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INTRODUCTION
LITERATURE REVIEW
OBJECTIVES
METHODS
Study Design
Sample Selection
Inclusion Criteria
Exclusion criteria
Procedures
Assessment
Statistical Analysis
2
RESULTS -Sociodemographic profiles
General
Ethnicity distribution
Religion distribution
Marital Status
Level of Education
Employment
Income
Sexual Contact
Blood Transfusion
RESULTS – Psychiatry
Substance-related Disorders
3
Opioids consumption
Cannabis consumption
Amphetamines consumption
Sedatives consumption
Alcohol-related Disorders
Summary Table
DISCUSSION
Sociodemographic profile
CONCLUSIONS
RECOMMENDATIONS
LIMITATIONS
REFERENCES
ACKNOWLEDGEMENT
4
INTRODUCTION
The community of prisoners has increased in recent years due to the rise in the
rate of criminal or civil cases. As a result, the prison population has been growing
where six out of 26 prisons receive more than 50% of their maximum capacity1.
The prevalence rate of HIV positive has been estimated about 2.3% among
prisoners in the United States which its prevalence rate is five time higher than
In Malaysia alone, there were about 1,959 HIV positive prisoners from about
5
HIV and psychiatric morbidity
It has been found that there is an association between psychiatric morbidity and
HIV disease. However, it always goes undetected due to the complex interaction
For the general population, in a study done in India about 3.4% of psychiatric
hospitalisations were HIV positive. The psychiatric diagnoses among HIV positive
(11.5%) and dementia (7.5%). 85% of those with seropositives were co-morbid
alcohol dependence.07
In a study done in US, HIV positive women is 4 times higher to get major
depression may influence the progression in HIV infection though the mechanism
remains unknown.
from 4.0%-18.4%.09
medication.
6
A smaller number of patients require treatment for psychoses, including the
dementia.11
medicines used to treat other HIV-associated illnesses12 are also a real concern.
There is a study to show that the use of protease inhibitor use has been
It is possible that a number of separate etiologic factors act jointly and lead to this
In the United Nation Basic Principles for the treatment of Prisoners it states that
the prisoners shall have free access to the health care services without
In Sao Paolo, Brazil, 14% of prisoners were HIV positive. 16 In Russian prisons,
there were a rapid increase of HIV-positive prisoners in year 2000, from 2500 to
17,18
3500. In a survey done in 1989, it has been found that about 18% of
7
In the year 2000, there were 12061 high risk prisoners in Malaysia. Out of this
numbers, 1488 or 12% of the prisoners were confirmed HIV positive. 20 High risk
prisoners were those who have been detained under Dangerous Drug Act, those
there was 76.2% of HIV infection cases occurred among intravenous drug users
The screening tests of HIV were compulsory for high risk prisoners. For non high
risk prisoners they were given option for undergoing the test. The prisoners
would be given counselling pre- and post-HIV test. Consent for the test by the
prisoners was also required the test were done. The tests were done on
admission and, 6 months after admission and prior to discharge from the
prison.21
In Malaysia, counselling is offered for those who are found to be HIV positive. In
thought.20
In Malaysia, prisoners with HIV positive were given free access to the treatment
which could be in the prison itself or at the nearby hospital. Prisoners with HIV
positive were advised to keep good hygiene. They were not allowed to donate
8
The prison could be an opportunity in improving health e.g. Improvement in
health education. Prison could be the first contact with health service. Health
There are no local data on the prevalence of psychiatric morbidity among HIV
population, those with HIV positive are at the higher risk to get psychiatric illness.
It could be due to the coping towards the illness such as denial, anger, shock or
grief. It has been established that the prognosis of HIV disease is poor and their
9
LITERATURE REVIEW
HIV in general population and prisoners
2004, HIV infection rose to 39.4 million worldwide with 3.1 million deaths from
There were 125.7 per 100000 population infected with HIV in the year 2002 in
the United States. There was an increment of 7% of HIV cases between 1999
and 2002. These cases progressed to AIDS over 12 months period after
diagnosis of HIV was made. Age between 35 and 44 years old accounted for
42% of cases. Among male, 58% of them were homosexual and 31% were
intravenous drug use. This data were reported by the Centre of Disease
Control.24 Intravenous drug use has shown four time likely to be HIV positive if
they had ever shared needles.25 However, among intravenous drug use
prisoners, there were eight times more likely to be HIV positive than prisoners
Routine screening for those with high risk of HIV infection is recommended.
