIDS and international experts, developed to injectingdruguse andHIVare summarised inTable 4. The effectiveness of key elements of this package (NSP and OST) and other generic responses grams toreach asmanyinjecting drugusers aspossible’(p.11). education), and barriers to access should be identified and removed to allow for these pro- thresholdlow drop-incentres,outreach, peer utilised(including deliverymodelsshouldbe multiple scale, in increased be should programslow, are interventions these of coverage (p.11),priority’ of matter a as ‘wherelevelsimplemented and should targetingbe PWID of The Statement also recommended that ‘NSPs, OST, ART and sexual risk reduction strategies 7. 6. 5. 4. 3. 2. 1. 9. 8. on HIVandInjectingDrugUse, 2010) Nations United the to Group (Reference rights. human of protective be and legislation, and policy appropriate by supported be should approaches, of combination a involve shouldpartners.Thisusing non-drug with contact sexual unprotectedthrough mission controlto rapidthe spread drug-usingamong HIV of populations preventto and trans - An effective and evidence-based response to HIV among people who use drugs is required condom programs forPWIDandtheirsexualpartners prevention andtreatment ofsexuallytransmitted infections (STIs) anti-retroviral therapy (ART) HIV testingandcounselling opioid substitutiontherapy (OST)andotherdrugdependencetreatment needle andsyringeprograms (NSPs) targeted information, education and communication for PWID and their sexual partners prevention, diagnosis andtreatment oftuberculosis. vaccination, diagnosis andtreatment ofviral hepatitis Responding to amphetamine-type stimulants globally 31 Effectiveness of evidence Strong of range in effectiveness and contexts settings that NSP is Economic evidence cost-effective demonstrated Correlation availability between increased of needles and syringes and HIV prevalence decreasing to the scale related Impact is — proportion of programs of PWID accessing sufficient of reuse quantity to prevent needles and syringes Limited evidence for for substitution therapy use ATS Combination of motivational interviewing and cognitive (CBT) therapy behavioural recommended can improve Brief CBT abstinence No evidence for effectiveness Cross, Saunders Saunders Cross, & Bartelli, 1998; in National Centre HIV Epidemiology and Clinical 2009; Research, et al., Palmateer 2009; Vickerman, Hickman, Rhodes & 2006; Wodak Watts, 2006 & Cooney, Amato et al., 2005; Gowing, Farrell, Sullivan, Bornemann, & Ali, 2008; WHO, UNODC, & UNAIDS, 2004 References Baker et al., 2004; Longo et al., 2010; 2008; Rose & Grant, et al., 2009 Shearer Baker et al., 2005; Baker et al., 2004; Lee et al., 2007; Lee 2008 & Rawson, World Health 2009 Organization,

Targets PWID PWID Targets of regardless drug of choice Majority of relates evidence to opiate replacement therapy Evidence limited for Relevance to to Relevance use ATS Common method of in treatment Southeast Asia Currently the Currently most effective treatment for ATS dependence psychostimulant substitution Table 4: Generic interventions targeting drug injection and HIV/BBV globally and HIV/BBV drug injection targeting interventions 4: Generic Table Psychosocial Psychosocial interventions Needle and syringe provision Oral substitution treatment Prevention Prevention measure Coerced Coerced drug treatment 32 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia # Adapted from Mathers etal.(2010) Macau# Viet Nam Thailand Singapore Philippines Myanmar Malaysia Lao PDR Indonesia Hong Kong China Cambodia Darussalam Brunei Country exchange programs. Key informantsinMacaunotetheoperation oftwooutreach programs/needle andsyringe Table 5:Interventions inSoutheastAsia forpeoplewhoinjectdrugs 2 Yes Yes No Yes Yes Yes Yes Yes No Yes Yes No programs syringe and Needle 0 140 254 413 0 800 29 411 5571 0 49 000 0 >38 000 Unknown 0 a year NSP in accessing of PWID Number 0 95 <1 (<1–<1) 0 5 (4–8) 39 (33–49) 2 (2–3) 0 23 (20–26) 0 2 (1–2) Unknown 0 (range) in ayear % accessing NSP of PWID Proportion 0 million 20.6–34.9 47 513 0 50 000 (2010) 6.8 million million 1.9–2.6 0 797 455 511 670– 0 million 1.14–1.53 117 631 110 982– 0 per year distributed of N&S Number (107–323) 189 <1 – 3 (2–5) 47 (39–58) 9 (7–13) – 3 (2–4) 0 32 (<1–84) 57 (14–118) – per year per PWID of N&S Number No Methadone and methadone Buprenorphine No No Methadone and methadone Buprenorphine No and methadone Buprenorphine Methadone and methadone Buprenorphine Methadone No OST available 0 source: VAAC) August 2011, 4199 (asof 4150–4696 0 0 1994 4135–6538 0 2536 104 068 103 595– Not reported 0 accessing OST drug users Number of Yes Yes Yes Yes in process transition Yes, Yes Yes Yes Yes treatment for drug detention Mandatory Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown for ATS interventions Behavioural – 1760 1435 – – – – – 5406 9300 0 – on ART of PWID Number – 4 (1–86) 2 (1–4) – – – – 0 6 (4–9) 3 (2–6) – – with HIV 100 PWID ART per PWID on Ratio of

33 Responding to amphetamine-type stimulants globally stimulants amphetamine-type to Responding 34 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 7.6 Responses toinjectingdruguse inSoutheastAsia Over the past five years, harm reduction services for PWID across the Southeast Asia region • • • • as detailedbelow: of NSPs and OST has reduced high-risk behaviours among PWID in a number of countries, PWID-focused interventions that currently exist. There is evidence that the implementation being established in many areas, coverage remains low (Hagarty, 2010). Table 5 areoutlines programs the although and varied, are Asia Southeast in use drug injecting to Responses drug use is containedinAppendix2. that services reduction and others noted that ATS users have a less consistent connection with treatment and harm informants key addition, In options. treatment and programs syringe and needle as such exist due to factors including resource limitations and legal and other conflicts with servicesstill countries within regions across and countries across services in Gaps improved. have reduction insharing 12months post-intervention. (WorldHealthOrganization, 2010a) cent per 25 a in resulted Nam Viet Provincein Son Lan Peer-basedthe interventionsin from 68percentpre-intervention to35.3percentpost-intervention. A social media strategy targeting PWID in China resulted in a reduction in needle sharing given regarding whichdrugs were beinginjected. were No reports cent. per 8.8 to from69.1 injecting significantly reduced clients found those not using the NSP. An evaluation of the first eight OST clinics established in China of cent per 43.7 with comparedsharing reported clients NSP of cent per 14.7 China In ment program implemented in Malaysia resulted in a 35 per cent reduction in opiate use. 33 per cent. In the first six months of operation, the pilot methadone maintenance treat 56 to 43 per cent and being injected by a ‘street or port doctor’ was reduced from 42 to At a pilot NSP in Malaysia the passing of injecting equipment to another was reduced from do exist. Country-specific information on the response to HIV and and HIV to response the on information Country-specific exist. - Responding to amphetamine-type stimulants globally 35 - - being extremely being high extremely (World Health 2009). such Organization, Furthermore, detention can rates. and infection behaviours in HIV risk be associated with increases often for prolonged periods of time (up to fiveyears) (World Health Organization, 2009). suchCommonly, are programs not drug-specific, and thereis little evidence that they are programs such from release following rates relapse high with use, drug reducing in effective 2011). There is little evidence that this intervention has been effective (Perngparn et al., 2011). al., et (Perngparn effective been has intervention this that evidence little is There 2011). As noted earlier in this report, responses to drug use in most Southeast Asian countries include registration of individuals found to be using drugs, and compulsory detention, 12-step recovery and counselling, including aspects of family engagement (Matrix Institute, Institute, (Matrix engagement family of aspects including counselling, and recovery 12-step Lao during the 2003 ‘war on drugs’, and from Myanmar to Thailand during crackdowns in crackdowns during Thailand to Myanmar from and drugs’, on ‘war 2003 the during Lao year). in the same Myanmar treatment, drug of Model Matrix the introduced Thailand reduction, demand to relation In therapy, behaviour cognitive on based program abstinence treatment outpatient 16-week a veillance and identification of manufacturing sites and trafficking routes extremely diffi cult. There is also evidence that increased efforts to find and dismantle laboratories have resulted in such operations being to moved neighbouring countries (i.e. from Thailand to amphetamine or opium, and 39 per cent substituted drug use with alcohol or sniffing glue sniffing or alcohol with use drug substituted cent per 39 and opium, or amphetamine et al., 2005). (Vongchak As noted the above, difficult of topographic terrain most of Southeast Asia has made sur- ever, four months after ever, the intervention, one-third replaced injecting with smoking meth- enacted a ‘war on drugs’, designed primarily to stop the use of methamphetamine, which of detention enforced the in resulted action This mid-1990s. the since increasing been had for people 55 000 than of more arrest the and users million drug a of a quarter than more the possession sale, production, and of use methamphetamine. The action in resulted also the killing of more than 2000 alleged drug dealers and some drug reportedly at users, the How- use. drug injecting in decreases initial in resulted ‘war’ so-called The police. of hands alty in Indonesia, Lao PDR, China, Viet Nam, Brunei Darussalam, the Philippines and Thai- and Philippines the Darussalam, Brunei Nam, Viet China, PDR, Lao Indonesia, in alty Thailand and conducted China in major have an campaigns land (Gallahue 2011). & Lines, attempt to halt the useand andmanufacture In oftrafficking 2003, illicit Thailand drugs. facture and trafficking of ATS and their precursors. In addition, the common response to ATS ATS to response common the addition, In precursors. their and ATS of trafficking and facture drugs. such using be to found those for registration and/or ‘treatment’ compulsory is users pen- death the include and severe, are ATS of trafficking and manufacture the for Penalties The majority of to responses ATS in Southeast Asia have so far focused on supply control manu the reduce to initiated campaigns government major with enforcement, law through 7.7 Responses to amphetamine-type stimulants in stimulants to amphetamine-type 7.7 Responses Southeast Asia 36 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia (World HealthOrganization, WesternPacific Region,2011, Technical Brief3). although they are not yet implemented by any country in the region (personal communica- byWHO/UNODC in 2008, have been recently adapted by WHO developed for use in Asia and the Pacific,ATS, of use the for treatment and prevention of principles following The condom use (from 32to44percentat12-monthfollow-up). use (from 99 to 53 per cent at 12-month follow-up) and significant increases in consistent methamphetamine self-reported in decline significant statistically a to led Thailand, Mai, education/network intervention or a life-skills intervention) with young ATS users in Chiang peer of model a either (using interventions group small that found (2009) al. et Sherman tion messages to young people at risk (Thailand 3). Evidence of impact is yet to be provided. support groups. The second is using a youth assembly model and film to provide harm reduc Bangkok, Thailand. The first aims to provide harm reduction information to users via small Key informants stated that there are some pilot activities being undertaken with ATS users in not have specific servicesfor ATS users (Myanmar 2; Thailand3). that ATS users were accessing NSPs or drop-in centres for PWID, although these services did to such services. In some countries, such as Myanmar and Thailand, service providers noted strongconnection alwayshavea ATSusersnot documented, might haverelevanceas but, informants. Mainstream key all confirmed behaviours interventionsby harm was reduction The lack of harm reduction interventions specifically targeting ATS users and associated risk • • • • • • • • • tion, Fabio Mesquita): Treatment systems: policy development, strategic planning and coordination of services. Clinical managementoftreatment servicesforATS dependence Community involvement, participation and patientorientation to treatment considered instead ofincarceration tice systems, with a view to supporting clients with legal problems and referral pathways All treatment services for ATS dependence should seek an alliance with the criminal jus- placed persons) dis and refugees workers, entertainment minorities, ethnic co-morbidities, psychiatric Targeting special subgroups and conditions (i.e. youth, women, people with medical and Treatment forATS dependence,humanrightsandpatientdignity Evidence-informed treatment forATS dependence Screening, assessment, diagnosis andtreatment planning Availability andaccessibilityofATS dependencetreatment intheAsia–Pacific region - - Comparison of amphetamine-type stimulant and opioid use 37 - - injectors (Ameri injectors

Strang, 1992; Kaye & Darke, 2000). 1992; Kaye Strang, analyses analyses (Braine et al., 2005), others have not (Kral et al., Bolding 2001; et al., 2005; Van de relate et mightVen findings toal., in differences 1997). the of The frequency disparate injection, reflecting levels of dependence (Darke & Hall, 1995; Gossop, Powis Griffiths, & injecting equipment (Braine, Des Goldblatt, Jarlais, 2005; Zadoretzky & Lorvick Turner, et al., 2006); no different in sharing injecting than likely equipment less or (Kral et2005); al.,al., et 2001; Bolding, Prestage Davis, 1997; al., et Ven de Van 2005; Elford, & Sherr Hart, in factors confounding for adjusted have Some 1999). al., et (Zule share to injectors heroin found that heroin injectors are more frequent injectors than ATS injectors & (Kaye Darke, 2000; Zule, Desmond, Morgan & Joe, 1999), but others show the opposite (Lorvick, Mar- tinez, Gee & Kral, 2006). Some have found that ATS injectors were: more likely to share There There have been some studies evaluating the comparative injection of risks ATS injectors compared to injectors of other These drugs. have Someproduced equivocal findings. have ence. ATS injectors are more likely to be dependent upon the drug than non- than drug the upon dependent be to likely more are injectors ATS ence. 2004a). Grant, & Patterson Semple, 1995; Hall, & Darke 1994; Association, Psychiatric can for marker a also is routes) other to (compared injection ATS use, heavier entails often it As 2004a). & Grant, taking and HIV (Semple, Patterson to possible risk exposure greater sharing sharing injecting equipment with other of reuse injectors, one’s own injection equipment, inject frenetic and discovery), fearing and place public a in injecting if (e.g. injection hurried All of ing these when behaviours have been risk on documented drug among use ‘binges’. other and (HCV), virus C hepatitis HIV, contracting of risk at PWID place and injectors, ATS infections. depend- and injecting drug between association strong a expect to reasons good are There tracting BBV infections related to non-sterile injection (Rusch, Lampinen, Schilder & Hogg, & Schilder Lampinen, (Rusch, injection non-sterile to related infections BBV tracting 2002; & & 1995; Kall 2004b; Nilsonne, Grant, Semple Anonymous, et 2004; al., Patterson include behaviours injecting Risky 2004). Richters, & Treloar Rawstorne, Ven, de Van 2002; 8.1.1 Injection risk behaviours 8.1.1 Injection risk con- of risk at users place may which injection drug with associated risks multiple are There 8.1 Literature review 8.1 Literature The review includes an assessment of the comparative risk of ATS and opioid drug use as a as use drug opioid and ATS of risk comparative the of assessment an includes review The the to due review, literature a to limited was assessment This BBV. other and HIV for vector Asia region. to the Southeast data sets relating of critical scarcity other blood-borne viruses blood-borne other as vectors for HIV and for HIV and as vectors stimulant and opioid use use and opioid stimulant amphetamine-type amphetamine-type 8. Comparison of of 8. Comparison 38 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia ies have found female ATS injectors to be more likely than those injecting other drugs to be risk behaviours (sharing) than males (Darke, Ross, Cohen, Hando & Hall, 1995). Some stud- A study of regular ATS users in Australia found female injectors had higher rates of injection 1997; Prestage etal.,2005;Volkow etal.,2007;Halkitis, Shrem &Martin, 2005). & Ross, 1999) or be unemployed (Welp et al., 2002; Bolding et al., 2005; Van de Ven et al., et al., 2002; Bolding et al., 2005), but were less likely to have a criminal record (Darke, Kaye, Some have also found that they had lower levels of education and social functioning (Welp de Ven, 1997;Prestage etal.,2005;Volkow etal.,2007). 2001; Drumright, Patterson & Strathdee, 2006; Welp et al., 2002; Bolding et al., 2005; Van al., et Kral 1998; al., et Ven de Van 1993; Wodak, & Ross Darke, (Hall, options reduction than opioid injectors, which might have an impact on capacity or inclination to access harm noted in the literature. Numerous papers have reported that ATS injectors tend been haveto drugs be other of youngerversus ATSinjection of correlates demographic important Some There was no adjustment for other factors such as demographics or 1999). drug al., et injection (Zule street frequency. the on than rather friends/dealers, from needles clean obtain to and less likely to use a needle multiple times (Zule et al., 1999). They were also more likely more frequent drug injectors), ATS injectors were less likely to be injecting in public places also were (who injectors heroin to compared that, found States United the in study One patterns, are liable toinfluencevulnerability toHIVandother BBV infection. the ATS injectors, such as age, lack of engagement with drug treatment and binge injecting biological risks of BBV as opiate (or other drug) injectors, although certain characteristics of we conclude that, based on the currently available data, ATS injectors are exposed to similar balance, On region.this in exist not risk do and behaviour of diversepatterns similar gest sug- reasonto thereisno Asia, Southeast in collected been havenot data these Although graphic characteristics. demo- as factors, such other by influenced be may differences These consistentdirection. suggest that there are likely to be differences in risk-taking behaviours, but not always in a for traditional service models to engage with these PWID may be limited. These studies also graphic location of ‘binge’ injecting. These findings suggest that the window of opportunity geo- and time) overof injecting shortperiods episodesof (multiple injecting frequencyof (after-hours),timing provideto harderto due coverageit tors)PWID, also makes these for The tendency for ATS injectors to inject in ‘binge’ patterns of use (similar to cocaine injec- time (Zuleetal.,1999). a at one up picking than rather needles, on up stock to injectors heroin than likely more are injectors ATS 1999). al., et (Zule services outreach HIV with touch in be to or 1999) al., et Zule 2000; Darke, & Kaye 1993; al., et Hall 2005; al., et (Braine treatment drug in ATS injectors have consistently been found to be less likely than heroin injectors to engage Drumright etal.,2006;Elifson, Klein&Sterk,2006;Welpetal.,2002). injection risk behaviours relative to heterosexual injectors (Reback, Larkins & Shoptaw, 2004; have sex with men and who are ATS injectors have also been found to have higher rates of taking injecting risks, such as sharing equipment (Klee, 1993; Lorvick et al., 2006). Men who Comparison of amphetamine-type stimulant and opioid use 39 - - they wish to feel sexually disinhibited, and some of the behav the of some and disinhibited, sexually feel to wish they because people may use ATS ATS use may people direct methamphetamine’s of aspects some (d) risky; are in engage consequently they iours play may perception risk HIV (e) and transmission; HIV and risk sexual facilitate may effects of users. in some populations an important role a constellation of other important factors, some of which are related to the drug, and some and drug, the to related are which of some factors, important other of constellation a related be may users ATS of characteristics the (a) that: evidence is There not. are which of many (c) arousal; and interest sexual increases ATS (b) general; in behaviours risk higher to 2004). Some studies have found that ATS users have higher rates of STIs (Semple, Patterson Patterson (Semple, STIs of rates higher have users ATS that found have studies Some 2004). et al., 2001). 2004; Kral 2002; Chouvy & Meissonnier, & Grant, within co-occur behaviours sexual risky and use ATS that suggest to evidence good is There Smith, Worth & Kippax, 2004; Van de Ven, Rawstorne, Treloar & Richters, 2004), particularly particularly 2004), Richters, & Treloar Rawstorne, Ven, de Van 2004; Kippax, & Worth Smith, with unprotected anal intercourse (Colfax et al., 2001; Halkitis et al., Rusch2001; et al., Shoptaw, Huber, Rawson Huber, Shoptaw, & Ling, 1996; & Halkitis, Parsons Stirratt, Halkitis, 2001; Shrem & Martin, 2005; Kall & Nilsonne, 1995; Molitor et al., 1999; Reback, Larkins & Shoptaw, 2004a). 2002; Grant, & Patterson Semple, 2004; Hogg, & Schilder Lampinen, Rusch, 2004; 2004; Slavin, 2004; Worth, & (Rawstorne Australia in found been have associations Similar 2007; Elford & Hart, 2005; Mercer et al., 2004). Multiple papers, many from the United States, have documented higher rates of sexual risk behaviours, such as unprotected anal using report who MSM among partners, multiple and use condom inconsistent intercourse, 2002; ATS (Anonymous, Colfax et 2002; & al., Frosch, Prendergast Cartier, 2005; Farabee, Numerous papers across several countries have mentioned higher rates of sexual risk behaviour behaviour risk sexual of rates higher mentioned have countries several across papers Numerous among ATS users or injectors compared to other drug users/injectors (Van de Ven et al., et al., 2006; Shoptaw & Reback, Drumright et al., 2006; Mansergh et al., 2001; 1998; Kral ATS ATS use has also been linked to sexual withinrisk many includinggroups, men who have certain and people, active heterosexually sex, purchase who men workers, sex men, with sex occupational groups. (or even made explicit), but these different kinds of will risk in different require responses of harm reduction. terms that make exposure to HIV or such STIs more likely, as having multiple sex hav- partners, work. sex in engaging or worker, sex a with sex having drugs, injects who partner sex a ing The literature on this topic is inconsistent in the way that these differences are addressed tiple and are considered below. considered tiple and are Sexual behaviours include: risk that (a) occur risks within a particular sexual episode, such and (b) those anal intercourse; or unprotected intercourse vaginal as anal sex, unprotected Sexual risk behaviours confer risk of both HIV transmission and sexually transmitted infec- and sexually transmitted of both HIV transmission confer risk behaviours Sexual risk tions (STIs), such as chlamydia, gonorrhoea and There is evidence syphilis. to suggest that of STIs also increase the HIV Prestage, Grulich, risks infection Van de (Law, Ven & Kippax, mul are taking risk sexual to linked is use drug which in ways The 1992). Wasserheit, 2002; 8.1.2 Sexual risk behaviours 8.1.2 Sexual risk 40 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia There have been conflicting findings with respect to the association of ATS injection and HIV, 8.1.3 Association withHIV behavioural sexualrisks, suchasyoung sexualdebutandmultiple partners. with associated was methamphetamine) (predominantly use substance found (2008b) al. et Celentano all. at activity sexual no or rangingdecreasedfromlibido to increased libido, experience, sexual their on use of effects varying reported users ATS that found (2008) al. et Sherman use.ATS risk and sexual to relating region the from data limited areThere analyses ofrisk. research that examines potential confounding variables, and which undertakes episode-level conduct to necessary is It 2006). Strathdee, Patterson & (Drumright, cross-sectional been has research the of much poor, and been has variables confounding for adjustment while types, drug differing for control to tended has and definitions, varying used has research drug use, risk behaviour and HIV transmission does not immediately imply causality. Existing to the association between ATS use and sexual risk/HIV transmission. An association between sexual behaviours. It remains unclear how much each of the above explanations contributes investigationsexclusivelyaddition, relyalmost self-reportingof In on MSM. focusedupon The literature on sexual risk and ATS use is largely concentrated in North America and often 4 and engagementinarange ofesoteric partner,HIV-positiverelationship an a with in being age, as such factors other for trolling MSM cohort, ATS use was not independently associated with HIV seroconversion after con among the group (Kozlov et al., 2006). In contrast, in Australia among a largely non-injecting use patterns, but emphasised the importance of concomitant sexual risks and polydrug use binge and injecting frenetic users, particularly such among injecting of characteristics the reflected have may association the that speculated authors The sharing. while used drug of sharing,type of or self-reportedtype the the frequencysharingequipment, of injecting ciated with sex work and frequent ATS use (Kozlov et al., 2006). It was not associated with In one study of PWID in Russia, HIV seroconversion during a one-year follow-up was asso- given below. examplesaretwo — study under population the and backgroundprevalenceHIV the of to related be may findings conflicting The 2005). Martin, & ShremHalkitis, 1996; al., et sch Fro 2002; al., et (Farabee not have others but 1998), al., et Molitor 2006; al., (Kozlovet al., 2002; Frosch et al., 1996), some have remained after controlling for background factors infection and ATS use (Boddiger, 2005; Colfax et al., 2005; Reback et al., 2004; Farabee et thisarea HIV havefocusedbetween studies has association Multiple an MSM. found upon Jones,However,& 2004). literatureUrbina the 2004; of al., all) in et not Smith (but much al., 2005; Colfax et al., 2001; Halkitis et al., 2001; Rawstorne & Worth, 2004; Slavin, 2004; et Buchacz (Boddiger,transmission2005; debate receivedconsiderablediscussion and has injecting risk behaviours among ATS users. The association with HIV infection through sexual havewhich moremade been unravel to difficult because co- the of discipline, and fetish sex. ‘Esoteric sex’ or ‘adventurous sex’includes fisting,water sports, sadomasochism, bondage and 4 sexpractices (Kippax etal.,1998). existenceand sexual of - - Comparison of amphetamine-type stimulant and opioid use 41 and strength of these associations remain undetermined. These associations are influenced are associations These undetermined. remain associations these of strength and frequency use, polydrug treatment, to access user, of age example, (for variables multiple by of use, sexual context, and underlying HIV or STI Many prevalence). of these variables are not for controlled in much of assessment making the risk a literature, current comparative time. at this difficult to opioid use use of ATS In summary, In ATS summary, use has been shown to be associated with both risky injecting practices nature the However, groups. population multiple across behaviour sexual risky increased and opioid use, HIV prevalence among users of amphetamines compared to users of opioids, routes of administration, polydrug use and other risk behaviours. Unfortunately, we were among HIV about studies further for need clear a is there and data such obtain to able not area. in this types of drugs of different users 8.2 Comparison of data from Southeast Asia of data from 8.2 Comparison used are they as opioids with amphetamines of risks HIV the compare to able be to order In in the region, a range of data This particularly is required. includes of prevalence ATS and and the prevalence and frequency of HIV risk behaviours. of HIV risk and frequency and the prevalence including the population, the background prevalence of HIV, the stage of the HIV epidemic, epidemic, HIV the of stage the HIV, of prevalence background the population, the including One study found that methamphetamine use, regardless of the route of administration, and Tijuana in workers sex female among infection HIV with associated independently was et al., 2008). (Patterson Mexico Ciudad Juarez, The nature and strength of association are likely to vary according to a number of factors 42 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia tions ofthis review. recommenda the of development the and region the from literature of identification the In addition to the information presented in Table 6, key informants played a critical role in and were interviewed. like countries, other country. In their in use ATS to relation in data reliable of lack a to due interviewed be to declined informants several key Nam), identified Viet and PDR Lao (China, countries some In Philippines. the Darussalam,or SingaporeBrunei from informants key recruit to unable werecountry.However, we each from informants key two recruit to made were Attempts commentary is incorporated into the body of the report, no specific analysis is provided here. sections.However, iscommentary informant providedkey of summary a Table in As noted throughout the report, the input from key informants is incorporated into the relevant from key informants 9. Summary of information China 1 Key informant Myanmar 1 • • • • • • • • • • • • • • Key comments