Among those categorized as high risk groups are those have sex man with man,
unprotected sex between man and women with multiple partners, intravenous
drug use, those with sexual transmitted disease and those with history of blood
10
The problem of HIV infection is amplified in the prison where the rate of HIV
prisoners who have been tested for HIV, those under drug offenses are the most
In the prison itself, there are complex of factors that contribute to the greatest
chance of ill health, optimal conditions for infection to progress to severe disease
and minimal opportunity for early diagnosis and adequate treatment. Therefore,
there is high prevalence of hepatitis, tuberculosis, HIV and mental illness among
occur. 30
earlier age, have a higher number of lifetime and recent sexual partners, and
11
HIV and Psychiatric Morbidity
illness.
HIV has also been associated with psychiatric morbidity particularly substance-
sexual activity which may occur in the early stages of schizophrenia and also a
has been shown that female patients with bipolar disorder were more likely to
report high risk sexual behaviours such as sex with intravenous drug users or
users. The psychiatric illness role in predicting HIV infection has to be identified
12
Psychosocial impact of devastating illness of HIV may also lead to psychiatric
morbidity. Issues such as social difficulties, stigma and discrimination have been
important impacts among those with HIV too.38 Besides that life-threatening
illness may also result in depressive illness or anxiety disorders. The feeling of
difficulties with problem solving, and it may be accompanied by apathy and social
cognitive function may also lead to dementia. Anxiety and depression can also
Hence, individual with HIV has been prone towards psychiatric morbidity. There
are numerous studies that showed high prevalence of psychiatric disorder among
13
Depression among HIV positive prisoners is more common than general
population. Those prisoners with HIV positive with depressed mood represent
06
about 80% and Major Depression represent about 10-15%. Evans (2005) et al
described the rate of depression are between 4 and 22% of HIV positive man.
The highest prevalence of depressed mood occurs immediately prior to HIV test
and while waiting for HIV results.45 HIV positive patients who had greater number
with HIV positive also showed faster disease progression.47 Therefore there is
improve functioning and well being. However, other study showed that there is no
marked different between HIV positive and negative population for anxiety
disorders.48
The symptoms of HIV infection such as fatigue, pain, anorexia and insomnia are
common throughout the course of the illness itself. However, in late stage of the
14
neuropsychological impairment.06 Drug abuse which is highly prevalence among
HIV positive population also decreases patients‟ threshold for the development of
psychosis when they are infected with HIV.52 For instances cannabis has been
symptoms.53, 54
It has been shown that high cannabis use is due to relieve
Psychotic disorders in HIV positive patients, psychotic patients had a higher rate
With regard to mania, it may present in 1-2% of early episode of HIV infection.
49,56
However, after the onset of AIDS the rate increases to 4-8%. Manic
symptoms has been closely associated with cognitive changes or dementia due
symptoms has been shown in a study. Therefore, the term „AIDS-mania‟ has
Suicide has also been the cause of death in up to 50% of prison fatalities which
showed that the suicide rates in correctional institution to be 4-11 times higher
suicides. Suicides rates are highest among new prisoners, those prisoners in
among HIV positive the rate of suicide is higher than general population at large.
HIV positive itself can lead to suicidal behaviour especially in the presence of
15
distal risk factors such as childhood trauma or neuroticism. Therefore, the
There are also numerous studies that describe psychiatric illness among
elevated than the rate among community. There was estimation that one in five
incarcerated persons in the United States has major psychiatric illness. This
prevalence rate for depression among male prisoners which showed that female
males‟ prisoners in the study which representing three to four times higher than
England, more than half of them has psychiatric disorders with 5% with psychotic
disorders. In these elderly prisoners, the rates of depression were five times
Philip. George (1996) et al64 who did prevalence study among Malaysian
prisoners at the same prison found that 81.2% has been diagnosed with
psychiatric morbidity. Out of this the distribution of diagnosis was 20.8% with
16
Major Depression, 4% with schizophrenia, drug-related diagnosis with 47.5% and
He also found HIV prevalence was 25% with 30.5% of HIV positive prisoners in
the same prison have psychiatric morbidity in the year 1996. However, he did not
of the attendee had HIV positive status. Among the attendees, 75.7% had
lifetime intravenous drug use and 41.5% had ever shared needle. In study,
lifetime intravenous injection with needle sharing and being Malay had been
services among HIV positive prisoners. There are numerous studies indicating
that by treating psychiatric illness effectively it will give a better outcome of HIV
treatment itself.