Thailand, extra key informants requested to participate in the review the in participate to requested informants key extra Thailand, No ATS-specific programs inplace. Treatment centres are non-drug-specific. ATS notincludedincurrent HIVstrategy. No reports ofHIVprevalence forATS users. Changing druguse patterns duetoavailability ofheroin. using ATS. be might workers sex and students drivers, truck farmers, Workers, A studydoesshow ATS use inopioidsubstitutiontreatment clients. No officialdataon ATS use inChina. know more about patterns of ATS and the daily problems facedservices bythey users.currently access or need from drop-in centres. We need to Research is needed to understand the daily lives of ATS users, and what generic services. receive they where centres drop-in existing visit usersdo ATS some There are no specific policies or interventions for ATS users, although is notcommon. ATS of injection but Myanmar in heroin than ATSuse people More Young people are also using ATS as it is cheap, availability andcombinedeffectofthedrugs.fun, and helps them to work. cost, to due ATS using users opioid with common, is use Polydrug need tobeexplored, forexample cross-border populations. Research is commencing into ATS use but remains limited; many areas Table 6:Summaryofkey informantinterviews 6. As the As 6. - Summary of information from key informants 43 The only current research on ATS was conducted by Burnet Institute Institute Burnet by conducted was ATS on research current only The with local partners. heroin or users ATS between distinguish not do policies drug and HIV users. PDR. Lao of north the in users opium/heroin in high is prevalence HIV No interventions for ATS users in place, no funding support but a on this. forward definite need to move Interventions need to include: ATS detoxification services and STI users. for ATS testing and treatment and for options ideas Research include in users, HIV ATS prevalence treatment. No research on ATS use in Myanmar, other than the UNODC SMART UNODC the than other Myanmar, in use ATS on research No reports. Special services needed for as ATS users they are generally different and in are to the users population. heroin general They differ- have cognition of loss like behaviours unsafe sex, unsafe as such risks ent and might be changing to injecting. We need more information for service development. UNODC. estimated by rates people, in young of use High rates to close Vientiane, in centre rehabilitation in users ATS of rates High 95% of clients. workers near Thailand. workers of lack to due users, opioid by and nightclubs in fun for used is ATS of heroin. availability Some workers use drugs either voluntarily or when forced by their employers. services other no but inject they if services IDU access can users ATS users. for ATS exist users. for ATS strategies no separate are There only but when usually sometimes services, access existing users ATS users. heroin also they are No official statistics, butuse noticed inYangon and Mandalay in young people, on the border areas with China and with migrant Key comments Key • • • • • • • • • • • • • • • • Lao PDR 1 Myanmar 2 Myanmar Key informant Key 44 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Thailand 1 Key informant • • • • • • • • • • • • • Key comments models ofpeereducationandservicedelivery. at looking Thailand, usersATSfor availableare with Several studies not sure howtoaccessATS users. Drug user networks are important but focus on heroin users; they are effectiveness is unmeasured. their but voluntary, or compulsory either exist, systems Treatment These programs focus ondemandreduction andare notevaluated. ATS strategies are includedinotherprograms, such aswithyouth. ings, inparticularaconcernaboutpossibleincreased sexualrisk. No mention of ATS use in any HIV policies, but mentioned in meet- Mai andBangkok,mainlyicebutmore informationneededhere. Chiang in noted ice ATSusers‘yaba’and of injecting pockets Small injecting ofATS are increasing. of rates and ATS, including drugs other use heroin, of availability Complicating this, old heroin users, with increased prices and decreased smoking, nowthemajorityofusers smoke crushed tablets. to ingestion from well, as changing are administration of Routes people. ATS use was mainly functional, now it is mainly recreational, in young Situation is changing, with changing economic situation; previously down over time. and up going vary, Thailand in use ATS of prevalence for Figures this is toohard tomeasure. ATS use; with less emphasis on primary prevention recommended, as treatment models and qualification of ‘harms’ or ‘risks’ associated with Recommendations for research include: research into effectiveness of Small project underway on injecting of ATS, with results due in 2012. Summary of information from key informants 45 - - Small studies behaviour show high-risk in ATS injectors who attend centres. drop-in users. ATS in risk HIV recognise not does Thailand in reduction Harm sup- – youth target which tried been have interventions of couple A symposium. and a youth port groups work migrants, women, as such ATS, of users the in diversity is There further research. and requires not well understood etc, which is ers research of development the in drugs use who people include to Need plans. ATS policy currently focuses on treatment and depression. on treatment focuses policy currently ATS in HIV policy. use No mention of ATS injection, no – users ATS with about thought not is reduction Harm and HIV. of both STIs risk, a sexual is but there no risk, Research ideas: in the cross-border regions and in closed settings, centres. justice in juvenile especially for many years. been and have using, people are Young expensive. still relatively but cheaper than heroin is ATS of administration. route as mainly preferred Smoking is ATS is generally smoked, used for fun and recreation, but there is work longer hours. to help users some functional use alcohol to enhance feelings. with Often used Possible use in sex workers, but most research is being done with people. young and partners sexual more have ATS using people young show Studies sex than non-users. pre-marital trans HIV for concern the is sex unsafe that show Thailand in Studies mission, not injecting. This might be different in those people who use heroin and ATS, but generally ATS are users scared of injecting and needles. No population prevalence rates. No population prevalence Key comments Key • • • • • • • • • • • • • • • • • • Thailand 3 Thailand 2 Key informant Key 46 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Hong Kong 1 Key informant Indonesia 1 • • • • • • • • • • • • • • • Key comments Research needs to focus on: better understanding of ATS use – inha Community perceptions are thatATS use is aproblem. ATS use is notlinkedtoHIVinthemindsofpolicymakers. No interventions forATS users. Drug strategies are mainlytargeting heroin users. No mentionofATS use incurrent HIVprogramming. ATS is more costlythanotherdrugs. recreational orpartydrugusers. class, upper to class middle usersPersonalare that observations are Newspapers report thatATS use is increasing. been undertaken. have studies small some use; ATS on statistics official of aware Not of ketamineby menwhohave sexwithmen. use the with priority,concerned morea not isuse ATS on Research rehabilitation. Interventions forATS users focus onprevention andtreatment/ Ice is generally smoked. MDMA is used recreationally, aswellice. decreasing, use ofketamineis anemerging problem. are use heroin of rates while concern; a of much so not is use ATS ated withuse. versuslation understandingharmsbetter of associ- a and injection; - Summary of information from key informants 47 - ATS not recognised by policy makers. policy by not recognised ATS are limited Interventions to facilities, and treatment/rehabilitation a little primary Most prevention. treatment is in centres but there is a underway. trial of community-based treatment Very limited research with ATS users in Cambodia, old study from behaviour. 2004 looked at HIV risk Research required on social/economic harms of ATS use, HIV and other health harms. More More work needed on standard treatment guidelines for ATS users, understanding social impact of ATS use, sexual and risk if injecting taking place. is of ATS users. data for ATS No prevalence ATS users include young people and young adults, and are mainly Cambodians. to do work and stay awake. strength, for more Some use HIV are based programs on opioid – users methadone maintenance and needle and syringe programs. treatment not use ATS mentioned as in a is there HIV belief policy, not is ATS injected so no HIV risk; risky sexual behaviour as a result of taking ple used drugs, 68% used ATS, less than 5% of people who used injected. drugs mid mainly years, 25 than older male, mostly were ATS using People purposes. for recreational dle class and using reports no partners; multiple have users ATS show Indonesia in Studies usage. on condom available users. in ATS of injecting suspected low rates Very use. HIV policy does not mention ATS Interventions for ATS users include treatment/rehabilitation; some in schools. primary prevention Data from 2009 provide national estimates – about 3.3 million peo- million 3.3 about – estimates national provide 2009 from Data Key comments Key • • • • • • • • • • • • • • • Cambodia 1 Indonesia 2 Key informant Key 48 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Malaysia 1 Key informant Macau 1 • • • • • • • • • • • • • • • • Key comments Limited interventions for ATS users: one organisation delivers out delivers organisation one users: ATS for interventions Limited There are limitednationalstrategies fordruguse andHIV. drugs. other and heroin not but use, ice and ketamine between switching people of evidence isThere high. alsoare ketamine of use of Rates fessions likecroupiers andsexworkers. Most people who use ATS are young children, except in certain pro- is on the decline in the general population, but increasing in women. Macau has a central registry of drug users and it indicates that ATS use ers fordependency;andprevalence ofinjecting. Research ideas include: treatment options for ATS users; genetic mark tres, buttheseare mainlyfocused onheroin users. Interventions with ATS users are limited; there are rehabilitation cen ATS use is considered amajorproblem andis onthe politicalradar. reduction policiesacknowledgeATS use. HIV strategy may have some mention of ATS use and national harm Harms related to sexual risk are not known, but studies are planned. Majority ofATS is smoked notinjected;significantpolydrug use. limited reports offunctionaldruguse. Youngarerecreation,usingadults yearATS:for olds, 19–40 mainly Prevalence estimatesare from 2009. Drug laws require review. Very limitedtreatment options are available fordrugusers. There are someprevention programs inschools. on harmreduction. reach but has limited coverage; focus on overdose recovery, not much - - - Summary of information from key informants 49 - - ily Health International (FHI), results not yet available. not yet ily Health International (FHI), results on opioid users. HIV policy focuses Most injectors are using opioids, but informant suspectsdata. no thatare there but the increasing are drugs other of injecting of rates drugs use who people for services users, ATS for place in services No on opioid users. focused are users. mainly for heroin are centres drug treatment Compulsory and HIV between relationship use; ATS of prevalence needs: Research men; with sex have who men than other groups in use ATS use; ATS and other harms. Research Research ideas include: behaviour;risky forreasons using ATS; and users. the basic situation of ATS use. data on ATS No prevalence injecting. of ATS No reports Used by young people, also using ketamine, in nightclubs, dancing, seeking. pleasure No real functional use noted – not used by truck drivers or factory workers. Fam by underway study – men with sex have who men in noted Use use in small but increasing. but in small use 6 are switching There cases to of as users ATS heroin a substitution for heroin. ATS. people sniffing 13 cases of young show Data also 53% ATS, used 32% old, years 21 below users drug registered 174 Of ketamine. used Interventions for drug users consist of two outreach services, one and the on focused users other heroin on or young new drug users. pre and transmission HIV on information disseminate services These vention. other the than Central by undertaken users, with is ATS No research Registry. Official reports exist on ATS use, the Central Registry; these show ATS ATS show these Registry; Central the use, ATS on exist reports Official Key comments Key • • • • • • • • • • • • • • • • • Viet Nam 1 Macau 2 Key informant Key 50 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia thermore, there are more limited treatment options, particularly pharmacotherapies. ATS pharmacotherapies. particularly options, treatment limited more are there thermore, are indications that ATS users may experience a more tenuous link with such services. Fur- Although many harm reduction strategies employed by services are not drug-specific, there harmful consequences. and advocate for appropriate prevention strategies to avert the spread of infection and other promotedevelop, to need a isThere drug. the of effects the to usersATSdue for concern transmission. Sexual transmission of HIV is a concern further for for all vector drug a risks provides consumers, associated the and but activity is sexual ofwith greaterconnection The HIV andotherBBV. sumers. ATS are injected, and therefore represent an emerging issue for the transmission of con such of numbers the of estimations accurate prohibits data quality of lack ever, the How choice. of drug primary their as ATS report also who PWID of groups arethere and heroin has been reported across several countries (Lao PDR, China, Myanmar and Thailand) for substitute a as ATS of injection The countries. many in use of understanding our in ATS use is stable in some countries, and increasing in others, yet there are substantial gaps Asia region. PanelcontributionsDelphi fromthe reach processconclusions to Southeast the specific to with and informants fromkey input analysiswith and weretriaged availableevidence The recommendations 10. Summaryand polydrug use, injecting drug use, and among groups such as FSW, MSM and young people. as such behaviours some with association in high particularly risks being with region, the high risk and low health service utilisation. ATS users are exposed to multiple HIV risks across The limited number of studies investigating risk behaviour in people who use ATS suggested • • • • • Stated concerns include: Cambodia. and Philippines Myanmar,the PDR, Thailand, Lao China, in region,particularly the in issue health public major a as membersPanel Delphi and informants key byraised Despite the lack of consistent quality epidemiological data, the use of ATS was consistently harm reduction activitiesinSoutheastAsia. coveragelow the of to services,due to users,drugs,access usersother havelimited like of disharmony. and productivity lowered including communities, on have use of rates high effects the and health harms not associated with HIV, such as traffic accidents and mental health issues, is employed nal justice system and risks associated with compulsory treatment in countries where this social and health harms related to high levels of interaction of drug users with the crimi- lack ofeffective treatment options available forpeoplewhouse ATS across theregion the effects of ATS on young people (inhibiting schooling and employment opportunities) - - Summary and recommendations 51 - - - Examine the impact of policy and policy implementation (including legislation) on preva on legislation) (including implementation policy and policy of impact the Examine behaviours. and associated risk use lence of ATS Identify any barriers for ATS users to access existing harm reduction and treatment serv treatment and reduction harm existing access to users ATS for barriers any Identify to these challenges. responses and trial and evaluate ices, may that pharmacotherapies, especially interventions, ATS efficacious emerging, Identify and disseminate to strategies effective assess and region, Asia Southeast the in useful be implement evidence-based approaches. Enhance capacity to identify the contexts of use, particularly the demographic and envi and demographic the particularly use, of contexts the identify to capacity Enhance ronmental factors that contribute to with ATS risks, a focus on identifying social and other determinants. than riskier are use of contexts and users of groups some that evidence existing on Build Clearer identificationothers. of thesegroups is factors andspecific indicated at-risk at a country level. Assess the prevalence of HIV in people who use ATS, in comparison with people who both drugs. opioids and people who use use and sexual risks. between ATS of associations consistency cross-country Examine BBV to responding and preventing for implications have that harms ATS other Examine mental health problems). impairment, (e.g. cognitive risk Enhance capacity to enable more precise prevalence estimates of ATS use, methamphetamine), includingor amphetamine (e.g. used being substances specific on information and harms. risks and associated of administration route Invest in rapid assessment and response strategies to ATS, which can be employed with employed be can which ATS, to strategies response and assessment rapid in Invest in the region. system an early warning to provide limited resources, 9. 7. 8. 4. 5. 6. 3. 1. 2. 10. for regional collaboration. This research could be facilitated by a forum to allow for sharing sharing for allow to forum a by facilitated be could research This collaboration. regional for initiatives These borders. adjoining across particular in and region the across information of SMART Program. such as Global monitoring systems with existing could be coordinated It is suggested that these recommendations inform the commencement of a regional research research regional a of commencement the inform recommendations these that suggested is It topics and themes country-specific both noting stakeholders, key with negotiated be to plan have relevance for the tailoring of interventions to local need. Country-specific data are responses. to inform required - recom following the note We needs. research identify to was review this of objective key A to research: in regards mendations The impact of other factors risk (e.g. poverty and mobility) Complicating remains unclear. These region. the across harms associated and use drug of patterns varying the are matters 52 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 11. More broadly, key informant and Delphi Panel participants also recommended the following: prevention andotherresponses toATS use throughout Southeast Asia. conclusiona to lead opinion thereexpert that and evidence able is HIV enhance to need a isunclear.countries generalisation Asian of isSoutheast capable availevidence all The - to thiswhich to extent exist.The do where they ATSservices users that to connected arenot concerned therearereasonsbe region,and to the in countries most strategiesavailablein ated sexual risk taking. There is evidence that there are limited demand and harm reduction behaviour. There is some evidence that ATS users have an increased risk of BBV from associ interact with ATS use to either increase or decrease BBV risk relative to other drug injecting may factors contextual risks. and BBV Demographic attendant the with ATS, injecting are others.increasingin usersand Some some, is relativelyin countries stable Asian high, east Existingnothing. literaturedo to prevalencethat indicate does ATS of South- use some in Asia and associated harms remain scant. However, a lack of information is not an invitation routes of administration, characteristics or risk profiles of people who use ATS in Southeast ATS, of use the publishedprevalenceliteratureof regardingand the summary,data In the 16. 15. 14. 13. 12. risks associatedwithcocaineasastimulantdrugmayhave synergies withATS. Undertake areview ofliterature pertaining to cocaine use andHIVtransmission, asthe international literature andexisting guidelines, andare adaptedtolocal need. the of reflective are that dependence ATS for guidelines treatment standard Develop other programs withkeyaffectedpopulations. and activities health sexual existing into messaging reduction harm ATS Incorporate ATS users. primary to related specifically effectiveness and accessibility their identify to need a is programs, where indicated, to better meet the needs of ATS users. As noted above, there Adapt existing harm reduction services, such as drop-in centres and needle and syringe Invest inHIVprevention strategies thatenhanceaccessforATS users. specific dataare required toinforminterventions. region, there is an urgent need to tailor interventions to local context; however, country- Given the varying patterns of use of ATS and associated harms across the Southeast Asia -

Bibliography 53

W. (2008). The ‘party drug’ crystal methamphetamine: risk factor for methamphetamine: risk drug’ crystal (2008). The ‘party W. Allerton, M. & Blake, Journal, 12(1): 56–58. Permanente HIV. of the acquisition & Mattick, R. (2005). An overview F. M., Faggiano, C., Ferri, M., Perucci, Amato, L., Davoli, available opiate maintenance therapies: of of the effectiveness reviews of systematic , Abuse Treatment Journal of Substance and research. clinical practice evidence to inform of Systematic Reviews, 2005(3): Database at Cochrane online also 28: 321–329; CD002207. Manual of Mental Association (1994). Diagnostic and Statistical American Psychiatric Association. DC: American Psychiatric . 4th ed. Washington, Disorders Kinh, N.V., N.T., Long, Hien, N.T., K., Duc Thuang, B., N., Fylkesnes, Anh Tuan, (HIV) infection patterns (2007). Human immunodeficiency virus & Manh, P.D. Thang, P.H. in Viet Nam. Bulletin of and provinces population groups in different behaviours and risk , 85(1): 35–41. Health Organization the World ‘Club among gay youth: heightening risks is use (2002). Methamphetamine Anonymous 123–125. AIDS Alert, 17(10): sensibilities. dull safe-sex drugs’ S. et al. (2005). Brief cognitive Pohlman, T., Grant, M., Lewin, T., A., Lee, N., Claire, Baker, a step in the right direction. amphetamine users: regular for interventions behavioural 367–378. Addiction, 100(3): Psycho- for L. (2004). Models of Intervention and Care A., Lee, N. & Jenner, Baker, Australian ed. Canberra: 2nd no. 51.) Series, . (NDS Monograph stimulant Users and Ageing. Department of Health Government for smoking K. (2008). Mass media interventions L. & Cahill, Bala, M., Strzeszynski, , 2008(1): CD004704. Database of Systematic Reviews Cochrane in adults. cessation et al. (2006). The W. D., Honer, Thornton, A., Lang, MacEwan, W., W., A., Panenka, Barr, addiciton. Journal of Psychiatry and an update on methamphetamine need for speed: 301–313. , 31(5): Neuroscience men who for neglected populations: of HIV infection Global prevention C. (2010). Beyrer, , 50(Suppl 3): 108–112. sex with men. Clinical Infectious Diseases have The expanding (2010). F. & Sifakis, B. D., Wirtz, A., Johns, S., Walker, C., Baral, Beyrer, sex with men in low and middle-income epidemics of HIV type 1 among men who have Epidemiological Reviews, 32: 137–151. and consistency. countries: diversity Stimulants and Harm Reduction: experiences Amphetamine Type (2011). Blickman, T. Briefing, no. 37.) Amsterdam: Thailand and southern China. (Drug Policy Myanmar, from Institute. Transnational Lancet, HIV transmission. linked to rising D. (2005). Metamphetamine use Boddiger, 365(9466): 1217–1218. J. (2005). Gay men who look for sex on L. & Elford, M., Hart, G., Sherr, Bolding, G., Davis, AIDS, 19: 961–968. with online partners? HIV/STI risk more there the Internet: is 11. Bibliography 11. 54 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia China 2011. Beijing:Ministry ofPublicSecurity. China National Narcotics Control Commission (2011). AnnualReportonDrugControl in Beijing: UnitedNations General AssemblySpecialSession(UNGASS). China Ministry ofHealth (2010). China2010 UNGASSCountryProgress Report2008–2009 . heterosexual methamphetamine users. JournalofPsychoactiveDrugs, 42(1):11–18. Increased druguse andSTIrisk withinjectiondrug use amongHIVseronegative Cheng, S., Garfein,R.,Semple,S.J.,Strathdee, S., Zians, J. &Patterson, T. (2010). workers inYunnan, China.AIDSPatient Care andSTDs,19:853–860. Chen, X., Yin,Y. &Liang, G.(2005).Sexuallytransmitted infections amongfemalesex Journal ofAIDS&STD,17(1):25. maintenance treatment clientsinYunnan provinces anditsassociatedfactors. Chinese Chang, Y., Yuan, W., Jiang, G.etal.(2011). Meta-amphetamineabuse amongmethadone adults inChiangMai,Thailand.SexuallyTransmitted Diseases , 35(4):400–405. Sexually transmitted infections andsexualsubstanceuse correlates amongyoung Wongworapat, K., Latkin,C.,Taechareonkul, S., Sherman,S.&Aramrattana, A. (2008b). Celentano, D., Sirirojn, B., Sutcliffe, C.,Quan,V., Thomson, N., Keawvichit, R., 66–73. symptoms inyoung adultsinnorthernThailand.JournalofAddictionMedicine,2(2): al. (2008a).Associations ofsubstanceabuse andsexualrisk withself-reported depressive Celentano, D., Aramrattana, A., Sutcliffe,C.,Sirirojn, B., Quan, V., Taechareonkul, S. et and STDs. among DrugUsers 2007. PhnomPenh: NationalCenterforHIV/AIDS,Dermatology Cambodia NationalCenterforHIV/AIDS,DermatologyandSTDs(2008).HIVPrevalence Special Session(UNGASS). period: January2006–December2007. PhnomPenh: UnitedNations General Assembly Cambodia NationalAIDSAuthority(2008).CountryProgress Report:reporting General AssemblySpecialSession(UNGASS). AIDS. Reportingperiod:January2008–December2009.PhnomPenh: UnitedNations the progress towards theimplementationofDeclaration ofCommitmenton HIVand Cambodia NationalAIDSAuthority(2010). CambodiaCountryProgress Report:monitoring homosexual men.MedicalJournalofAustralia, 150:634–639. factors forhumanimmunodeficiencyvirus seroconversion inacohort ofSydney Burcham, J., Tindall,B., Cooper, D., Berry, G. &Penny, R. (1989).Incidenceandrisk with meninSanFrancisco. AIDS,19:1423–1424. Amphetamine use is associatedwithincreased HIVincidenceamongmenwhohave sex Buchacz, K., McFarland, W., Kellogg, T., Loeb, L., Holmberg, S., Dilley, J. etal.(2005). Education &Prevention, 17(6):515–524. risk behavioramongamphetamineinjectors atU.S.syringeexchange programs. AIDS Braine, N., DesJarlais, D.C., Goldblatt,C.,Zadoretzky, C. &Turner, C. (2005).HIV Bibliography 55 , 12: 377–385. 12: , , 98(9): 1229–1237. 98(9): , Addiction American Journal of Addiction of Journal American K. (2003). Abuse and violence history of men and women in in women and men of history violence and Abuse (2003). K.

L. (2003). Impact of federal ephedrine and pseudoephedrine pseudoephedrine and ephedrine federal of Impact (2003). L.

A. & Horner, & A.

J. & Liu, & J.

J., Dickow, J.,

treatment for methamphetamine dependence. dependence. methamphetamine for treatment J.J. (2008). Health and human rights concerns of drug users in users of drug and human rights concerns J.J. (2008). Health Cohen, J.E. & Amon, , 5(12): e234. . et al. (2005). B. S., Koblin, Buchbinder, Y., M.J., Huang, Husnik, T.J., Colfax, G., Coates, and popper (amyl nitrite), and cocaine use of methamphetamine, Longitudinal patterns sex with men. men who have a cohort of San Francisco sexual behavior among high-risk Journal of Urban Health, 82(1 Suppl): 1. M. et al. (2001). G., Rader, R., Vittinghoff, E., Marks, G., Guzman, Colfax, G., Mansergh, men who attend circuit among gay and bisexual behaviour and sexual risk Drug use Deficiency Immune JAIDS: Journal of Acquired comparison. parties: a venue-based , 28(4): 373–379. Syndromes S. et al. (2010). E., Pluddemann, A., Kumar, Vittinghoff, G.-M., Chu, P., Colfax, G., Santos, Lancet, 376(9739): 458–474. HIV. substances and Amphetamine-group injection in of methamphetamine R. (2009). Predictors C. & Booth, K., Kwiatkowski, Corsi, , 44(3): 332–342. AIDS and Behaviour PWIDs. out of treatment of Correlates K. (2012). L. & Page, N., Sichan, K., Maher, J., Sothy, M-C., Evans, Couture, among young risks with HIV-related associations and amphetamine-type stimulant use Cambodia. Drug and Alcohol Dependence, Penh, women engaged in sex work in Phnom 120: 119–126. and needle of of educational D. (1998). The effectiveness C. & Bartelli, J., Saunders, Cross, for injecting drug users. strategies of HIV prevention a meta-analysis programs: exchange Quality and Quantity, 32(2): 165–180. Cunningham, admissions. hospital methamphetamine-related in regulations of chemical regulations precursor Cunningham, J. & Liu, L. (2005). Impacts of federal 479–488. Addiction, 100(4): methamphetamine arrests. and users among heroin use of polydrug and correlates (1995). Levels Darke, S. & Hall, W. Drug and Alcohol Dependence, 39: 231–235. amphetamine users. regular and between the injection of heroin J. (1999). Transitions S. & Ross, Darke, S., Kaye, Addiction, 94(12): 1795–1803. amphetamines. Cohen, L. (2005). L. (2005). D. & Valleroy, MacKellar, W., S., McFarland, D., Gregorich, Choi, K., Operaria, Asiana among young intercourse anal choice and unprotected substance Substance use, , 17(5): Prevention sex with men. AIDS Education and men who have Islander and Pacific 418–429. and consumption of traffic Baa: production, J. (2004). Yaa & Meissonnier, P.A. Chouvy, Press. University Singapore in mainland Southeast Asia. Singapore: methamphetamine 56 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia 41: 1551–1601. HIV acquisition amongmenwhohave sex withmen:areview. SubstanceUse&Misuse, Drumright, L., Patterson, T. &Strathdee, S. (2006).Clubdrugs ascausal risk factors for 229–232. and non-injectingmethamphetamineusers. JournalofPsychoactiveDrugs,32(2): Domier, C., Simon,S.,Rawson, R., Huber, A. &Ling,W. (2000).Acomparison ofinjecting National CouncilonDrugs. Responses intheAsia–Pacific Region.(ANCDResearch Paper 12.)Canberra: Australian Devaney, M., Reid,G.&Baldwin,S.(2006).SituationalAnalysisofIllicitDrugIssuesand from theWHODrugInjectionStudyPhaseII.BMCPublicHealth,6:54. for research onHIVandinjectingdruguse indeveloping/transitional countries:casestudy Des Jarlais, D., Perlis, T., Stimson, G. &Poznyak, V. (2006).Using standardized methods public health.InternationalJournalofDrugPolicy, 21(5): 347–358. (2010). Meth/amphetamineuse andassociatedHIV:implications forglobalpolicyand Degenhardt, L., Mathers, B., Guarinieri, M.,Panda, S., Phillips, B., Strathdee, S.A. etal. Centre. on useandassociationswithHIVotherharm.Sydney: NationalDrugandAlcohol (2007). TheGlobalEpidemiologyofMethamphetamineInjection:areview oftheevidence Degenhardt, L., Mathers, B., Guarinieri, M.,Panda, S., Phillips, B., Strathdee, S.A. etal. Cancer Institute. Department ofHealthandHumanServices, NationalInstitutes ofHealth,National (Tobacco Control Monograph No 19.NIHPub. No.07-6242.)Bethesda,MD:US Davis, R.M. etal.(2008).TheRoleoftheMediainPromoting andReducingTobacco Use. virus (HIV) infections in homosexual men. Darrow, behaviour amongregular amphetamineusers. AIDSCare, 7(1):19–26. Darke, S., Ross, J., Cohen,Hando,J.&Hall,W. (1995). Injectingandsexualrisk-taking Union. and MethamphetamineUsein Europe. Luxembourg: Publications OfficeoftheEuropean European Monitoring Centre forDrugs andDrugAddiction (2010). Problem Amphetamine Meth Project. Prevention Science , 9:256–263. Erceg-Hurn, D.M. (2008).Drugs, money, andgraphic ads:acriticalreview oftheMontana drug users. JournalofSexResearch , 43:4. Elifson, K.W., Klein, H.&Sterk,C.E.(2006).Predictors ofsexualrisk-taking amongnew health promotion. SexuallyTransmitted Infections , 80:451–454. among Londonhomosexualmen1998–2003:implications forHIVprevention andsexual Elford, J., Bolding,G.,Davis, M., Sherr, L. &Hart,G.(2004).Trends insexualbehaviour Elford,

J. & Hart,

W., Echenberg,

G. (2005). HAART, viral load and sexual risk behaviour.

D. & Jaffe,

H. (1987). Risk factors for human immunodeficiency American Journal of Public Health AIDS , 77: 479–483. , 19: 205–207. Bibliography 57 , 34(3): 295–300. 34(3): , Journal of Psychoactive Drugs Psychoactive of Journal J. (2002). Methamphetamine use and HIV risk among among risk HIV and use Methamphetamine (2002). J.

M. & Cartier, & M.

D., Prendergast, D.,

G. et al. (2007). N., Harper, J., Ibanez, G., Hernandez, S., Warren, M., Bowen, Fernandez, sex have men who for Hispanic risk of added sexual a source methamphetamine: Crystal , 86: 245–252. with men. Drug and Alcohol Dependence among risk (1996). Sexual HIV R.A. & Ling, W. A., Rawson, S., Huber, D., Shoptaw, Frosch, , Abuse Treatment Journal of Substance male methamphetamine abusers. gay and bisexual 13(6): 483–486. 2011: for Drug Offences: global overview The Death Penalty R. (2011). & Lines, Gallahue, P. consequences. London: International Harm Reduction and shared responsibility shared Association. Stimulants of Amphetamine-Type and Trends Patterns (2010). Global SMART Programme and on Drugs Office . Bangkok: United Nations 2010 and Other Drugs: Asia and the Pacific and the Pacific. for East Asia Crime, Regional Centre route of dependence and J. (1992). Severity & Strang, B. Powis, P., Gossop, M., Griffiths, British Journal of Addiction, 87: and amphetamines. cocaine of heroin, of administration 1527–1536. L. & Ali, R. (2008). Substitution R., Sullivan, M., Bornemann, Gowing, L., Farrell, of HIV infection. Cochrane for the prevention for injecting opioid users treatment Database of Systematic Reviews 2008(2): CD004145. of methamphetamine Economic analysis D. (2011). Guyll, M., Spoth, R. & Crowley, Journal of Studies of Alcohol and Drugs, 72: costs. effects and employer prevention 577–585. access to harm universal towards Harm Reduction in Asia: progress C. (2010). Hagarty, inject drugs. Melbourne: Burnet Institute. services among people who reduction A double epidemic: crystal M. (2001). & Stirratt, J.T. Parsons, P., Halkitis, gay men. Journal of among to HIV transmission in relation methamphetamine use 17–35. Homosexuality, 41(2): of behavior patterns (2005). Sexual & Martin, F.W. M.T. Shrem, P.N., Halkitis, , 40(5): 703–719. men. Substance Use & Misuse gay and bisexual methamphetamine-using and risk-taking of drug use M. & Wodak, A. (1993). Patterns Darke, S., Ross, Hall, W., Addiction, Australia. in Sydney, among injecting amphetamine and opioid drug users 88(4): 509–516. HIV/AIDS Situation in Hong Kong (2010). for Health Promotion Centre Hong Kong for Health Promotion. Centre factsheet. Hong Kong: Farabee, P. P. A. & Lemma, E., Zambon, A., Borraccino, Versino, F., Vigna-Taglianti, F., Faggiano, Preventive review. a systematic use: for illicit drugs prevention (2008). School-based Medicine, 46(5): 385–396. substance-abusing offenders in California. California. in offenders substance-abusing 58 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Special Session (UNGASS). UNGASS Country Progress Report2010. Vientiane:United Nations General Assembly Laos NationalCommitteefor theControl ofAIDS(2010). LaoPeople’s Democratic Republic analysis. Lancet,357:1397–1401. transmission ofHIV-1amonginjectiondrugusers inSanFrancisco, USA: risk-factor Kral, A., Bluthenthal, R., Lorvick,J.,Gee,L.,Bacchetti,P. &Edlin, B. (2001). Sexual drug users inStPetersburg, Russia [seecomment].AIDS,20(6):901–906. al. (2006).HIVincidenceandfactors associated with HIVacquisition amonginjection Kozlov, A.P., Shaboltas, A.V., Toussova, O.V., Verevochkin, S.V., Masse, B.R., Perdue, T. et Jakarta: KPAandIHPCP. Rapid AssessmentandResponsePengguna JarumSuntikNarkobaNTT: summaryreport. Komisi Penanggulangan AIDSandIndonesiaHIVPrevention andCare Project (2007). Rights, 9:11. minority inNorthernThailand:across sectionalstudy. InternationalHealthandHuman (2009). Methamphetamineuse andcorrelates intwovillagesofthehighlandethnicKaren Kobori, E., Visrutaratna, S., Maeda,Y., S., Kada, Wongchai, A., Ono-Kihara, M. etal. compared. Addiction,88(8):1055–1062. Klee, H. (1993).HIVrisks forwomendruginjectors: heroin andamphetamine users cohort ofSydney gaymen.AIDSCare, 10(6): 677–688. Cultures ofsexualadventurism asmarkers ofHIVseroconversion: acasecontrol studyina Kippax, S., Campbell,D.,Van deVen, P., Crawford, J., Prestage, G. &Knox, S. (1998). heroin andamphetamines. DrugandAlcoholDependence,58(1–2):189–195. Kaye, S. &Darke,(2000).Acomparison oftheharms associatedwiththeinjectionof 171–188. behaviour amongmaleintravenous amphetamineusers inStockholm. AIDSCare, 7(2): Kall, K. &Nilsonne, A. (1995).Preference forsexonamphetamine:amarkerHIVrisk Name ofDrugTreatment: reports from thefield.NewYork: OpenSocietyInstitute. International HarmReductionDevelopment Program (2009).HumanRightsAbusesinthe Bangkok, 18–20July2011. ATS inIndonesia.Paper presented attheGlobalSMARTProgramme RegionalWorkshop, Indonesian NationalNarcotics Board (BNN)(2011). Situation,Problems andThreats of 2008–2009. Jakarta:UnitedNations General AssemblySpecialSession(UNGASS). the Follow-UptoDeclaration ofCommitmentonHIV/AIDS(UNGASS):reporting period Indonesian NationalAIDSCommission (2010). RepublicofIndonesiaCountryReporton and AIDSResponseStrategies. Jakarta:NationalAIDSCommission. Indonesian NationalAIDSCommission (2007).NationalAIDSCommission2007–2010 HIV 2229–2236. Youth Anti-DrugMediaCampaignonyouths. AmericanJournalofPublicHealth98(12): Hornik, R., Jacobsohn,L.,Orwin,Piesse,A.&Kalton, G. (2008).EffectsoftheNational Bibliography 59 K. (2011). (2011). K.