17
harm reduction programme also reduce HIV risk behaviours, illicit drug use, and
therapy, supportive group therapy has been town to enhance long term
marginalized in the society. Hence, treatment for HIV that provided in the prison
could also extend the benefit after they are released from the prison. This finding
injection drug use, sexual risk behaviour and infectious disease have contributed
individuals with severe mental illness can be coordinated. There has been
and its correlation with prisoners, to examine the effect of imprisonment and
release from prison on HIV risk behaviour, to find the most effective treatment
18
OBJECTIVES::
Secondary objectives :
and negative
19
METHODS
Study Design:
morbidity.
Sample Selection:
The sample pool came from male section of Kajang Prison, one of the largest
prisons in Malaysia. The prisoners‟ census was obtained from the Prison Record
Office. The census was updated daily as there were daily admissions and
discharges. Therefore, the census on the 8th September 2004 was used to do
selection.
For HIV negative prisoners, sampling interval was applied. Every 20th prisoner on
the census was picked to participate in this study. This would make up 200
The total number of sample of HIV negative prisoners was also 200. Sampling
interval was also used in this group of prisoners. Every second prisoner would be
20
Inclusion criteria:
The duration of the sentenced prisoners in the prison has been more
than 24 hours. There was some difficulty in determining those who was
The age was more than 18 years old. This is the age where one can
Exclusion criteria:
21
Procedures:
prior to the attachment at the prison for conducting this study. Elective
attachment was allowed in the month of September 2004 to conduct this study.
Upon the selection of particular prisoner via sampling interval for an interview, he
was invited to join this study by a security officer at the cell. He was brought to
the investigator‟s room and brief information regarding this study was told to the
prisoner. During interview and in the prison itself, a security officer of the prison
Assessment:
(Appendix II), each prisoner was asked about their sociodemographic profiles
included age, gender, race, citizenship status, religion, marital status, highest
imprisonment.
Risk factors for HIV were also sought from the prisoner which were history of
having sexual contact, intravenous drug use and blood transfusion. Some prison
22
Another part of interview was using a questionnaire, the Structured Clinical
the SCID-I (Appendix III). It has high inter-rater reliability for psychiatric
reliability of alcohol symptoms and disorders and substance use disorders with
kappa value lying between 0.82-0.94. SCID-I has also good validity which has
Investigator has been trained to use this tool during a workshop conducted by
Statistical analysis
All information was compiled into a database, Epi Info 3.3.2 by the Centers for
Disease Control and Prevention. All nominal data were analysed using chi-
square.
23
RESULTS
There were 4430 male prisoners on the month (October 2004) when the study
was conducted. The distributions were those for short stay (less than 6 months
represented 67%, with actively addicted to illicit drugs represented 7%, life
For those with confirmed HIV positive on admission to the prison, they were
isolated in different block from those who were found to be HIV negative. There
were 423 prisoners had been found positive at their entry to the prison. They
were about 10% of the Kajang Prison population. Daily activities were also
The total sample of prisoners who participated in this study was 400 which were
200 with HIV positive and another 200 were HIV negative. Malaysian citizen
The mean age of the subjects was 35.7 (+ 8.5) years old. The mode of age was
37 years old. The mean age for HIV positive prisoners was 37.1 (+ 7) years old
whereas for HIV negative group was 34.2 (+ 9.4) years old. The modal values for
HIV positive and negative were 37 and 28 years old respectively. There was
significantly different age between the mean ages of these two groups (p =
0.0004).
24
Bumiputera prisoners represented 65.3% of the subjects followed by Indian
(Indian and others) in the prison. However, it was not statistically significant.
250
123
200
Frequency
HIV negative
150
HIV positive
100
138
29
50
27
27 35 21
0 0
Bumiputera Chinese Indian Others
Races
Foreigners
25
The rate for HIV positive and negative prisoners for Bumiputera, Chinese and
Indian were comparable. In this study, there was no other races had HIV positive
status.