, 22(3): 203–209. 22(3): , , 83(3): 497–505. 83(3): , , 27(3): 309–317. 27(3): , M.C. & Page, & M.C.

E., Couture, E.,

Journal of Urban Health Urban of Journal S., Stein, S.,

Drug and Alcohol Review Alcohol and Drug A.H. (2006). Sexual and injection risk among women women among risk injection and Sexual (2006). A.H.

International Journal of Drug Policy Drug of Journal International L. & Kral, & L.

A., Gee, A., R.A. (2008). A systematic review of cognitive and behavioural therapies therapies behavioural and cognitive of review systematic A (2008). R.A.

P., Mooney-Somers J., Keo, J., Mooney-Somers P.,

J., Martinez, J.,

L., Phlong, L.,

N.K. & Rawson, & N.K.

Amphetamine-type stimulant use and HIV/STI risk behaviour amoung young female sex sex female young amoung behaviour risk HIV/STI and use stimulant Amphetamine-type Cambodia. Penh, Phnom in workers who inject methamphetamine in San Francisco. Francisco. San in methamphetamine inject who J.D. (2010). HIV risk behaviors among three three among behaviors HIV risk J.D. (2010). Mai-Nhung, L., D’Onofrio, C.N. & Rogers, , 47(1): 38–48. Nam. Journal of Sex Research in Viet classes of female sex workers Report: UNGASS Country Progress Malaysia: 2010 of Health (2010). Ministry Malaysia Assembly Special General January 2008 – December 2009. Kuala Lumpur: United Nations Session (UNGASS). HIV (2010). F. & Mastos, Y. A., Linhares, Malta, M., Magnanini, M., Mello, M., Pascom, sex with men in who have and men drug users among female sex workers, prevalence 317. , 10: BMC Public Health and meta-analysis. review a systematic Brazil: S. et al. (2006). M., Buchbinder, G., Guzman, R., Rader, R.L., Marks, G., Shouse, Mansergh, and receptive linked to unprotected use are Methamphetamine and sildenafil (Viagra) sex with men. Sexually of men who have in a sample anal sex, respectively, insertive Infections, 82(2): 131–134. Transmitted F., Greinsven, van Mock, P., P., S., Sunthrarasamai, Martin, M., Vanichseni, injecting drug of HIV infection amongst and risk Drug use et al. (2010). P. Pitisuttithum, trial in Bangkok, 1999–2003. International Journal participating in an HIV vaccine users 296–301. , 21: of Drug Policy Maher, A. (2005). Methamphetamine use A. (2005). Methamphetamine use L. & Kral, L., Gee, Lorvick, J., Martinez, A., Wenger, National Conference at the First presented Paper in San Fransisco. among female injectors 2005. Utah, 19–20 August C. Salt Lake City, on Methamphetamine, HIV and Hepatitis and modern dependencies in development drugs, pleasures: C. (2004). Relative Lyttleton, , 35(5): 909–935. Development and Change Golden Triangle. Asia’s Lorvick, for methamphetamine dependence [Review]. [Review]. dependence methamphetamine for men who among HIV-1 infections of recent X. (2008). Detection Li, S., Zhang, X. & Li, 1105–1108. , 121: in Beijing. Chinese Medical Journal sex with men have S., Cahill, S. & White, J.M. (2010). Smout, M., Harrison, W., Longo, M., Wickes, of maintenance for the treatment trial of dexamphetamine controlled Randomised 146–154. , 105(1): methamphetamine dependence. Addiction Lee, S. (2002). Modelling HIV S. (2002). & Kippax, P. de Ven, G., Grulich, A., Van M., Prestage, Law, infections. sex and sexually transmitted unsafe treatment, increased incidence in gay men: AIDS, 16(3): 499–501. R. (2007). K., Hall, K. & Cash, J., Connolly, R., Johnston, L., Jenkinson, Lee, N., Johns, , no. 14: Methamphetamine Guidelines for Alcohol and Drug Clinicians Clinical Treatment Inc. Alcohol and Drug Centre Point Victoria: Turning Fitzroy, dependence and treatment. 60 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Mathers, systematic review. Lancet,372(9651): 1733–1745. Global epidemiologyofinjectingdruguse andHIVamongpeoplewhoinjectdrugs: a Mathers, B., Degenhardt, L., Phillips, B., Wiessing, L.,Hickman,M.&Strathdee, S. (2008). review of global, regional, and national coverage. HIV prevention, treatment, and care services for people who inject drugs: a systematic Ageing. Monograph Seriesno.69.)Canberra: Australian Government DepartmentofHealthand Amphetamine-Type Stimulant Strategy: background paper . (NationalDrugStrategy National DrugResearch Institute &Australian Institute ofCriminology(2007).National South Wales. Australian Government DepartmentofHealthand Ageing;Sydney: University of New 2: Evaluatingthecost-effectivenessofneedleandsyringe programs inAustralia. Canberra: National Centre inHIVEpidemiologyandClinical Research (2009).ReturnonInvestment Nations General AssemblySpecialSession (UNGASS). AIDS Programme: reporting period January2008–December2009.Naypyidaw: United Myanmar Ministry ofHealth(2010). UNGASSCountryProgress Report:Myanmar. National users. Western JournalofMedicine , 168(2):93–97. use duringsexwithrisky sexual behaviors andHIVinfectionamongnon-injectiondrug Molitor, F., Truax, S.R., Ruiz,J.D.&Sun,R.K.(1998).Associationofmethamphetamine injection drugusers. AmericanJournalofDrugandAlcoholAbuse , 25(3):475–493. Methamphetamine use andsexualinjection risk behaviours amongout-of-treatment Molitor, F., Ruiz, J.,Flynn,N.,Mikanda,Sun,R.&Anderson, R. (1999). setting. JournalofAdolescentHealth,44(3):302–304. independently predicts hepatitis Cinfectionamongstreet-involved youth inaCanadian Miller, C.L., Kerr, T., Fischer, B., Zhang, R.&Wood,E.(2009).Methamphetamineinjection Journal, 5:26. HIV epidemicintheWesternPacific andAsia:the role ofWHO(WPRO).HarmReduction Fujita, M. &Singh,N.(2008).Accelerating harmreduction interventions toconfront the Mesquita, F., Jacka, D.,Ricard, D., Shaw, G., Tieru,H.,Yifei,Poundstone, K., Salva, M., 2000: evidencefrom nationalprobability surveys. AIDS,18:1453–1458. Increasing prevalence ofmalehomosexualpartnerships andpractices inBritain1990– Mercer, C., Fenton, K., Copas, A., Wellings, K., Erens, B., McManus, S. etal.(2004). Dependence, 58:198–204. methamphetamine use andmethamphetaminedependence.DrugAlcohol McKetin, R., McLaren, J. &Kelly, E. (2006).Therelationship betweencrystalline Research: Theory&Practice, 18(6):729–742. McBride, N. (2004)Asystematic review ofschooldrugeducation.HealthEducation Matrix Institute (2011). , accessed22March 2011.

B.M., Degenhardt,

L., Ali,

H., Wiessing,

L., Hickman, Lancet , 375(9719): 1014–1028.

M., Mattick,

R.P. et al. (2010). Bibliography 61 D. (2009). D. (2009). & Goldberg, T. S., Rhodes, J., Hickman, M., Hutchinson, N., Kimber, Palmateer, in preventing provision of sterile injecting equipment Evidence for the effectiveness users: drug among injecting transmission immunodeficiency virus C and human hepatitis 844–859. Addiction, 105(5): of reviews. a review J. et al. (2008). Bucardo, P., H., Lozada, R., Orozovich, Semple, S.J., Staines, T., Patterson, in two Mexico–US female sex workers of HIV infection among correlates and Prevalence Diseases Journal of Infectious, 197: 728–732. cities. border C. & C., Areesantichai, A., Pilley, Aramrattana, B., U., Limanonda, Perngparn, in rehabilitation treatment Methamphetamine dependence S. (2011). Taneepanichskul, Association of Thailand, 94(1): Journal of the Medical Thailand: a model assessment. 110–117. 2008 Country Report of the Philippines: January Philippine National AIDS Council (2010). Assembly Special Session (UNGASS). General to December 2009. Manila: United Nations A., Liddell, S. S., Phengsavanh, Manivong, V., S., Sychareun, Phimphachanh, C., Menorath, Infection Risk Sexually Transmitted et al. (2009). Amphetamine-type Substance Use and Lao People’s and Vientiane Province, in Vientiane Capital People Behavior among Young Republic. Vientiane. Democratic between methamphetamine D. & Stall, R.D. (2007). The relationship M., Ostrow, Plankey, JAIDS: AIDS cohort study. in the multicentre seroversion of HIV and risk and popper use , 45: 85–92. Syndromes Immune Deficiency Journal of Acquired J. (2005). Contexts L., Grulich, A., Kippax, S. & Kaldor, Mao, P., de Ven, G., Van Prestage, gay men in among HIV-negative anal intercourse of unprotected for last occasions , 17(1): 23–32. the health in men cohort. AIDS Care Sydney: of role and sexual effect: C. (2002). Drugs C. & Reiber, A., Domier, R., Washton, Rawson, , 22: 103–108. Journal of Substance Abuse Treatment drug type and gender. sex. HIV and ‘unsafe’ use methamphetamine & Worth, H. (2004). Crystal P. Rawstorne, , 3(4): 14–15. Australia sexual risk S. (2004). Changes in the meaning of S. & Shoptaw, Reback, C.J., Larkins, and after drug before male methamphetamine abusers among gay and bisexual behaviors AIDS & Behavior, 8(1): 87–98. treatment. Consensus (2010). on HIV and Injecting Drug Use to the United Nations Group Reference Drug Use. to the United Nations on HIV and Injecting Group Statement of the Reference Vienna: UNAIDS. In definition and practice. history, Harm reduction: (2000). P. D. & O’Hare, Riley, . L. (eds), Harm Reduction: national and international perspectives J. & Harrison, Inciardi, London: Sage Publications. for methamphetamine dependence: a J.E. (2008). Pharmacotherapy Rose, M.E. & Grant, basis theoretical of methamphetamine addiction and the of the pathophysiology review [Review]. Annals of Clinical Psychiatry, interventions and efficacy of pharmacotherapeutic 20(3): 145–155. 62 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Chiang Mai,Thailand: atypologyofrisk. DrugandAlcohol Review,27(3):263–269. (2008). Aqualitative studyofsexualbehaviours amongmethamphetamine users in Sherman, S., Gann,D.,German, D., Sirirojn, B., Thompson, N.,Aramrattana, A. etal. dependence. Addiction,96(9):1289–1296. Pilot randomized controlled studyofdexamphetamine substitution foramphetamine Shearer, J., Wodak,A.,Mattick, R.P., Van Beek, I.,Lewis, J., Hall,W. &Dolan, K. (2001). (200mg perday)formethamphetaminedependence.Addiction , 104: 224–233. Mattick, R. &Wodak,A.(2009).Adouble-blind,placebo-controlled trial ofmodafinil Shearer, J., Darke,S.,Rogers, C., Slade, T., van Beek, I.,Lewis, J., Brady, D., McKetin, R., dependence. DrugandAlcoholReview,27(3):301–308. Shearer, J. (2008).Theprinciplesofagonist pharmacotherapy forpsychostimulant individual-focused interventions. DrugandAlcoholDependence,113(1): 76–81. Crystal methamphetamineuse amongfemale street-based sexworkers: moving beyond Shannon, K., Strathdee, S., Shoveller, J., Zhang, R., Montaner, J. &Tyndall, M. (2011). Sexual Behavior,38:583–590. methamphetamine use amongHIVpositive menwhohave sexwithmen.Archives of Semple, S., Zians, J., Strathdee, S.A. &Patterson, T. (2009).Sexualmarathons and use. JournalofSubstanceAbuseTreatment, 29(2):85–93. Semple, S., Zians, J., Grant, I. &Patterson, T.L. (2005).Impulsivity andmethamphetamine heterosexual methamphetamineusers. AddictiveBehaviors, 29(4):807–810. Semple, S., Patterson, T.L. &Grant, I. (2004b).Thecontextofsexualrisk behavioramong Alcohol Dependence,76(2):203–212. injection methamphetamine-using HIVpositive menwhohave sexwithmen.Drugand Semple, S., Patterson, T.L. &Grant, I. (2004a).Acomparison ofinjectionandnon- Abuse Treatment, 22:149–156. methamphetamine use amongHIV+menwhohave sexwithmen.JournalofSubstance Semple, S., Patterson, T.L. &Grant, I. (2002).Motivations associatedwith Neuropsychology Review,17:275–297. (2007). Neurocognitive effectsofmethamphetamine:acriticalreview andmeta-analysis. Scott, J.C., Woods, S.P., Matt, G.E.,Meyer, R.A., Heaton,R.K.,Atkinson, J.H. &Grant, I. issues, withspecial reference totheUK.AnnIstSuperSanita,43(1):110–115. smokable amphetamine-typestimulants:clinicalpharmacologicalandepidemiological Schifano, F., Corkery, J. &Cuffolo,G.(2007)Smokable(‘ice’,‘crystal meth’)andnon- on partnertypeandintercourse role. SexuallyTransmitted Diseases,31(8): 492–498. associated withrecreational druguse amongyoung menwhohave sexwithmendepends Rusch, M., Lampinen,T.M., Schilder, A. &Hogg,R.S.(2004).Unprotected analintercourse European JournalofPharmacology,479:23–40. Rothman, R. &Baumann,M.(2003).Monoaminetransporters andpsychostimulant drugs. Bibliography 63 A. & Celentano, D. (2009) Latkin, C., Aramrattana, B., C., Sirirojn, Sherman, S., Sutcliffe, in methamphetamine users young trial among peer network intervention of a Evaluation Social Science & Medicine, 68(1): 69–79. Chiang Mai, Thailand. disease-related and infectious use C. (2007). Methamphetamine S. & Reback, Shoptaw, , 102: Addiction for interventions. sex with men: implications who have in men behaviors 130–135. A-N., Wang, J., Swanson, T., E., Steward, K.G., Rotheram-Fuller, S., Heinzerling, Shoptaw, trial placebo-controlled (2008). Randomized, & Ling, W. T. De La Garza, R., Newton, dependence. Drug and Alcohol of methamphetamine the treatment for of bupropion Dependence, 96(3): 222–232. Contemporary among gay men in Sydney. use methamphetamine Slavin, S. (2004). Crystal 425–465. , 31(3): Drug Problems Men Sexual Adventurism among Sydney Gay. Smith, G., Worth, G. & Kippax, S. (2004). of New South Wales. University Social Research, in HIV National Centre Sydney: C. (2006). Long-term effects of universal S., Shin, C. & Redmond, Spoth, R.L., Clair, of Archives among adolescents. on methamphetamine use interventions preventive & Adolescent Medicine, 160(9): 876–882. Pediatrics to Thai AIDS presented Paper issues. in Thailand: current ATS J. (2010). Sripramong, January 2010. Harm Reduction Center, Mitsampan and Group Action Treatment S., McDermott, L. & Eadie, D. A., Minty, R., MacNeil, M., Mackintosh, Stead, M., Stradling, examination a multi-perspective practice: Bridging the gap between evidence and (2010). , 17(1): 1–20. and Policy drug education. Drugs: Education, Prevention of real-world to exposure Potential L. (2011). S., Szczypka, G. & Johnston, Emery, Y., Terry-McElrath, among United and behaviors beliefs, attitudes, and drug-related anti-drug advertising , 36(1–2): 116–124. 1995–2006. Addictive Behaviors States youth, UNGASS Country and Alleviation Committee (2010). Thailand National AIDS Prevention period: January 2008 – December 2009. Bangkok: Report: Thailand. Reporting Progress Special Session (UNGASS). Assembly General United Nations R.D. et al. (2009). K.K., Stall, Hutcheson, R., Thomas, J.W., R.A., Carey, Thiede, H., Jenkins, sex with men. men who have HIV infection among Seattle-area Determinants of recent American Journal of Public Health, 99(S1): S157–S164. in detention of methamphetamine users Detention as Treatment: N. (2010). Thomson, Open Society Institute. Cambodia, Lao PDR and Thailand. New York: UNAIDS. . Geneva: UNAIDS Report on the Global AIDS Epidemic 2010 UNAIDS (2010a). Report: Brunei Darussalam. Reporting period: UNGASS Country Progress UNAIDS (2010b). January 2008 – December 2009. Bandar Seri Begawan: UNAIDS. 64 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Retroviruses and Opportunistic Infections, Montreal, 8–11 February 2009. have sexwithmenin Bangkok,Thailand.Paper presented atthe16thConference on Kittinunvorakoon, C. (2009).ContinuinghighHIV incidenceinacohortofmenwho Van Griensven, F., Wimonsate, W., McNicholl, J.,Chaikummao,S.,Thienkrua,W. & HIV infectionandprevention responses among MSMinAsia.AIDS,24(Suppl3):S30–S40. Van Griensven, F. &deLind van Wijngaarden, J. (2010). Areview oftheepidemiology National Centre inHIVSocialResearch, University ofNewSouthWales. Sexually Transmitted InfectionsinAustralia: annualreport ofbehaviour2004.Sydney: Van deVen, P., Rawstorne, P., Treloar, C. &Richters, J. (2004).HIV/AIDS,Hepatitis,and partnerships inSydney, Australia. AIDSCare, 9(6):637–649. (1997). Factors associatedwithunprotected analintercourse ingaymen’s casual Van deVen, P., Campbell, D.,Kippax,S.,Prestage, G., Crawford, J., Baxter, D. etal. Sydney MenandSexualHealthStudy. InternationalJournalofSTD&AIDS , 9(6):336–340. Gay menwhoengagerepeatedly inunprotected analintercourse withcasualpartners: the Van deVen, P., Campbell, D.,Kippax,S.,Knox, S., Prestage, G., Crawford, J. etal.(1998). 38(6): 890–894. infection: medicalandpsychiatric aspects ofanewepidemic.ClinicalInfectiousDiseases, Urbina, A. &Jones, K. (2004).Crystal methamphetamine,itsanalogues, andHIV Geneva: UNAIDS. United Nations Program onHIV/AIDS(2010). UNGASSCountryProgress Report:China. summary. Geneva: UNAIDS&WorldHealthOrganization. United Nations Program onHIV/AIDS(2008).AsiaAIDSEpidemicUpdate:regional United Nations Office on Drugs and Crime (2010c). SMART Programme. Type StimulantsandOtherDrugs:AsiathePacific 2010. Vienna:UNODCGlobal United Nations OfficeonDrugs andCrime(2010b). Patterns andTrends ofAmphetamine- Amphetamine-Type Stimulants,2010. Vienna:UNODCGlobalSMARTProgramme. United Nations OfficeonDrugs andCrime(2010a). Myanmar:SituationAssessmenton 2009. Vienna:UNODCGlobalSMARTProgramme. Type StimulantsandOtherDrugsinEastSouth-EastAsia(andneighbouringregions) United Nations OfficeonDrugs andCrime(2009).Patterns andTrends ofAmphetamine- Centre forEastAsiaandthePacific. Cambodia, China,LaoPDR,Myanmar, ThailandandVietNam.Bangkok:UNODCRegional South EastAsia:anexploratory review intotheissueofHIV/AIDSandcustodialsettingsin United Nations OfficeonDrugs andCrime(2006).HIV/AIDSCustodialSettingsin Regional Centre forEastAsiaandthePacific. East AsiaandthePacific: analysisof2003 regional ATS questionnaire. Bangkok:UNODC United Nations OfficeonDrugs andCrime(2004).Amphetamine-Type Stimulantsin World Drug Report 2010 . Vienna: UNODC. Bibliography 65 C. (2006). Model projections on the Model projections C. (2006). & Watts, T. M., Rhodes, Hickman, Vickerman, P., injecting drug HIV epidemics among to prevent of syringe distribution coverage required , 42(3): 355–361. Immune Deficiency Syndromes JAIDS: Journal of Acquired users. drug situation in Viet Nam Viet Nam Country Report: of Health (2010). Viet Nam Ministry Assembly Special General . Hanoi: United Nations months of 2010 in 2009 and the first Session (UNGASS). C. (2007). Jayne, M. & Wong, F., J.S., Telang, G.-J., Fowler, N.D., Wang, Volkow, contributing factor in HIV as a potential enhanced sexual desire Stimulant-induced Psychiatry American Journal of, 164(1): 157–160. transmission. Latkin, C. et al. T., S., Sherman, S., Celentano, D., Sirisanthana, Kawichai, T., Vongchak, use drug policy on self-reported 2003 ‘war on drugs’ (2005). The influence of Thailand’s , Mai, Thailand. International Journal on Drug Policy in Chiang among injection drug users 16: 115–121. to change of mass media campaigns Use & Hornik, R. (2010). Wakefield, M., Loken, B. Lancet, 376: 1261–1271. health behaviour. Estimating K. et al. (2010). X., Poundstone, Sun, Wang, N., Wang, L., Wu, Z., Guo, W., in China, 2003–09. International Journal of the number of people living with HIV/AIDS Epidemiology, 39(Suppl 2): ii21–ii28. between human interrelationships Wasserheit, J. (1992). Epidemiological synergy: Sexually diseases. and other sexually transmitted infection immunodeficiency virus Diseases, 19: 61–77. Transmitted Manopaiboon, C., O., Rhucharoenpornpanich, F., Griensven, van Wattana, W., to assess sampling Bannatham, R. et al. (2007). Respondent-driven Thienkrua, W., in Bangkok, Thailand. number of injection drug users and estimate the characteristics Drug and Alcohol Dependence, 90(2): 228–233. Ameijden, E.J. (2002). R.A. & van Coutinho, A.C., Langendam, M.W., Welp, E.A., Lodder, AIDS, 16(9): in Amsterdam. drug users in young behaviour and risk HIV prevalence 1279–1284. HIV infection: reduce A. (2006). Do needle and syringe programs Wodak, A. & Cooney, , 41(6): of the international evidence. Substance Use & Misuse review a comprehensive 777–813. Who of People (2009). Assessment of Compulsory Treatment World Health Organization WHO. Use Drugs in Cambodia, China, Malaysia and Viet Nam. Geneva. the HIV Epidemic to Halt and Reverse A Strategy (2010a). World Health Organization WHO. . Geneva: Who Inject Drugs in Asia and the Pacific among People Access: scaling up priority HIV/AIDS Universal Towards (2010b). World Health Organization WHO. . Geneva: 2010 report interventions in the health sector: progress 66 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Drug andAlcoholAbuse,25:1–23. of HIVrisk behaviors amongheroin andmethamphetamineinjectors. AmericanJournalof Zule, W.A., Desmond, D.P., Morgan, P. &Joe, K.A.(1999).Anethnographic comparison Journal ofInfection,55(5):456–463. behavior amongmenwhohave sexwithmeninanorthernChinesecity, 2002–2006. Zhang, D., Bi,P., Iv, F., Zhang, J.&Hiller, J. (2007).ChangesinHIVprevalence andsexual International AIDSConference, Vienna,18–23July2010. sampling (RDS)survey inBangkokandChiangMai,Thailand.Presentation attheXVIII behaviours andhighHIVprevalence amonginjectingdrugusers ina respondent driven Yongvanitjit, K., Manomaipiboon,P., Aramrattana, A. etal.(2010). Continuedrisk 39(Suppl 2):ii29–ii37. program inChina:achievements andchallenges. InternationalJournalofEpidemiology , Luo, W. &Wu, Z.(2010). Scalingupthenationalmethadonemaintenancetreatment Yin, W., Hao, Y., Sun, X.,Gong,Li,F., Li, J.,Rou,K.,Sullivan, S., Wang,C.,Cao,X., 61–83. stimulant users inanationalsample. AmericanJournalofDrugandAlcoholAbuse,30(1): Wu, L., Pilowsky, D., Wechsberg, W. &Schlenger, W. (2004). Injectiondruguse among Amphetamine-type Stimulants(ATS). Manila:WHO. World HealthOrganization, WesternPacific Region(2011). Technical Briefson in theManagementofOpioidDependenceandHIV/AIDSPrevention. Geneva: WHO. World HealthOrganization, UNODC&UNAIDS(2004).SubstitutionMaintenanceTherapy & Access QualityInternational. Chiang Mai:NationalDrugand AlcoholResearch Centre, University ofNewSouthWales Howard, J. (2011). ‘OpeningDoors’ Enhancing Youth-Friendly HarmReduction:atoolkit. Drug Policy, 19(2):122–129. intersection ofsexual parternships, druguse, andsocialnetworks. InternationalJournalof Aramrattana, A. &Celentano,D.(2008).Young Thaiwomenwhouse methamphetamine: German, D., Sherman,S.,Latkin,C.,Sirirojn, B., Thompson, N.,Sutcliffe, C., and middle-incomecountries. LancetInfectiousDiseases , 7(1):32–41. Dolan, K., Kite,B., Black, E.,Aceijas, C. &Stimson, G. (2007).HIVinprison inlow-income harms ofamphetamineuse. DrugandAlcoholReview , 27(3):253–262. Darke, S., Kaye, S., McKetin, R. &Duflou, J. (2008).Majorphysical andpsychological Kyrgyzstan. Almaty:AllianceforOpenSocietyInternational. demand reduction program in Uzbekistan, Tajikistan andtheFerghana Valley region of Alliance forOpenSocietyInternational(2007).Break theCycle:USAID-fundeddrug References consulted not

cited Bibliography 67 H. (2010). The Chinese government’s response to drug use to drug use response government’s The Chinese H. (2010). Zhang, C. & Liu, Li, J., Ha, T., Harm Reduction Journal, 7: 4. of policies and programs. and HIV/AIDS: a review Structural- R. (2010). S. & Detels, Wang, C., Shoptaw, K., Yin, W., Lin, C., Wu, Z., Rou, in program maintenance therapy implementation of the methadone affecting factors level , 38(2): 119–127. Abuse Treatment China. Journal of Substance Market: patterns E. (2005). The Sydney Metamphetamine J. & Kelly, R., McLaren, McKetin, Government Australian harms and social consequences. Canberra: use, personal of supply, and Ageing. Department of Health The limits of D. (2010). M. & Wolfe, N., Gusmano, N., Thomson, R., Berlinger, Saucier, International in drug detention centers. care dilemmas in providing ethical equivalence: Journal of Prisoner Health, 6(2): 37–43. stage of I. (2004). Determinants of condom use & Grant, T.L. Semple, S., Patterson, AIDS and Behavior, users. methamphetamine change among heterosexually-identified 8(4): 391–400. A. & Celentano, D. N., Aramrattana, Thompson, B., Sherman, S., German, D., Sirirojn, a qualitative Thai drug users: among young use (2008). Initiation of methamphetamine Journal of Adolescent Health, 42(1): 36–42. study. among A. (2006). Methamphetamine use D. & Baskin-Sommers, I., Baskin, Sommers, 1469–1476. , 31: Addictive Behaviors adults: health and social consequences. young S., Razak, M., Jittiwuttikarn, J., Tovanabutra, T., S., Vongchak, N., Kawichai, Srirak, C., Wiboonatakul, K., Sripaipan, T., R., Beyrer, Rungruengthanakit, K., Keawvichit, in northern drug users & Celentano, D. (2005). HIV infection among female V. Suriyanon, , 78: 141–145. Thailand. Drug and Alcohol Dependence (2003). School-Based Drug and Crime Prevention Office for Drug Control United Nations and the wider community. Vienna: United Nations Education: a guide for practitioners and Crime. Office on Drugs Manual. (1990). The HIV Risk-taking Behaviour Scale (HRBS) J., Darke, S. & Hall, W. Ward, of New South Wales. University Centre, Research National Drug and Alcohol Sydney: adults who abuse in young R. (2007). Stroke A., McBride, S. & Haley, Westover, Psychiatry, 64: 495–502. of General amphetamine or cocaine. Archives M.W. & Ross, M.T. Leshabari, J.S., Kilonzo, G.P., S.A., Atkinson, M.L., McCurdy, Williams, injection of Tanzanian gender in a sample by behaviors in HIV risk (2007). Differences 137–144. AIDS & Behavior, 11(1): drug users. and Substance Use on Adolescent Expert Consultation (2011). World Health Organization 2011. 23–25 March Region. Manila, Philippines, in the Western Pacific of HIV and Other Sexually and Treatment Prevention (2011). World Health Organization People: Infections among Men Who Have Sex with Men and Transgender Transmitted WHO. . Geneva: for a public health approach recommendations 68 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia chlorphentermine/ ORexpmephentermine/ ORexpamphetamine-related disorders/ exp methamphetamine/ORbenzphetamine/ OR expphentermine/ methylamphetamine/ ORexpp-hydroxyamphetamine/ OR expiofetamine/ dextroamphetamine/ ORexpp-chloroamphetamine/OR exp2,5-dimethoxy-4- sulphate ORstimulant$expamphetamines/ OR expamphetamine/ OR dextro-amphetamine sulphateORdextroamphetamine sulphate ORd-amphetamine OR d-amphetaminedextroamphetamine sulphate ORdexamphetamine ORdexedrine methamphetamine hydrochloride ORmethylamphetamine ORn-methylamphetamine deoxyephedrine ORdesoxyephedrine ORDesoxyn ORmadrinemetamfetamine ATS OR“amphetamine typestimulant$”ORamphetamine$methamphetamine OR Amphetamine-type stimulants exp HIVseroprevalence/ ORexpAIDSserodiagnosis/ infections/ ORexpacquired immunodeficiency syndrome/ ORHIVseropositivity/ OR Deficiency Syndrome” ORexpHIV/HIV-1/ OR expHIV-2/HIV Deficiency Virus” OR“Acquired ImmunodeficiencySyndrome” OR “Acquired Immune OR HIVorAIDSHIV/AIDS“HumanImmunodeficiency Virus” OR“HumanImmune HIV/AIDS substance-induced/ OR expheroin dependence/ORexpmorphinepsychoses, related disorders/ ORexpcocaine-related disorders/ OR expopioid-related disorders/ Opium/ orexpHeroin/ ORexpsubstance-related disorders/ ORexpamphetamine- OR expamphetamines/amphetamine/methamphetamine/ OR expdesigner drugs/ ORexpstreet drugs/ ORexpCocaine/crack cocaine/ abuse ORsubstanceuse$ ORsubstancemisuse ORsubstancedependen$addict$ opiate ORdrugabuse ORdruguse$ ORdrugmisuse ORdrugdependen$substance heroin ORcocaineamphetamine$methamphetamine$opioid$opium Drugs anddruguse OR “injectingsubstance”expsubstanceabuse, intravenous/ PWID ORPWIDs“injectingdrug”“intravenous drug”OR“intravenous substance” Injecting druguse ture foreachregion: The following keywords and ‘MeSH’ terms (in bold) were used in the searches of the litera- Medline search strategy conducted. Details ofthesesearches are given below. werePubMed and platform) OVID the Searches(via electronicMedline the of of databases This studycomprised adesk-based literature review ofpeer-reviewed andgrey literature. Search strategy Appendix 1: Appendix 1: Search strategy 69 Amphetamine-type stimulants amphetamine OR amphetamine OR type stimulants” OR OR “amphetamine ATS OR OR Desoxyn OR desoxyephedrine methamphetamine OR deoxyephedrine OR methylamphetamine OR hydrochloride” metamfetamine OR “methamphetamine sulphate” OR “n-methylamphetamine” OR “d-amphetamine” OR “dextroamphetamine sulphate” OR “d-amphetamine OR “dextroamphetamine OR dexedrine dexamphetamine OR “2,5-dimethoxy-4- sulphate” OR stimulant OR stimulants OR “P-chloroamphetamine” OR methamphetamine OR iofetamine methylamphetamine” OR “P-hydroxyamphetamine” OR OR benzphetamine OR phentermine OR chlorphentermine OR mephentermine ” [MH] OR “2,5-dimethoxy- OR “P-chloroamphetamine disorders” “amphetamine-related iofetamine ” [MH] OR 4-methylamphetamine” [MH] OR “P-hydroxyamphetamine [MH] OR [MH] OR methamphetamine [MH] OR benzphetamine [MH] OR phentermine ” disorders chlorphentermine [MH] OR mephentermine [MH] OR “amphetamine-related [MH] HIV/AIDS OR OR “Human Immunodeficiency Virus” OR “HIV/AIDS” HIV OR AIDS OR AIDS [sb] OR “HIV-1” OR “HIV-2” OR “HIV seropositivity” Immunodeficiency Syndrome” “Acquired OR “HIV-1” [MH] OR “HIV-2” [MH] OR “AIDS serodiagnosis” OR OR “HIV seroprevalence” [MH] [MH] OR “AIDS serodiagnosis” seroprevalence” [MH] OR “HIV “HIV seropositivity” Drug use OR “drug OR “drug misuse” “drug users” OR OR “drug user” “drug use” OR “Drug abuse” OR “drug dependent” OR “substance abuse” dependence” OR “drug dependency” OR OR OR “substance misuse” OR “substance users” OR “substance user” “substance use” dependency” OR “substance dependent” OR “substance dependence” OR “substance OR “amphetamine- disorders” addict OR addicts OR addiction OR “substance-related OR disorders” OR “opioid-related disorders” OR “cocaine-related disorders” related ” disorders dependence” OR “substance-related dependence” OR “morphine “heroin ” [MH] disorders ” [MH] OR “cocaine-related disorders [MH] OR “amphetamine-related dependence” [MH] OR “morphine ” [MH] OR “heroin disorders OR “opioid-related dependence” [MH] Injecting drug use substance” drug” OR “intravenous “injecting drug” OR “intravenous PWID OR PWIDs OR ” [MH] intravenous OR “substance abuse, intravenous” OR “substance abuse, - litera the of searches the in used were bold) (in terms ‘MeSH’ and keywords following The for each region: ture PubMed search strategy PubMed search 70 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia • • • sources, eachofwhichis describedbelow. The information presented in the following country summaries is drawn from a number of Country summaries Appendix 2: Reid &Baldwin,2006). researchers from the Burnet Institute and Turning Point Alcohol and Drug Centre (Devaney, by compiled report Asia–Pacific Region the in Responses and Issues Drug Illicit of Analysis Where possible, information contained in these has been cross-referenced with the • • • • issues ofinterest tothis report include: The group. steering the by conducted activities research from findings the on based is 2010).Use, Drug Injecting Consensusand The HIV Statement on Nations United the to on the global response to PWID and HIV among people who inject drugs (Reference Group Consensus Statement in 2010 which identified key issues and recommendations for action a producedUse Drug Injecting and HIV on Nations United the to GroupReference The tries ofinterest (UnitedNations OfficeonDrugs andCrime,2010b). on that submitted by the drug control agencies and institutions in Southeast Asian coun Pacificthisthe in and reportcontained Asia information Drugs: isOther The and . based The Global SMART Program report Nations OfficeonDrugs andCrime,2010b). (United Programreport SMART Global UNODC the fromsourced was presented mation Myanmar did not submit reports to the Global AIDS Report. For these countries the infor DarussalamBrunei MSM. workersand and sex PWID, reductionfor harm including tion years. These reports ( Secretariateverytwo UNAIDS Progressthe Country reportsto themselvessubmit ted to Member states who adopted the 2001 Declaration of Commitment on HIV/AIDS commit regional situationalanalysis and recommendations foraction. strengthening thedata,and among peoplewhoinjectdrugs policy, legislation and law enforcement impacting upon HIV risk and response to HIV PWID among HIV of care and prevention,treatment the interventionsfor evidenced-based UNGASS Country Reports Patterns and Trends of Amphetamine-Type Stimulants ) contain information on HIV/AIDS preven Situational - - - - Brunei Darussalam 71 - - kg).

000 (Devaney, Reid & Bald & Reid (Devaney, 000

currently run was available. There were 102 drug treatment admissions during 2009, all but all 2009, during admissions treatment drug 102 were There available. was run currently one for crystal methamphetamine use (one for inhalants) (United Nations Office on Drugs and Crime, 2010b). clinics and counselling is available from psychiatric institutions and non-government organi non-government and institutions psychiatric from available is counselling and clinics the over took Bureau Control Narcotics the 2008 In 2006). Baldwin, & Reid (Devaney, sations take-over the to Prior facility. treatment drug sanctioned officially one the of management is facility the how about information No treatment. to approach punitive a took facility the Drug treatment Treatment for drug dependency in Brunei Darussalam can be sought from general health No ATS pills or powdered amphetamine seizures were reported (United Nations Office on and Crime, 2010b). Drugs Drug seizures Less than half a kilogram of crystal methamphetamine was seized during 2009 (0.32 There There were 556 drug-related arrests in 2009, 75 per cent of which were for ATS and half of which non-national The involved persons. vast majority of all those arrested were male and Crime, 2010b). Office on Drugs (85%) (United Nations Drug-related arrests Drug-related Injecting drug use who people of number the of estimates no and use ATS injecting of reports no were There and Crime, 2010b). Office on Drugs (United Nations in Brunei Darussalam inject drugs to Malaysia then trafficked into Brunei (United Nations Office on Drugs and Crime, 2010b). Crime, and Drugs on Office Nations (United Brunei into trafficked then Malaysia to The most recent assessment of ATS use in Brunei was Darussalam conducted in 2000 and of 0.06 per cent. estimated a population prevalence available. were MSM or sex workers among use No estimates of ATS in 2008 use was estimated to be stable. There are no reports of the use of ATS pills nor were were nor pills ATS of use the of reports no are There stable. be to estimated was use 2008 in of of any The manufacturing clandestine reports source there or factories. the dismantling shipped is it where from Philippines the be to thought is Darussalam Brunei in ATS crystal of Amphetamine-type stimulant use Amphetamine-type is which ATS crystal 2003, since been has and is, Darussalam Brunei in use most of drug The although 2005, since use ATS crystal in trend downward a been has There smoked. commonly the state of Sarawak, Malaysia. the The state capital, Malaysia. of Bandar Sarawak, Seri Begawan, has an estimated population of 140 000. Brunei is a sovereign state with an estimated population of 400 of population estimated an with state sovereign a is Brunei win, 2006). It is located on the north coast of the island of Borneo and is surrounded by Brunei Darussalam Brunei 72 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia The World AIDS Report (UNAIDS, 2010a) indicated 15 individuals received ART to June 2010. HIV treatment were reported (UNAIDS,2010b). PWID) MSM, workers, (sex groups high-risk among testing for figures No donors. blood of cent per 100 and women pregnant of cent per 100 included testing HIV on Reports HIV testing (Devaney, Reid&Baldwin,2006). estimates from 2003 which indicated 3.8 per cent of HIV notifications were linked to PWID HIV previous noting data, PWID and HIV in discrepancies to point also Reports PWID. of noted a cumulative total of 609 HIV cases, only one of which was reported to be the result This conflicts with information previously reported by the World Health Organization, which to bring the cumulative total of HIV cases to 56 (between 1986 to 2009) reported was This 2009. Darussalamin Brunei in diagnosed were HIV of cases new Eleven HIV inthecommunityandamonginjectingdrugusers There are noharmreduction services(NSP, OST)available inBrunei(Mathers et al.,2010). Harm reduction (UNAIDS, 2010b). Cambodia 73 managed counselling 000 ATS users (Cambodia