There were 72.8% of those participated were Muslim, 11.3% were Hindus, 8.8%
69.0% of those with HIV positive prisoners in Kajang Prison whereas Chinese
and Indian prisoners were 13.5% and 17.5% respectively. There was about the
same distribution between HIV positive and negative prisoners for each religion.
26
FIGURE 2: Religion distribution among prisoners
146 145
Frequency
HIV Positive
HIV Negative
22 23
18 17
13 12
1 3
27
Two third of those with HIV positive prisoners were single.
The remaining one third of those with HIV positive had been married or divorced.
140
132
120
108
100
Frequency
80
HIV positive
66
HIV negative
60
39
40
28
26
20
1 0
0
Divorced Married Single Widow
Marital Status
28
Among all prisoners who participated in this study, 65.8% had completed primary
school or until form 3 (15 years old age). Only about a fifth of them held SPM
90
80
70
60
Frequency
50 HIV positive
40 HIV negative
30
20
10
0
ee
e
ol
a
5
M
ol
re
m
ho
rm
ho
gr
SP
lo
th
de
sc
fo
sc
ip
rm
/D
in
to
to
er
y
fo
ar
ld
gh
p
e
o
im
ll
U
on
hi
Ti
ST
pr
g
ng
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to
ng
di
ev
di
ol
U
N
ol
H
H
There were about 66.5% of those with HIV positive status had completed
education between ages of 12-15 years old where another 31.5% completed
education between 16 and 17 years old. This was about the same for those with
29
HIV Positive (%) HIV Negative (%)
at primary school
up to 15 years old
up to 18 years old
higher qualification
FIGURE 4
30
FIGURE 5: Employment status prior imprisonment
160, 40%
240, 60%
Yes No
In the figure 5, there were about 60% the prisoners had been unemployed prior
to the imprisonment, where about 62% (n=123) of those with HIV positive were
31
Frequency
FIGURE 7: Total monthly income among prisoners
90
80 77
HIV positive 69
70
HIV negative
60
50 47
44
36 38
40
30 24 25 24
20 16
10
0
less RM500 RM500-RM799 RM800-RM1199 RM1200-RM2399 RM2400 and above
Estimate total monthly income
It has been shown that in this study, there were about 36.5% of prisoners earned
in the range of RM1200 to RM2399 with overall about 78% of prisoners earned
more than RM800 per month. This income were informed by prisoners which
32
FIGURE 8: PATTERNS OF CRIME AMONG PRISONERS
46
Others
41
38
Against human
5
HIV negative
HIV Positive
38
Property related
33
78
Substance related
121
33
Type of Crime HIV Positive (%) HIV negative Total
Substance related 121 (60.5) 78 (39.0) 199 (49.8)
Property related 33 (16.5) 38 (19.0) 71 (17.8)
Sex related 0 14 (7.0) 14 (3.5)
Violence related 3 (1.5) 12 (6.0) 15 (3.8)
Homicide 0 11 (5.5) 11 (2.8)
Fire Arm 1 (0.5) 1 (0.5) 2 (0.5)
Threats 1 (0.5) 0 1 (0.3)
Others 41 (20.5) 46 (23.0) 87 (21.8)
As shown in the figure 8, 60.5% of HIV positive prisoners had been sentenced for
property related offences had been about the same between the two prisoners
fire-arm and threat had been predominantly higher in HIV negative prisoner
which represented about 19.0% of them as compared to only 2.5% of those with
HIV positive. Surprisingly, in this study there was no foreigner found to be HIV
positive and none of HIV positive prisoners committed sex-related and homicide
offences.
34
FIGURE 9: History of sexual contact among prisoners
Frequency 113
99 101
87
HIV positive
HIV negative
As shown in figure 9, there were more than half of those with HIV positive have
admitted sexual contact in the past. However, among those with HIV negative the
figure was about the same between those who had history of sexual contact and
those who did not have. However, in this study there was no significant different
35
Out of the total of 400 prisoners who participated in this study, about 61% of
With history of
Without history of
IVDU, 243, 61%
IVDU, 157, 39%
36
As illustrated in the figure 11, among HIV positive prisoners, about 94.5% of
them admitted of administering IVDU at some stage in their life. This is possible
the mode of transmission of HIV among them. There were only about 5.5% of
HIV negative, 54
With history of
IVDU
HIV positive, 189
Frequency p=0.0000
In the contrary, 73% of those who were HIV negative had no history of IVDU and
another 27% of those who were HIV negative had injected themselves. There
was odd ratio of 46.45 for those who were in the prison with HIV positive to have
history of IVDU.