5 (Mathers et al., 2008).non-government organisations However, 6

The Integrated Drug Abuse Drug Information Network is a UNODC F-97 regional project, project, a UNODC F-97 regional Drug Information Network is Drug Abuse The Integrated for an infrastructure to establish which aims Data and Information Systems’, ATS ‘Improving abuse data pertinent to ATS and for exchanging use of ATS of the patterns better understanding and control. prevention per cent. of 0.01–0.09 of PWID in the range (15–64 years) Based on a population prevalence 6 5 in Cambodia reported referring almost 1500 to persons government- and testing services and, of these, half (788) were reported to be people who inject drugs and Crime, 2010b). Office on Drugs (United Nations There are no recentare officialnational There size estimates of PWID in Cambodia. Therecent most figures for PWID in Cambodia are from 2004 and suggest there are between1000 and 7500 PWID in Cambodia trafficked into Cambodia are actually destined for markets other than domestic. actually into Cambodia are trafficked Injecting drug use Office on Drugs and Crime, 2010b). The original source of ATS is Myanmar and reports have have reports and Myanmar is ATS of source original The 2010b). Crime, and Drugs on Office for Cambodia in re-tableted being are source this from ATS of quantities that received been drugs the of proportion substantial a that evidence also is There market. street domestic the The source of crystal methamphetamine in Cambodia was predominantly Thailand but since since but Thailand predominantly was Cambodia in methamphetamine crystal of source The Nations (United Delta Mekong the from particular in Lao, through trafficked have drugs 2003 cent of aged drug and 18–25 users 17 years A per of survey cent street years. aged 10–17 had pills ATS of use and lifetime their in drug illicit an used had half almost found children 12 per population cent from in among 2000 this to 87 increased per cent in 2007 (United 2010b). and Crime, Office on Drugs Nations users but noted that in the absence of national surveys this is likely to be an under-estimate. under-estimate. an be to likely is this surveys national of absence the in that noted but users In 2004, an expert consensus per group 60 estimated with there people to young be 20 affects largely use drug appears It 2008). Authority, AIDS National Between 2003 and 2006 the trend was towards increasing use of crystal methamphetamine crystal of use increasing towards was trend the 2006 and 2003 Between 2010b). Crime, and Drugs on Office Nations (United reported) not was trend 2009 to (2007 The 6800reported United drug approximately OfficeNations on and Drugs Crime (2010b) Amphetamine-type stimulant use Amphetamine-type pills. ATS and methamphetamine crystal were 2009 in Cambodia in concern most of drugs The Nam to the south-west. It has a population of almost than 15 2 million million with more Abuse Drug Integrated the to signatory a is Cambodia Penh. Phnom capital, the in residing (IDADIN). Drug Information Network Cambodia, officially known as the Kingdom of Cambodia, is a monarchy with a parliamentary parliamentary a with monarchy a is Cambodia, of Kingdom the as known officially Cambodia, Viet and north-east the to PDR Lao north-west, and west the to Thailand borders It system. Cambodia 74 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Drug treatment materials reported (UnitedNations OfficeonDrugs andCrime,2010b). with five manufacturing sites being dismantled in 2009 and significantCambodia, seizures in ofATS of precursor manufacture the in increases recent been also have There 16.2kg). (ATSpills428 period 2006 the reportedfor those than lower 2010b). significantly Crime, However, figures are and Drugs these on Office Nations pills) and crystal methamphetamine seizures more than doubled from 1.9kg to 4.6kg (United(116 2008 between cent per 18 increased seizures pill ATS Drug seizures (United Nations OfficeonDrugs andCrime,2010b). 615 drug-related arrests in Cambodia in 2009, but figures were not separated by drug type illicit substances were for ATS pills (61%) and crystal methamphetamine (37%). There were Nations Drugs 2010b). on Crime, Office and arrests Furthermore, of majority the to related 41 to 139 (a 57% increase), while arrests for ATS pills also increased from 199 to 232 (United Between 2007 and 2008, the number of arrests for crystal methamphetamine increased from Drug-related arrests Office onDrugs and Crime,2010b). nificant increase from the 14 per cent found in the same population in 2006 (United Nations among PWID referred to government-managed counselling in 2007 was 35 per cent, a sig- injecting also occurs in Cambodia, the risk associated with ATS is unknown. HIV prevalence AIDS Authority, 2010). This report did not discriminate between drug types and, since heroin of injectors were HIV-positive compared to 1 per cent of non-injectors (Cambodia National cent first-ever per The 24.4 2008). found al., survey drug (n=528) et of users Cambodia in (Mathers HIV for positive were Cambodia in PWID of cent per 22.8 estimated an 2006 In from 1.2 per cent to an estimated 0.9 per cent (68 Between 2003 and 2006 HIV population prevalence among adults aged 15–49 years decreased HIV inthecommunityandamonghigh-risk groups Primary drugprevention occurs inschools andinthecommunitybutis reportedly limited. Drug prevention activities (World HealthOrganization, 2009). cent per 100 to up be to estimated been has centres these from discharge following rate 2010b). Detention for the use of crystal Crime, methamphetamineand Drugs on Office and Nations ATS (United yearspills 19–25 aged dominated. males young A majority the the military or civilian police. In the same year 2382 people were detained in these centres, In 2008 there were 14 compulsory drug treatment centres in Cambodia, the majority run by

000 cases; 51% female) (UNAIDS, 2010a). 553 and crystalmethamphetamine and 553

772 pills) and 2009 (137 2009 and pills) 772

relapse

249 249 Cambodia 75 000 sterile needles and and needles sterile 000

- avail ART on figures No 2010a). (UNAIDS, 247) 315 people were receiving 315 ART in 2009 (World Health Organization, 2010b), Phnom Penh in 2007 (Hagarty, 2010). In 2009, NGOs distributed 92 distributed NGOs 2009, In 2010). (Hagarty, 2007 in Penh Phnom in Cambodia commenced in 2010. OST program The first syringes. Harm reduction in sites two through distributed were syringes and needles million a of quarter a than More ability for PWID were available, although ART is linked to OST clinics and available in some in available and clinics OST to linked is ART although available, were PWID for ability (Mesquita et al., 2008). prisons There There was an increase in facilities providing ART therapy from 16 in 2005 to 20 in 2007. A total of 37 (12 2005 in recorded figure the times three HIV and anti-retroviral treatment (ART) treatment HIV and anti-retroviral AIDS Authority, 2010). AIDS Authority, transmitted sexually other and HIV of treatment and prevention the for guidelines recent In people, ATSthe onuseinfluenceamong sexual of ofMSM the and infections transgender 2011). behaviour was noted (World Health Organization, time they injected. The remainder reported using ‘clean’ needles but this included sterile units and needles and syringes that had been cleaned prior to (Cambodiare-use National conducted among MSM reported that 96 per cent of MSM had received HIV prevention 2010). Authority, AIDS National (Cambodia interview to prior months six the in information While a survey among PWID in treatment found that 99 per cent of PWID knew where to access than clean needles 30 needles the more per sharing and last cent syringes, reported based and per51 cent of non-brothel-based sex workers reportedly had been tested for HIV and knew There are no - their previ results (Cambodia National 2010). AIDS Authority, ous measures of this variable with which to compare these figures. A behavioural survey HIV prevention among high-risk groups among high-risk HIV prevention In 2007, 93 per cent of brothel-based and 90 per cent of non-brothel-based sex workers education. reported they prevention In had the received 68 same year per cent of brothel- Prevalence Prevalence of HIV among female sex workers varies between provinces and is reported to be between 20 and 30 per HIV cent. Among sex men with who men have in Phnom Penh, among highest was Prevalence cent. per 2 was it towns rural two in while cent per 8.7 was 2010). Authority, (17%) (Cambodia National AIDS groups transgender 76 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Injecting druguse inhaled orsmoked (UnitedNations OfficeonDrugs andCrime,2010b). commonly is methamphetamine Crystal 2006). Baldwin, & (Devaney,Reid million 6–8 as number of drug users in the country. Other estimates put the number of drug users as high The Chinese Government recognises that this number is likely to be an under-estimate of the of these were newly registered in 2009 (China National Narcotics Control Commission, 2010). cent were ATS users (United Nations Office on Drugs and Crime, 2010b). More than 97 2009 there were more than 1.3 million registered drug users, of which an estimated 27 per has been an annual increase in recorded use of crystal and pills between 2003 and 2007. In 2010b). Drugs Crime, Nations on and (United Office China usedin drug Furthermore there frequently most second the as overopium fromtaken recentlyhave crystal, and pills both stimulants, amphetamine-type but China in concern of drug primary the remains Heroin Amphetamine-type stimulantuse more than17million.Chinais asignatorytotheIDADIN. of population a has Beijing, capital, The 2008. in billion 1.34 of population a with world the in country populous most the is state, communist a China, of Republic People’s The China in 2009)(UnitedNations OfficeonDrugs andCrime,2010b). 2005 and 2008 but fell by 50 per cent between 2008 and 2009 (5523kg in 2008 and 2518kg previousthe in seized year. Seizures crystalof remained methamphetamine between stable number the times six than more 2009, during seized were pillsATS million 40 than More Drug seizures and Crime,2010b). DrugsYunnan on into provinceNationsOffice byland (United China enter to arethought pills Myanmar. The from China into brought being are pills ATS of number increasing an domestically.manufactured However,primarily is China in used methamphetamine Crystal 21 provinces (UnitedNations Officeon Drugs andCrime,2010b). of ephedrine-containing compounds and more than 400kg of ephedrine were seized across chemicals and precursor manufacturing centres have occurred. More than 40 metric tonnes Following law enforcement initiatives implemented in 2009 significant seizures of precursor Manufacture andtrafficking ofamphetamine-typestimulants were injecting(UnitedNations OfficeonDrugs andCrime,2010b). usersATS of 11 cent suggested Abuse per Drug on Centre Surveillance National the 2006 remains to but difficult occur to ATSisknown of injection The 2008). al., erset mate), although other estimates are somewhat higher at 2.35 million current PWID (Math- The number of injecting drug users in China is estimated to be 2.3 million (mid-range esti- assess.In 000 China 77 - 000 000 new diagnoses of HIV

000 drug users were being held across 746 compulsory drug drug compulsory 746 across held being were users drug 000

000 cumulative cases of HIV and 48

000 drug-related arrests were made during 2009, an increase of 20 000 drug entered users community drug treatment centres and 173 were available, although ART is linked to OST clinics and available in some prisons (Mesquita (Mesquita prisons some in available and clinics OST to linked is ART although available, were et al., 2008). HIV and anti-retroviral treatment HIV and anti-retroviral forin on PWID China. ART No availability free figures available is treatment Anti-retroviral The 2009 National HIV Sentinel indicated Surveillance that 36 per cent of 45 sex workers, per cent of MSM, and 37 per cent of PWID surveyed had participated in HIV testing and of Health, 2010). (China Ministry knew the results reportedly HIV testing (Wang et theOverall al., majority 2010). (59%) of HIV infections are reported to be sexu 2010). al., et (Wang homosexual cent per 15 and heterosexual cent per 44 transmitted, ally Guangxi, Guizhou and Guangdong). This report further suggests that HIV among PWID, rising. is MSM among that while stabilising is women pregnant and clients STI workers, sex while, cent per 5 of region the in is MSM among prevalence the cities medium and large In in main cities in the south-west of China, among prevalence MSM per is 10 cent or more. This study estimates 15 per cent of HIV cases are the result of homosexual sexual contact (Wang et According al.,to 2010). sentinel surveillance data, an estimated 9.3 per cent of PWID were infected with HIV (China in Ministry of some However, Health, Chinese 2010). provinces the prevalence is reportedly more than 50 per cent (Yunnan, Xinjiang, Sichuan, HIV in the community and among injecting drug users HIV in the community and among of prevalence HIV Population in China is in the region of 0.06 per cent and in 2009 there were an estimated 740 labour camps and, in 2006, 300 2006, in and, camps labour 2010b). Organization, (World Health centres treatment were detained in compulsory drug detoxification centres. However, a classification ofdetained were drug in However, drug compulsory centres. detoxification user by drug type was not reported (United Nations Office on Drugs and Crime, 2010b). and through 300 centres China re-education than has rehabilitation 700 more compulsory Drug treatment During 2009, 47 China does not disaggregate drug arrests by the type of drug for which an arrest occurred. occurred. the type of drug for which an arrest by drug arrests China does not disaggregate more Overall, than 90 and Crime, 2010b). Office on Drugs (United Nations year per cent on the previous Drug-related arrests Drug-related 78 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia been implementedacross China(UNAIDS,2010a). have population general the targeting campaigns awareness major addition, In 2009. ing MSM, and 38 per cent of PWID indicated they had received HIV prevention education dur- Sentinel Surveillance surveys in China report that 75 per cent of sex workers, 75 per cent of HIV prevention education tuberculosis (Yinetal.,2010). and information, psychosocial support and referrals for treatment of HIV and other STIs and Thisprogram revisedrecentlybeen HIV,has also include to testing hepatitissyphilisC and 242 serving clinics 680 than more to expanded been had program the treatmentmaintenance Methadone programs were first 2009, By 2004. in China in piloted (Hagarty, 2010). services NSP accessing PWID of cent per 2 only with (<1–84) 32 at number the put which tributed per PWID per year at 110 in contrast to 2008 data from the Consensus Statement, dis needles of number average the puts report This provinces. 17 across sites 775 from According to the Harm reduction Harm Reduction in Asia report in 2009, needles and syringes are available

000 heroin users. heroin 000 - China 79 000 registered drug users in Hong in users drug registered 000 Arrests Arrests related to ATS in Hong Kong have doubled since 2004, from 390 to 788 in 2009. and Drugs on Office Nations (United (874) 2008 in occurred arrests of number highest The Crime, 2010b). Drug-related arrests Drug-related Drug seizures While there were no seizures of ATS pills in Hong Kong during 2009 and 2008, 43.7kg of during seized those to similar amounts 2009, during seized were methamphetamine crystal and Crime, 2010b). on Drugs Office 2007 and 2008 (United Nations (United Nations Office on Drugs and Crime, 2010b) and manufacturing of ATS in Hong Kong Kong Hong in ATS of manufacturing and 2010b) Crime, and Drugs on Office Nations (United of meth/amphetamine. and re-packing the tableting involves predominantly Manufacture and trafficking Manufacture Two small crystal methamphetamine laboratories were dismantled in Hong Kong in 2009 injection of methamphetamine in either the UNODC Global (2010) report SMART Program 2010). (Hagarty, or the Harm Reduction in Asia report Injecting drug use There was no available information on the rates or numbers of drug users reporting the Office on Drugs and Crime suggests that a lack of nationally representative figures on crystal crystal on figures representative nationally of lack a that suggests Crime and Drugs on Office Nations (United challenge major a remains China and Kong Hong in use methamphetamine and Crime, 2010b). Office on Drugs and Crime, 2010b). This represents 10–15 per 10–15 This cent represents and of Of Crime, drug of all users 2010b). users. registered users per cent of registered and methamphetamine, 10–15 8–9 per crystal cent of all users Nations United The 2010). Program, SMART (Global years 21 of age the under being reported Amphetamine-type stimulant use Amphetamine-type 12 to close were there 2009, of months three first the In Drugs on Office Nations (United users methamphetamine crystal were whom of 1050 Kong, Hong Kong is one of Regions attached two to Special China. Administrative With a popu- executive. unelected an with democracy partial non-sovereign a is it million, 7.06 of lation Hong Kong 80 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia No informationwasavailable concerningPWIDaccesstoHIVART. HIV anti-retroviral treatment In 2005 more than 90 per cent of PWID received testing and knew the results (UNAIDS, 2010a). HIV testing 9 percentofHIVoccurs amongPWID,anincrease of300percentsince1998. an overall prevalence of 0.1 per cent (Devaney, Reid & Baldwin, 2006). Overall, an estimated There were 396 new cases of HIV reported in Hong Kong during 2009 and the country has HIV inthecommunityandamonghigh-risk groups more than15NGOfacilities(Devaney, Reid&Baldwin,2006). sites. There are a further four residential treatment centres, a variety of halfway houses and those in the prison system; there are voluntary drug treatment clinics located in six hospital 2010b). Crime, Drugs and on NationsOffice (United to only Compulsory treatment applies No information about drug treatment offered to those using ATS was available from UNODC Drug treatment session ofneedlesandsyringesis notunlawful. NSPs. However,thereofficial areKongand no is Hong limited reduction in Harm pos- the Harm reduction HIV prevention educationinschools andthecommunityis basedonanti-drug messages. There were nodatameasuringHIVrisk behaviours ofPWID. 93 per cent were thought to have been reached with prevention education (UNAIDS, 2010a). In 2004, 99 per cent of PWID reportedly had comprehensive knowledge of HIV and, in 2005, Prevention education China 81 (UNAIDS, 2010a). HIV in the community and among injecting drug users HIV in the community and among Latest figures are from 2004, whichshowed that approximately 18 cases of HIV among PWID were identified. These casesrepresented 60 per cent of all cases of HIV in Macau by the government is geared towards heroin users. No details of treatment offered for No of offered ATS details treatment users. heroin towards geared is the by government services (Macau 1). government through available could be located. Methadone is Drug treatment managed unit detoxification primary The Macau. in treatment drug compulsory no is There Drug-related arrests Drug-related No information reported. Injecting drug use of few reports are although for there heroin, the Injecting of major is administration route heroin some indicated Centre Treatment Complex Drug the from Data ATS. of injection the (n=6) (Macau 2). the past year in had switched to ATS users No reports of ATS manufacturing were found. Drugs are thought to be trafficked into Macau Macau into trafficked be to thought are Drugs found. were manufacturing ATS of reports No from mainland China and Hong Kong with limited amounts from other Southeast Asian Reid & Baldwin, 2006). countries (Devaney, Manufacture, trafficking and seizures trafficking Manufacture, Amphetamine-type stimulant use Amphetamine-type (Dev- used reportedly are ATS and ice although unknown, is Macau in use ATS of level The 2006). Reid & Baldwin, aney, Macau is one of two special regions of administrative China, the other being Hong Kong. of 430 000. Macau has a population Macau 82 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Outreach and NSPs act as referral points to government-run methadone programs (Macau 1). users (Macau1). 2010,69 In distributed NSPs the governmentTherebywith arerun NGOs operating Macau, currently NSPs in funding. two Harm reduction activities were found. of type or scope the about details no Macau, in exists education prevention HIV While Prevention education No informationavailable. HIV anti-retroviral treatment No informationavailable. HIV testing 000 needles and syringes and had 258 regular registeredregular 258 had and syringes and needles 000 Indonesia 83 - 000 islands and has 000 a islands population in the vicinity of 240 429 people who inject drugs in Indonesia in 2008, a number a 2008, in Indonesia in drugs inject who people 429

Crime, 2010b). There are Crime,concerns however that2010b). a increase suspected in domestic - produc pattern. changing this methamphetamine is tion of crystal A large proportion of crystal methamphetamine seized in Indonesia in 2009 was apparently apparently was 2009 in Indonesia in seized methamphetamine crystal of proportion large A intotrafficked the and country China Iran from from (United Office Nations on and Drugs Drugs Drugs and The Crime, National 2010b). Narcotics Board suggests that ATS producers may Nar National (Indonesian detect to harder are which operations smaller towards moving be 2010) cotics Board, Manufacture and trafficking Manufacture These 2009. during Indonesia in dismantled were laboratories manufacturing 35 than More included 25 large-scale operations and 12 smaller laboratories (United Nations Office on proportion of PWID who inject crystal methamphetamine as opposed to heroin is unknown. is heroin practices. to opposed as injecting methamphetamine crystal inject unsafe who PWID by of proportion driven be to considered is Indonesia in epidemic HIV the However, Injecting drug use The 126 estimated an were There 2010). Commission, AIDS National (Indonesian estimates previous than lower considerably Drugs and Crime, 2010b). The most Drugs and commonly Crime, used drugs in 2010b). this study group of students and Crime, 2010b). Office on Drugs (United Nations ecstasy and ATS cannabis, were 10–59 10–59 years had used an illicit drug in the andprevious year, 6.8 per year. cent last of the those in aged use drug reporting cent per 4.4 with use, drug lifetime reported years 11–19 This suggests that drug use among young people is increasing (United Nations Office on A national survey of drug use in Indonesia indicated that 2 per cent of the population aged aged population the of cent per 2 that indicated Indonesia in use drug of survey national A In Indonesia cannabis has been the drug of most concern since 2004. Crystal methamphet Crystal 2004. since concern most of drug the been has cannabis Indonesia In and 2008 in However, 2005. in fifth and 2006, and 2004 in overall fourth ranked was amine echo these, figures in usage second. The methamphetamine trend was ranked 2009 crystal both 2008 and 2009 (only). in increased to have reported use with ATS While smoking is the predominant mode of for administration crystal meth/amphetamine, Office on Drugs most common method (United Nations as the second reported injecting is and Crime, 2010b). Amphetamine-type stimulant use Amphetamine-type Indonesia comprises more than Indonesia more 17 comprises Indonesia a sig- Indonesia is and president. with million an a people. elected republic It legislature is natory to the IDADIN. 84 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia opiate users (United Nations Office on Drugs and Crime, 2010b). Twelve per cent of Oftreatment the 14 Drug treatment in trafficking from othercountries. resultthe recordedbe the of increase productiondecreasedomestic concomitant in a with 2010b). Crime, Drugsand on However,NationsOffice (United (237.8kg) thisdecreasemay Seizures of crystal methamphetamine decreased markedly between 2006 (1241kg) and 2009 Drug seizures sale ofATS, especially inJakarta(UnitedNations OfficeonDrugs and Crime,2010b). trafficking and involvedthe be in to arethought Africa, groups,fromWest Criminal often rity resources andare thus vulnerable totrafficking. including international airports (22) and 150 seaports. Most reportedly lack adequate secu- points entry recognised 150 almost to equates This residents. permanent have one-third Office on Drugs and Crime, 2010b). Nations Indonesia (United consists country ofthe moreof thancharacteristics 17 geographic the to due country the of out Indonesia faces special problems in terms of opportunities for the trafficking of ATS in and No cross-over dataexamining ATS use amongthesehigh-use groups were available. is unprotected, nospecific dataare available. PWID and sex workers are acknowledged but, beyond the fact that 25 per cent of paid sex ing drugs, unprotected paid sex and unprotected sex among MSM. Cross-over risks between These prevalence figures confirm that the major risk factors for HIV transmission are inject- (UNAIDS, 2010a). PWID female among cent per 56.1 and PWID; male among cent per 52.2 MSM; among cent per 5.2 workers; sex female of cent per 7.1 workers; sex male among cent per 20.3 groups: high-risk among higher is it cent, per 0.2 is HIV of prevalence country the While HIV inthecommunityandamonghigh-risk groups from 2008 figures. The vast majority of those arrested were male and Indonesian nationals. 2010b). Crime, increase Drugs and cent on per NationsOffice This 29 (United represents a Of the 38 Drug-related arrests is available foropiateusers, nodetails ofthetreatment given toATS users were available. admissions were for ATS: 984 for methamphetamine and 332 for amphetamine. While OST

852 individuals admitted to treatment in Indonesia in 2009, the vast majority were 173 drug-related arrests, just under one-third were for crystal methamphetamine

000 islands, of which Indonesia 85 - lenges, one being that disease surveillance has become more difficult (Indonesian National (Indonesian difficult more become has surveillance disease being that one lenges, 2007). AIDS Commission, Concerns Decentralisation of health services, which occurred in Indonesia in has 2001, reduced the chal in resulted has This priorities. health about decisions influence to ability government’s and syringe units distributed in 2007 was 1.17–1.52 million (Hagarty, 2010). However, this this However, 2010). (Hagarty, million 1.17–1.52 was 2007 in distributed units syringe and and syringe units per PWID per year. needle only three represents Harm reduction needle of number total the and services NSP accessing are PWID of cent per 23 estimated An Condom use among male and female sex workers was greater than two-thirds while, among among while, two-thirds than greater was workers sex female and male among use Condom the in use Condom 2010a). (UNAIDS, cent per 39.3 at lower was it sex, anal practising men low at 33.9 per cent. also last sexual encounter among PWID was per cent for sex workers (59.9% for male sex and workers, 34.3% for female sex workers), for PWID (UNAIDS, 2010a). 40.1 per cent for MSM and 44.7 per cent Prevention education Prevention 39.6 between was 2006 during programs prevention of terms in groups high-risk of Coverage females, at 43.8 per cent (UNAIDS, 2010a). No breakdown of those on ART by high-risk group group Almost a quarter (22.2%)high-risk of menby with ART HIV were on This receiving figureART. was higherthose for of breakdown No 2010a). (UNAIDS, cent per 43.8 at females, ART. receiving reportedly per cent of PWID living with HIV are Six was available. HIV anti-retroviral treatment HIV anti-retroviral Data on HIV testing in the general community were not available. However, during 2005, 50 50 2005, during However, available. not were community general the in testing HIV on Data (35.7%) one-third per than cent of male sex More workers and 25 per cent of female sex workers reported having been 2010a). (UNAIDS, results their knew reportedly and HIV for tested results. their knew and tested been also had PWID female of cent per 41.5 and PWID male of HIV testing 86 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia that Lao is becoming a major transit country for ATS and precursor chemicals, with traffick majority of ATS pills are thought to originate in nearby Myanmar, although there are reports 2010b). Crime, and The Drugs on Office Nations (United 2008 in million 1.2 to compared on Drugs and Crime, 2010b). However, more than two million ATS pills were seized in 2009, There were no reports of the manufacturing of any type of ATS in Lao (United Nations Office Manufacture, trafficking andseizures reports ofMDMAorcrystal methamphetamineare recorded. the type of ATS is not specified, it could be assumed that dependence is on ATS pills, as no 2010b). Although Crime, and Drugs on Office Nations (United ATS on dependent people ATS pills are the most commonly used drug in Lao and there are an estimated 35 Amphetamine-type stimulantuse natory totheIDADIN. sig- isa PDR Lao west. the to Thailand and south, the to Cambodia east, the to Nam Viet of 730 single-party state, with a population of 6.6 million. The capital, Vientiane, has a population communist, a is PDR), (Lao Republic Democratic Lao People’s the as known officially Lao, Democratic Republic Lao People’s Between 2008and2009,arrests forATS pills in2009increased by 60percent. 94 per cent reported in 2006 and 2007 (United Nations Office on Drugs and Crime, 2010b). decreasefromthe a 2009, arrestsin total 81 of to ATSpillscent amounted Arrestsfor per Drug-related arrests there were noavailable data. reported injecting drug use. Injecting is also thought to occur among MSM populations but cent per 3 which of drugs,use to thought are cent per 40 workers, migrant male Among used drugs and half reported injecting (United Nations Office on Drugs and Crime, 2010b). cent of Chinese migrant workers inject drugs. Among female migrant workers, 3.9 per cent of HIV (27%) (Laos National Committee for the Control of AIDS, 2010). An estimated 2 per ing among those living on the Lao–Viet Nam border is high and accompanied by high rates inject- that However,concern 2009). isthere al., et (Phimphachanh province(n=220)) the 19–25 year-old current and former users of ATS (0.9% in the capital (n=223), and 1.8% in among injecting of rates minimal found Vientiane of province the and Vientiane capital the in usersATS of study quantitative One limited. are Lao in use drug injecting on Data Injecting druguse ing of drugs from Myanmar to Thailand (United Nations Office on Drugs and Crime, 2010b). 000. Lao is a landlocked country bordered by Myanmar and China to the northwest,

000–40

000 - Lao People’s Democratic Republic 87 - - pro no prevention are there However, National Committee of for AIDS, the 2010). Control PWID. targeting grams Prevention education Prevention interventions, and HIV is groups, targeted towards comprehensive prevention marginalised including peer-led behaviour change, have been delivered to MSM and sex workers (Laos available in four provinces in Lao (Hagarty, 2010). Three hospitals provide OST for approximately approximately for OST provide hospitals Three 2010). (Hagarty, Lao in provinces four in available 2010). (Hagarty, centres in two drug treatment available reportedly 64 women and OST is Harm reduction needle of reports no and programs syringe and needle government-sanctioned no are There Limited OST for opiate dependency is 2010). NGOs (Hagarty, from and syringe distribution Coverage of ART in Lao is estimated at 100 per cent (Mesquita et al., 2008). However, there there However, 2008). al., et (Mesquita cent per 100 at estimated is Lao in ART of Coverage HIV ART. receiving users ATS on HIV-positive no data available are HIV anti-retroviral treatment HIV anti-retroviral portion of MSM reportedly tested for HIV tripled to 22 per cent between 2006 and 2008. there are no data on However, testing among PWID groups since they are not included as 2010). activities (Hagarty, in sentinel surveillance a population group HIV testing of high-risk groups HIV testing of high-risk testing specialised sites There for are now sex 110 workers and MSM in Lao, and the - pro 5.6 per cent, although no report other HIV regions among population. this Among female sex workers, HIV prevalence is around 1 per cent (UNAIDS, There 2010a). are no data on HIV among PWID. The population HIV prevalence in Lao is 0.2 per cent. Among high-risk groups, however, prevalence is Among considerably higher. MSM in the capital Vientiane, HIV prevalence is HIV in the community and among injecting drug users and among injecting drug HIV in the community Compulsory drug treatment centres providing ATS treatments are located in seven prov inces of figuresLao. wereHowever, available for only one centre in the capital Vientiane, where 95 per cent of admissions were for ATS users (United Nations Office on Drugs and no are harm services There and reduction in centres no treatment informa- Crime, 2010b). programs. treatment ATS tion regarding Drug treatment 88 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia than 100 than in Malaysia. This is supported by the seizure of large quantities of precursor chemical. More SMART Program Global reported The that 2010b). a significantCrime, quantity ofand crystalDrugs methamphetamine on is being producedOffice Nations (United 2008 in down Eleven ATS manufacturing operations were dismantled in 2009, one less than the 12 closed Manufacture, trafficking andseizures for thefirst timeinMalaysia in2008(UnitedNations OfficeonDrugs andCrime, 2010b). reported was crystal of 2010b). injection Crime, The and Drugs on Office Nations (United 2009 and 2008 between cent 10byper increasedpills ATS and methamphetamine crystal of use the Malaysia, in concern most of drugs the remain cannabis and heroin Although Amphetamine-type stimulantuse population 14years orunderandamedianageof23.8years. Malaysia’s of one-third than more with young, predominantly is structure age population Lumpur.The Kuala capital, the in live whom of million 1.6 million, 28.1 of population a ritories. It shares borders with Thailand, Indonesia and Brunei Darussalam. The country has Malaysiais federala constitutional monarchy consisting threeand states 13 federalof ter- Malaysia 2009, only8percentwere forATS drugs (1131 forcrystal and84foramphetamine). and 2009 (United Nations Office on Drugs and Crime, 2010b). Of all drug-related arrests in Drug-related arrests for amphetamines (type not specified) and ATS declined between 2008 Drug-related arrests (United Nations OfficeonDrugs andCrime, 2010b). werecrystalavailablemethamphetamine inject who people of number the of estimates no 2010b). Crime, Drugsand and on 2009 first crystalOffice in was of reported injection The 170 the to 195 to 205 of mean a between vary Malaysia in PWID of number the of Estimates Injecting druguse Nations OfficeonDrugs andCrime,2010b). sia from Myanmar, most of the crystal methamphetamine is produced domestically (United While the majority of the ATS pills and small quantities of crystal are trafficked into Malay- of ATS is ofconcern. manufacture the in involvement criminal transnational of reports in 2010b).increase The Crime, and Drugs on Office Nations (United 2008 in seized that half was seized pills of crystal methamphetamine seized in 2009 was almost double that in 2008, while the number

000 in 2006 and 235 and 2006 in 000

000 ATS pills and 1160kg of crystal were seized during 2009. The quantity of of quantity The 2009. during seized were crystal 1160kg of and pills ATS 000 000 PWID reported in the 2010the reportedin PWID Program Nations000 SMART report(United Global

000 in 2009 (Hagarty, 2010). The 2009 figure is in contrast in is figure (Hagarty,2010). 2009 2009 The in 000

000 in 2002 2002 in 000 Malaysia 89 710 cumulative cumulative 710

645 people were admitted to drug treatment, the vast majority

based rehabilitation to voluntary open access services for drug users, their families families their users, drug for services access open voluntary to rehabilitation based Prevention education Prevention for secondary school students in 20 schools. piloting HIV life skills currently is Malaysia ART is available in Malaysia, however no details of ART for PWID are reported (World Health Health (World reported are PWID for ART of details no however Malaysia, in available is ART 2010b). Organization, fewer returning for the results. fewer returning treatment HIV anti-retroviral figures for 2008–2009 indicated that only one-third of PWID and 20 per cent of sex workers workers sex of cent per 20 and PWID of one-third only that indicated 2008–2009 for figures Malaysia 2010). Health, of Ministry (Malaysia results the knew and HIV for tested been had reports that increased availability of testing had resulted in more people being tested but HIV testing that reported was it period 2006–2007 the In sites. NSP from referral by is PWID for Testing However, results. their knew and HIV for screened been had MSM and PWID of cent per 100 per cent resulted from sexual HIVtransmission. among PWID is 22 per cent and the vast per 22 indicated groups high-risk of surveys Behavioural 2010a). (UNODC, men are majority and 4 per cent of MSM. of sex workers per cent 11 infected with HIV, cent of PWID were workers, sex female use, drug injecting by driven be to said is Malaysia in epidemic HIV The people. MSM and transgender cases reported since 1986 (UNAIDS, 2010a). Until 2008, 70 per cent of HIV infections were were infections HIV of cent per 70 2008, Until 2010a). (UNAIDS, 1986 since reported cases thought to be the result of injecting Reid drug & use (Devaney, Baldwin, 2006). However, 2009 data suggest that 55 per cent of new infections were the result of injecting and 32 HIV in the community and among injecting drug users HIV in the community and among 87 with cent per 0.5 is population general the among HIV of prevalence The There are no ATS-specific drug treatment services in Malaysia and mostATS users enter centres. community drug treatment and their employers. More Cure and Cure Clinics More Care in are the of and process being their opened employers. across the A country. total of 15 Crime, 2010b). and Office on Drugs Nations of them men (United Malaysia’s drug laws are among the most stringent in the world and compulsory centres of Malaysia the Government until (n=28) run 2009. were the by In government July 2010, opened the first Cure and Care Clinic. The Cure and Care Clinics areinstitution- ashift away from Drug treatment 90 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia munication, DrBergenstorm, June2011). As of 2010, the Government of Malaysia reported 10 per PWIDyear (Hagarty, 2010). syringes and needles (7–13) 9 of rate a at sites distribution needle 23 by distributed were syringes and needles million 2 than 2010). More (Hagarty, NGOs by run many Malaysia, across sites NSP 240 now are There PWID. programs for condom and NSPs both for calls Malaysia adopted a harm reduction approach in 2005 and the Third National Strategic Plan Harm reduction

664 active OST patients (personal com - Myanmar 91 - - - 400 bottles of

were seized (United Nations Office on Drugs and Drugs on Office Nations (United seized were 7

Meth/amphetamine powder is concentrated meth/amphetamine used in the manufacture of in the manufacture used meth/amphetamine concentrated Meth/amphetamine powder is 339kg will yield 3.7 million meth/amphetamine pills. meth/amphetamine pills: 7 ing Injecting countries of are concern (United OfficeNations on and Drugs Crime, 2010b). for heroin. of administration the major route is Injecting drug use neighbour in injecting of levels high but Myanmar, in ATS of injecting reported no is There ing 2009. Increased interventions targeting precursor drugs are likely to result in alternative alternative in result to likely are drugs precursor targeting interventions Increased 2009. ing India, from Myanmar into trafficked are drugs Precursor used. and sought being precursors and Crime, 2010b). Office on Drugs China and Thailand (United Nations There was also a marked increase in the seizure of precursor chemicals in 2009 (United Nations Nations (United 2009 in chemicals precursor of seizure the in increase marked a also was There Office on Drugs and Crime, More than2010b). 1600kg of ephedrine, 122 - dur seized were tablets ephedrine-containing million 9.4 and drops nasal ephedrine-based methamphetamine and 3.9kg ATS powder) is thought to pres be thepolitical to result Due of pressure control. being government under come to groups ceasefire ethnic on exerted into Thailand. stocks ATS moved have many manufacturers sure, - meth crystal of 124kg pills, ATS million 23.9 2009, In markets. non-domestic for destined powder ATS of 339kg and amphetamine Manufacture, trafficking and seizures trafficking Manufacture, is which of much meth/amphetamine, of manufacturer major a is Myanmar above, noted As be restricted to ATS pills wealthier in users. Myanmar are typically smoked and there is no 2010b). Crime, and Drugs on Office Nations (United methamphetamine crystal of use reported (Devaney, Reid (Devaney, & Baldwin, 2006). While heroin and opium rank one and two respectively China, near areas border in especially pills, ATS of use increased the used, drugs of terms in Lao PDR and Thailand, is of concern (United Nations Office on Drugs and Crime, 2010b). ATS pills in these areas are cheaper than those in major cities where their use appears to Myanmar is a major manufacturer of ATS pills and, while much of this production is for demand domestic in increase recent a been has there countries, neighbouring to trafficking Amphetamine-type stimulant use Amphetamine-type Myanmar was once considered the world’s second-largest producer of opium, although sus although opium, of producer second-largest world’s the considered once was Myanmar Reid (Devaney, produced currently amount the reduced have activities eradication crop tained (United ATS of producers largest the of one considered also is Myanmar 2006). Baldwin, & and Crime, 2010b). on Drugs Office Nations Myanmar Myanmar is bordered by China in the northeast, Lao PDR in the east and Thailand in the a signatory to the IDADIN. is southeast. Myanmar Myanmar Crime, 2010b). The 2008 massive increase over seizures (ATS pills Crime, 1.1 2010b). million, 14kg crystal 92 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia HIV inthecommunityandamonginjectingdrugusers not available. run by the United Nations and non-government organisations), though data on these were users receive treatment through private facilities (psychiatric 2010b).ATS Most Crime, wards,and Drugs on private Office Nations clinics (United andATS for centreswere (n=23) cent per 2 only 2009 in admissions1000treatment than more of use: opiate on focus centres treatment69 centres 2010b). DrugsNations Crime, on (United and Office these in Services drug treatment for those found in possession of drugs and the Ministry of Health operates compulsory has Myanmar term. five-year gaol a usersface registerrequiredareDrug or to Drug treatment cent since2007. per 34 by increased have ATS for Arrests women. were ATS for arrested those of quarter 2010b). Crime, One- and Drugs on Office Nations (United meth/amphetamine) crystal for Of more than 3400 drug-related arrests, 26 per cent were for ATS (995 for ATS pills and six Drug-related arrests mar, while76 000require ART(Myanmar Ministry ofHealth,2010). According to the UNAIDS Progress Report 2010, 29 HIV anti-retroviral treatment PWID were testedforHIV, afraction oftheestimated 90 000–300000PWIDinMyanmar. coverage1731cent 2008, per lower,(Devaney,During 7 2006). only Baldwin, with & Reid & Baldwin, 2006). However, the figures for testing for HIV among PWID were considerably sex workers and 50 per cent of MSM received testing and counselling for HIV (Devaney, Reid There has been an increase in testing for high-risk groups. In 2009, almost three-quarters of HIV testing heroin/opium is amajorconcern,soATS injectioncouldincrease. low,of be injection to thought areMyanmar in injection ATSlevels of Although PWID. to due be to thought are Myanmar in cases HIV all of 2010a). One-third (UNAIDS, MSM in cent per 28.8 and workers sex female in cent per 18.1 prevalenceishigh-riskgroups, HIV per cent of PWID infected (United Nations Office on Drugs and Crime, 2006). Among other 80 to up showing data surveillance sentinel higher, evensome is prevalence centres ment prevalence may be 38 per cent (United Nations Office on Drugs and Crime, 2010b). In treat Myanmar has a population HIV prevalence (15–49 years) of 0.6 per cent; among PWID the 825 people are receiving ART in Myan- - Myanmar 93 heroin/ between particular in groups, drug-using of mixing the on information no was There opium users and ATS users, leading to risks of injecting initiation. Little is known about women. need to target and services female drug users, than the intended target (Devaney, Reid & Baldwin, 2006). (Devaney, than the intended target Concerns Prevention education in schools promotes abstinence from drugs and emphasises the dan- and emphasises drugs abstinence from promotes education in schools Prevention less cent per 30 PWID, 8274 reached PWID targeting education Prevention use. drug of gers Prevention education Prevention majority were provided in four townships Harmonly. reduction services that do exist are oriented towards males and female PWID are not encouraged to access these services. No of details injection In available. of 2008, were ATS OST 580 (World clients Health received 2010b). Organization, Harm reduction in Myanmar is still in its infancy. By 2005 a number of still international in is non- its in infancy. Harm Myanmar reduction lack the address to beginning were projects UNAIDS-funded and organisations government of harm reduction services for PWID. An estimated 3.5 million sterile injecting units were The 2010b). Organization, Health (World 2007 in than more two-thirds 2008, in distributed Harm reduction 94 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia Precursor chemicals such as ephedrine and pseudoephedrine are trafficked into the Philip- the aretrafficked into pseudoephedrine and ephedrine Precursoras chemicalssuch Drugs andCrime,2010b). laboratories have been closed down and 2057kg of largesmallerto units ATSmanufacturing are32 which 1997, ones Since conceal. to easier movefroma been alsoareas. has Thereurban in detected again was manufacturing 2009 and 2008 However,in detection. avoid to areas rural to urban from moving laboratories 2006 and 2007 appear to have had an effect on crystal methamphetamine production with were seized (United Nations Office on Drugs and Crime, 2010b). Law enforcement efforts in During 2009, 149kg of crystal methamphetamine and 832 litres of liquid meth/amphetamine Manufacture, trafficking and seizures Office onDrugs andCrime,2010b). Polydrug use is commoninthePhilippines. lion estimated in 2004. An estimated 62 per cent of drug use involves ATS (United Nations number of drug users was 1.7 million, although this figure is markedly less than the 6.7 mil estimated the 2008, In snorted. alsois drug the that suggests Programreport SMART bal ‘shabu’ and typically smoked (United Nations Office on Drugs and Crime, 2010b). The Glo- as referredto methamphetamine crystalis Philippines the in concern of drug primary The Amphetamine-type stimulantuse population of1.66million.ThePhilippinesis asignatorytotheIDADIN. The Philippines is a republic with a population of 92.3 million. The capital is Manila with a Philippines ATS treatment programs were available. (90%) were male (United Nations Office on Drugs and Crime, 2010b). No details of specific treatment centres indicate that most clients used multiple illicit drugs and the vast majority in 2009 is significantly lower than the almost 5000 ATS-related arrests in 2005. Data from arrested those of five constantover number past years,been the the ATShas although for phetamine (United Nations Office on Drugs and Crime, 2010b). This pattern of drug arrests More than half of all treatment admissions (n=2863) in 2009 (59%) were for crystal metham Drug treatment (United Nations OfficeonDrugs andCrime, 2010b). methamphetamine crystal for cent per 73 arrests, drug-related 9052 were there 2009, In Drug-related arrests Reid &Baldwin,2006). & Baldwin, 2006). No details of the number of PWID injecting ATS were available (Devaney, isPhilippines in PWID of number 14 estimated and The 7000 between Injecting druguse Nations OfficeonDrugs andCrime,2010b). pines from China and India, and East Asian drug syndicates are known to be involved (United shabu seized (United Nations Office on 500 (Devaney,500 Reid - - Philippines 95 000 units in 2009,