37
There were only 11% of all prisoner had ever received blood transfusion at some
stage of their life (figure 12). However, the association between receiving blood
transfusion and HIV positive status was not significant as shown in Figure 13.
There were only 12.5% of those with HIV positive ever received blood
transfusion.
38
FIGURE 13: Prevalence of prisoners who had been receiving blood
183
175
HIV Positive
HIV Negative
25
17
p=0.2
39
FIGURE 14: HISTORY OF CONTACT WITH PSYCHIATRISTS
Had contacted
psychiatrist, 40, 10%
Never contacted
psychiatrist, 360, 90%
Among all prisoners, there was about 10.0% of them had history of contact with
40
As described in methodology, all prisoners who participated in the study were
interviewed using SCID-I. There were about 40% of them had been found to
there was about 40% had lifetime diagnosis of psychiatric illness but only 10%
Presence of psychiatric
diagnosis, 160, 40%
Absence of psychiatric
diagnosis, 240, 60%
41
However, the difference between lifetime prevalence of psychiatric illnesses
among subgroups of HIV positive and negative prisoners was not statistically
different. This is shown in the figure 16. There were 42.0% and 38.0% of HIV
124
Absence of psychiatric
illness
116
HIV negative
HIV positive
76
Presence of psychiatric
illnesses
84
Frequency p=0.4
42
FIGURE 17: Prevalence psychiatric illnesses among prisoners
Bipolar II disorder 1
0
OCD 1
2
Substance-induced 2
Mood Disorder 3
Dysthymia 2
2
Bipolar I disorder 5
2
5 HIV Negative
Cyclothymia
3 HIV Positive
Anxiety Disorder 4
4
Drug induced psychosis 9
10
Adjustment Disorder 19
13
Psychotic Disorder 11
23
Major Depression 17
22
Frequency
43
HIV Positive (%) HIV Negative (%)
(including substance-
induced psychosis)
Among HIV positive prisoners, the prevalence of psychotic disorders and major
depression represented about 27.1% and 25.9% respectively. These were the
the Figure 17. This was followed by adjustment disorder and drug induced
psychosis.
44
There was large proportion of prisoners had been receiving lifetime substance-
related diagnosis. They represented about 82% of all prisoners in this study as
Presence of substance
related diagnosis, 329,
82%
45
FIGURE 19: Prevalence of substance-related diagnosis among prisoners
69
No substance-related
diagnosis
2
HIV Negative
HIV Positive
131
Presence of substance
related diagnosis
198
Frequency p=0.000000
This study also showed that it is very highly likely to have lifetime substance-
related diagnosis among prisoners with HIV positive. This is illustrated in the
diagnosis with the contraction of HIV. 99.0% for those with HIV positive had been
This study found that all prisoners with HIV positive status who had Adjustment
Disorder, Major Depression and Psychotic Disorders had also been diagnosed
substance-related disorders.
46
As shown in the figure 20, most of the prisoners admitted that they used more
than one type of illicit drugs. It represented about 71% of the total prisoners
FIGURE 20: Prevalence of prisoners using one versus more than one illicit drugs
47
FIGURE 21: Prevalence of the number of illicit drugs used among prisoners
82
More than one illicit drugs
153
HIV Negative
HIV Positive
49
One illicit drug
45
Frequency p=0.004
There was a significant difference between prisoners with HIV Positive and
Negative as in the figure 21. There was about 77.3% of HIV positive prisoners
admitted they took more than one illicit drugs. There was 62.6% of those with
HIV negative had history of consumption more than one illicit drugs. This study
showed that those who consumed one illicit drug are half likely to have contract
HIV.