Additionally a lack of support for harm reduction in the Philippines hampers HIV prevention prevention HIV hampers Philippines the in reduction harm for support of lack a Additionally groups. among high-risk Concerns concern. a is Philippines the in ATS of manufacturing the in syndicates crime of Involvement The 2009 national behavioural survey indicated that 85 per cent of PWID surveyed (n=958) surveyed PWID of cent per 85 that indicated survey behavioural national 2009 The sterile equipment during the last injecting event. used these organisations these are organisations vulnerable to arrest because of the laws governing the possession of drug-injecting equipment. Only medical officers are legally allowed to be in possession of injecting equipment. in the outreach area. These distributedorganisations an estimated 50 an average of three needles and syringes per PWID per year. Although non-government organisations are encouraged to be involved in harm reduction activities, workers within Harm reduction Possession of needles and syringes is illegal in the Philippines. Needles and syringes are available from pharmacies and a small number of working non-government organisations Prevention education Prevention of cent per 29 workers, sex female of cent per 55 that indicated survey behavioural 2009 A education per (Philip- cent of PWID with had HIV been prevention reached MSM and 11.5 PWID was reported. education targeting No prevention pine National AIDS Council, 2010). HIV anti-retroviral treatment HIV anti-retroviral was available. groups ART for high-risk of No information on the availability of the test in 2009 Testing (UNAIDS,was more 2010a). common, but still for low, female (19%) and MSM (7%). sex workers HIV testing HIV testing facilities are available across the Philippines, although none targets PWID in result the knowing and HIV for tested being reported PWID of cent per 1.5 Only particular. reportedly due to unsafe sex (MSM 29%; heterosexuals 55%; bisexuals 15%). Around one- Around 15%). bisexuals 55%; heterosexuals 29%; (MSM sex unsafe to due reportedly Council, 2010). to PWID (Philippine National AIDS attributed fifth were (31%) of all new infections in the country were detected in 2008 to 2009 (UNAIDS, 2010a). (UNAIDS, 2009 to 2008 in detected were country the in infections new all of (31%) Of cumulative HIV cases reported between 1984 and 2009, the vast majority (90%) were Population prevalence of prevalence HIV Population in the Philippines is less than 0.1 per cent (UNAIDS, 2010a). Office Nations (United cent per 0–7 be to estimated but scarce are PWID among HIV on Data on Drugs and Between Crime, 1984 2010b). and 2009, 4424 individuals were reported to the Philippine HIV and AIDS Registry (Philippine National AIDS One-third Council, 2010). HIV in the community and among injecting drug users and among injecting drug HIV in the community 96 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia border surveillance rather thananincrease intrafficking. 10in increasedseparateresultevents.of the ATSbe increaseseizuresin to The is thought seized werepillsATS million 1.24 2009, In seized. was crystal of 3.7kg total a when 2009 Seizures of ATS have increased over the past four years from 96 incidents in 2004 to 268 in country from eitherMalaysia orThailand. the into trafficked are drugs most and occur not does Singapore in manufacturing ATS Manufacture, trafficking and seizures amine meth/amphet of use the although Singapore, in drug used commonly most the isHeroin Amphetamine-type stimulantuse and studythere. Foreign workers makeup50percentoftheservicesector. Caucasians.and Singapore’sof Morecent per 40 than arepopulation foreigners work who 5 to close of lation Singapore is a parliamentary republic with a population of 4.5 million. It has a diverse popu Singapore 8 these arrests, 80percentwere males. Of 2007. 221 in and 208 in 306 from up 2009, in ATS to related arrests 357 were There Drug-related arrests tion. Nodetails oftheextentinjectingwere reported. administraof - mode secondary a is injecting smoked;isSingapore in ATS of majority The Injecting druguse 2005. However, specific details were notavailable. in Singapore in introduced first was ATS, including drugs, synthetic for Treatment 2009. in 143 and 2008 in 87 2005, in 39 to 2004 in zerofrom steadily risenhaveATS for sions admis Treatment treatment. receiving those all of cent per 23 and admissions treatment new of one-third than more for admissions.usersaccounted ATS new were101 whom of Just over 530 individuals were undergoing compulsory drug treatment in Singapore in 2009, Drug treatment Drug statistics inSingapore donotdifferentiate betweenATS andcrystal methamphetamine. 8 hasincreased annuallyover thepastthree years. million people of Chinese, Malays, Indians, Asians of variousdescents,Malays,Indians,of Asians Chinese, of people million - - Singapore 97 000 000

Harm reduction in Singapore. available not activities are Harm reduction HIV prevention education is targeted at the general population and emphasises the risks Singapore associated with casual groups. sex and the of for promotes use condoms at-risk discrimination. and stigma HIV-related reduce to designed campaigns educational has also aim to of awareness increase School HIV programs and AIDS and Sex the of use condoms. use the promote and awareness raise to campaigns of target the also are MSM and workers organisations. non-government by mostly administered are These programs of condoms. Prevention education Prevention HIV anti-retroviral treatment HIV anti-retroviral available. were but no details in Singapore available is ART treatment Subsidised Anonymous testing is available for high-risk groups. In the 2008–09 period, more than 18 than more period, 2008–09 the In groups. high-risk for available is testing Anonymous positive. per cent were performed, of which 1.2 tests were HIV anonymous HIV testing The majority of HIV cases in Singapore are the result of sexual transmission (66%) and only and (66%) transmission sexual of result the are Singapore in cases HIV of majority The 2 per cent are the result of PWID. This is thought to be due to the stringent drug laws in Singapore (there are only 330 registered PWID in Singapore). The population prevalence one- 2008, In male. are cases of cent per 90 and cent per 0.09 is older) and years 15 (aged among PWID. among MSM and 4 per cent were of new cases third HIV in the community and among injecting drug users and among injecting drug HIV in the community 98 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia ATS, whileinChiang Maithefigure waslowerat32percent(Yongvanitjit et al.,2010). tions in the injection of ATS are evident: in Bangkok, 63 per cent of PWID usually injected stances does occur (United Nations Office on Drugs and Crime, 2010b). Geographical varia- sub- these both administrationof of pillscrystalinjection both and methamphetamine, of AIDS Prevention andAlleviationCommittee,2010). students and almost 25 per cent of male vocational students had used ATS (Thailand National A school drug use survey conducted in 2008 revealed that 12 per cent of male high school survey is importantwiththe‘warondrugs’ commencingin2003. 2006). These numbers represent a decline in ATS use from 2001 but the timing of the 2001 and half a million had used ATS in the 30 days prior to interview (Devaney, Reid & Baldwin, A 2003 National Household Survey estimated that 3.5 million Thai people had ever used ATS were themostcommonlyused illicitdruginthecountry. pillsATS that and Thailand in concern of drug ranked one number the as cited was form, is also increasing. The UNODC report (2010b) noted that in 2009 meth/amphetamine, in pill Thailand since the mid-1990s and there is evidence that in the useconcern most of of crystal drug methamphetthe been has (2010b),methamphetamine UNODC to According Amphetamine-type stimulantuse to thesouthby Malaysia. Thailandis asignatorytotheIDADIN. island bordered bynorth the to Myanmarby east the and to Lao, Lao, and and Cambodia Thai- million. 7 of population a has Bangkok, monarchy.constitutionalcapital, a The has It million. 65 of population a has Thailand, of Kingdom the as known officially Thailand, Thailand There are an estimated 30 estimated an areThere Injecting druguse other marketsbothinAsiaandoverseas. thisisuseisfor of some domestic supply destined Some and Myanmarfor Cambodia. and from originates methamphetamine Crystal (10%). PDR Lao from coming amounts smaller with (80%) Myanmar from originate to thought are Thailand in pills ATS of majority The meth/amphetamine (UnitedNations Officeon Drugs andCrime,2010b). crystalmanufactureof the reportsthereweredismantledof aresmallno and 2009 edly in While there is evidence of ATS manufacturing in Thailand, most of the laboratories report- mar, theresult ofpoliticalunrest inthearea. increasesthese that aresuggests increased UNODC with associated trafficking from Myan- 2009. in 209kg to 2008 in from52.9kg alsoincreasedsubstantially methamphetamine tal 2010b). Crime, Drugs and on NationsOffice (United crys2009 Seizures of in - million 26.6 Seizures of ATS pills almost doubled between 2007 and 2009, from 14.4 million in 2007 to Manufacture, trafficking and seizures 000 PWID in Thailand and, while smoking is the primary mode primary the issmoking while and, Thailand in PWID 000 amine Thailand 99 000 000), 000),

000 to 112 to 000

000 individuals in compulsory treatment and 18 and treatment compulsory in individuals 000 000 drug treatment in admissions Thailand in 2009, 82 per cent were for ATS HIV anti-retroviral treatment HIV anti-retroviral no is there ART for those infected with HIV, free committed to providing While Thailand is 2010). PWID (Hagarty, target for services that specifically information available smaller smaller provinces to per 31 cent in major cities such as Bangkok, Chiang Mai and Phuket and Alleviation Committee, 2010). (Thailand National AIDS Prevention brothel-based sex workers and those working in the entertainment industry. Prevalence was was Prevalence industry. entertainment the in working those and workers sex brothel-based AIDS National (Thailand cent per 5.3 at Bangkok in workers sex female direct among higher almost is workers sex male among Prevalence 2010). Committee, Alleviation and Prevention double per at cent. 11 Among MSM, HIV ranging prevalence is from higher, 5 per cent in 1990s when it was estimated to be 28 per cent (Thailand National AIDS Prevention and cent for both of 5 per was in the region By 2009 prevalence Alleviation Committee, 2010). almost 9 per cent of HIV infections were the result of injecting drug use (Thailand National (Thailand use drug injecting of result the were infections HIV of cent per 9 almost Committee, 2010). and Alleviation AIDS Prevention of HIV among The female has prevalence sex declined workers significantly since the mid- to be HIV-positive. According to a 2004 report, an estimated 5 per cent of all HIV infections infections HIV all of cent per 5 estimated an report, 2004 a to According HIV-positive. be to Crime, and Drugs on Office Nations (United use drug injecting of result the were Thailand in 2004).the However, Thailand UNGASS Country estimated Progress report from that 2010 - Surveil in Thailand was 1.5 per cent in 2003 (UNAIDS, 2010a). HIV prevalence Population (UNAIDS, 2009 for cent per 38.7 was PWID among prevalence HIV that indicate data lance of one-third those around in drug in treatment Thailand thought are Additionally, 2010a). and behavioural, educational and 12-step counselling (Devaney, Reid & Baldwin, 2006). (Devaney, counselling educational and 12-step and behavioural, groups high-risk HIV in the community and among institutions, religious organisations and NGOs. Thailand also has 90 compulsory centres and and centres compulsory 90 has also Thailand NGOs. and organisations religious institutions, (World 2010b). Health in Organization, Thai available prisons are programs drug treatment 67 than more were there 2009 During in voluntary treatment. for Treatment ATS is described as a combination of detoxification pills and 0.8 per cent were for crystal methamphetamine (United Nations Office on Drugs and and Drugs on Office Nations (United methamphetamine crystal for were cent per 0.8 and pills available Thailand in centres treatment voluntary 1000 than more are There 2010b). Crime, psychiatric practitioners, general centres, treatment drug specialised hospitals, general through Drug treatment Of the 106 than 1000 in 2006 to almost 3000 in 2009. However, arrests for crystal methamphetamine crystal for arrests However, 2009. in 3000 almost to 2006 in 1000 than arrests. per cent of all drug-related account for only 2 ATS pill-related arrests decreased by 6000 between 2008 and 2009 (from 118 (from 2009 and 2008 between 6000 by decreased arrests pill-related ATS for account and 2010b) Crime, and Drugs on Office Nations (United overall high remain but methamphet crystal for Arrests 2009. in Thailand in arrests drug-related all of cent per 83 more from risen had This arrests. 265 were there when 2004 since annually risen have amine Drug-related arrests Drug-related 100 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia reported tohave beenimplemented(Devaney, Reid&Baldwin,2006). are MSM programsfor condom and areas some in workers sex Thai among implemented transgenderand persons provinces.some in 100A usecondom cent per program been has workers sex female and male to education prevention HIV providingvolunteers peer with skill-based education programs are being implemented. There is evidence of peer education While direct drug prevention education has not been implemented in schools in Thailand, life Prevention education programs are operated by NGOsandthrough somepharmacies(Hagarty, 2010). and syringes are nevertheless available in the city of Bangkok and 15 other provinces. These Although needle and syringe programs are not supported by the Thai Government, needles Harm reduction Viet Nam 101 - 000 pills pills 000 000 drug-related arrests. Unfortunately drug arrests Unfortunately drug arrests arrests. 000 drug-related 000 people who inject drugs (0.25% prevalence among 15–64 15–64 among prevalence (0.25% drugs inject who people 000

000 drug users in treatment in 2009, 98 per cent were admitted for opiate opiate for admitted were cent per 98 2009, in treatment in users drug 000

drug treatment for ATS was not available. for ATS drug treatment Viet Nam has 70 provincial drug treatment centres and more than 700 drug treatment units units treatment drug 700 than more and centres treatment drug provincial 70 has Nam Viet United at Nations the Office 2010; district onlevel (Hagarty, Drugs Of and Crime, 2010b). 65 estimated the use and 1 per cent for ReidATS use (Devaney, & Baldwin, 2006). Information on specific Drug treatment Drug-related arrests Drug-related 2010b). Crime, than 25 more and were During 2009 there Drugs on Office Nations (United gender or type drug by separated not were year year olds), mostly injecting heroin and to a lesser extent opium (United Nations Office on was available. the injection of ATS No information on and Crime, 2010b). Drugs Injecting drug use 125 estimated an has Nam Viet in activities involving international criminal drug organisations, in particular from Africa and Crime, 2010b). Office on Drugs (United Nations quantity of ATS is manufactured in Myanmar and trafficked by land through Cambodia and and Cambodia through land by trafficked and Myanmar in manufactured is ATS of quantity 500 plus pills of 6kg and methamphetamine crystal of 4kg Almost Nam. Viet into increase the with concerned also is country The Nam. Viet for seizures in increase significant Manufacture, trafficking and seizures trafficking Manufacture, unspecified but large a that reports (2010b) Crime and Drugs on Office Nations United The 2010b). The 2010b). use of ATS pills is also reported to be high among construction and mining industry. and those in the transport workers Nations Office on Drugs and Crime, 2010b). The use of crystal methamphetamine was first methamphetamine wasuse first of crystal The and Crime,Office 2010b). on Drugs Nations in recorded Viet Nam in 2008 and most crystal methamphetamine are young people users Crime, and Drugs on Office Nations (United Hanoi and Minh Chi Ho as such cities in living were seized in 2009 (United Nations Officerepresents a on This Drugs andCrime, 2010b). While heroin and opium remain the drugs of most concern in Viet Nam, the use of both crystal methamphetamine and ATS pills is increasing. ATS collectively are the third ranked drugs of concern. In 2009 ATS drug users comprised 4 per cent of all drug users (United The capital is Hanoi with a population of 6.5 million. Viet Nam is a signatory to the IDADIN. the to signatory a is Nam Viet million. 6.5 of population a with Hanoi is capital The stimulant use Amphetamine-type The Socialist Republic of Viet Nam has a population of 86.1 million. The country is bor dered by China in the north, Lao PDR to the northwest and Cambodia to the southwest. Viet Nam Viet 102 Amphetamine-type stimulant use and blood-borne viruses in Southeast Asia tected sex, in particular among young men, is considered to drive the epidemic in Viet Nam. cent of MSM are HIV-infected. The interaction between unsafe injecting practices and (Viet unpro Nam Ministry of Health, 2010). Approximately 4 per cent of highfemale risk of sexexposure to workersHIV: injecting drug users;and sex 9 workers andper their partners; and MSM 2010b). Viet Nam’s HIV epidemic is concentrated among key populations consideredCrime, and Drugs on Office Nations (United to cent per is29 be PWID among at infection HIV of responsible for 55–70 per cent of HIV cases in Viet Nam and the overall estimated MinistryNam Health,2010).of prevalence unsafeThe injectionheroinof opiumisand bethought to The population HIV prevalence in Viet Nam is 0.53 per cent equating to 132 HIV inthecommunityandamonginjectingdrugusers all treatment remained highand‘there haveremained limitationsandshortcomings’ (p.9). following rate relapse the that however noted report The treatment. for volunteered who 1900 to comparedtreatmentcompulsory for admitted were people 8000 than More (p.6). remedialapplied and staff for capacity methods, concentratedand rehabilitation programs and improved skills treatment, of models socialised’ and ‘diversified developing including rehabilitationimprove and to treatment 2009 in taken been had measures of series a that 2010),MinistryHealth, Nam of (Viet Report Country Nam Viet updated an In noted was it and syringeunits were distributed in2009(VietNam Ministry ofHealth, 2010). 189 needles and syringes per PWID per year. Between 20.5 million and 34.9 million needle During 2009 up to 95 per cent of PWID accessed needle and syringe programs at a rate of Harm reduction a condomonthelastsexual encounter. The figure for MSM was lower at 61 per cent, while only one-third of PWID reported using on the last sexual encounter among male and female sex workers was high at 97 per cent. preventionHIV in participated programs 2010).MinistryHealth, Nam of (Viet useCondom Two-thirds of FSW, one-quarter of MSM and 43 per cent of male PWID are reported to have Prevention education dred PWID(UNAIDS,2010a). Treatment is available for PWID infected with HIV but participation is low at four per hun- treatmentneeding were2010).those Ministry Health, of Nam receivingof cent (Viet per it 28 only 2007 in although Nam, Viet in provinces 64 all in available is HIV for Treatment HIV anti-retroviral treatment (Viet NamMinistry ofHealth,2010). results the knowing and 11HIV and for respectively16 tested cent 15, being reportedper PWID, male and FSW,remainslow. MSM groups high-riskAmong among HIV for Testing HIV testing

000 cases (Viet -