48
This study also revealed the patterns of illicit drugs used by prisoners. Out of 329
who received substance-related diagnosis on this study, there were about 304 of
304
Frequency
193
146
53
This was followed by cannabis which accounted about 58.7% of 329 prisoners.
about 44.4% of them. The use of solvent among prisoners population as shown
49
FIGURE 23: Opioids consumption among HIV positive and negative
prisoners
22
HIV Negative
HIV Positive
109
Using Opioids
195
Frequency p= 0.000001
History of opioids related use has been shown to increase the odd ratio as much
as 13.11 for prisoners to contract HIV (Figure 23). This association has been
significant. There was 98.5% of those with HIV positive had consumed opioids
whereas only 83.2% among those with HIV negative. About 16.8% of HIV
negative prisoner had ever used opioids. There was only 1.5% of HIV positive
50
FIGURE 24: Cannabis consumption among HIV positive and negative
prisoners
59
Never Used Cannabis
77
HIV Negative
HIV Positive
72
Using Cannabis
121
Frequency p=0.3
In contrast to opioids, there was lesser percentage among HIV positive prisoners
who consumed cannabis (61.1%) as shown in the figure 24. This figure was
about the same with those who were HIV negative. Therefore, there was no
51
FIGURE 25: Amphetamines consumption among HIV positive and negative
prisoners
73
Never Used
Amphetamines
110
HIV Negative
HIV Positive
58
Using Amphetamines
88
Frequency p=0.98
With regards to amphetamines, there was about the equivalent proportion among
HIV positive and negative who consumed amphetamine though there was about
status. As most preparation is in the form of oral rather than injection, this could
52
FIGURE 26: Sedatives consumption among HIV positive and negative
prisoners
123
Never used sedatives
153
HIV Negative
HIV Positive
8
Using Sedative
45
Frequency p=00006
Surprisingly as shown in the figure 26, there was significant association between
sedatives use and HIV positive. There was about 22.7% of those with HIV
53
.
Presence of
Alcohol-related
disorders, 68,
17%
No alcohol related
disorders, 332, 83%
With regards to alcohol, there were about 17.0% prisoners who participated had
been found to have alcohol-related disorders. This is shown in the figure 27.
54
However, as shown in the subsequent chart, figure 28, there was no significant
association between the presences of alcohol related disorders and HIV status
167
No Alcohol related
disorder
165
HIV Negative
HIV Positive
33
Presence of alcohol
related disorder
35
Frequency p=0.8
55
FIGURE 29: Table summarising the sociodemographic data, criminal profile,
Sociodemographic data:
Age:
Mode 37 28
56
Marital Status (%): 0.0
57
Criminal Profile (%): 0.0000
58
Presence of substance-related disorders (%): 198 (99.0) 131 (65.5) 0.00
59
DISCUSSION
Psychiatric morbidity among prisoners with and without HIV
This is the first study of its kind that looked at the psychiatric morbidity among
prisoners with HIV positive status in Malaysia. It revealed that the life time
prevalence of mental illness among all prisoners was 40%. Another study done in
morbidity.
This study showed that the prevalence of psychiatric diagnosis among those with
HIV positive and negative was similar with 42% and 38% respectively as shown
in the figure 16. Springer3 stated that the rate of psychiatric illness among HIV
illness.
Depression and Adjustment Disorder regardless of their HIV status. With a small
cell, overcrowding and strict disciplinary regulations, these are among the
60
There are some prisoners who already had psychiatric morbidity prior to the
psychiatric morbidity. This showed that prison has high rate of psychiatric
Overall, the highest prevalence of mental illness was Major Depression which
accounted for 24.2% of those who had mental illness (other than substance-
Disorder) which accounted for 21.1%, Adjustment Disorder accounted for 19.9%
and Drug induced psychosis accounted for 11.8%. These four mental illnesses
accounted for 77% of all prisoners with mental illness. This result was
comparable to other study that was done in the same location among all
In fact, among HIV negative prisoners the rate of psychotic disorders only 14.5%.
Adjustment Disorder and drug-induced psychosis follow with the rate of 19.9%
and 11.8% respectively. There was quite high prevalence of drug induced
amphetamines (58.7% and 44.4% of those who took illicit drugs respectively)
61
When the HIV status is taken in into account, the rate of Major Depression in HIV
positive was 25.9% which was slightly higher than those with HIV negative status
(22.4%) but not statistically significant different. However, there are few factors
which could explain higher rates of Major Depression in HIV positive patients.
poor partner choice in relationships may cause Major Depression as a risk factor
for HIV infection79. Secondly, HIV infection leads one to have psychiatric illness.
Indirectly, those who are diagnosed with HIV positive which is life-threatening
lead them to have higher rate of Major Depression than those who have HIV
negative. This could be due to chronic stress, worsening social isolation and
intense demoralisation. HIV can also directly cause insult to subcortical areas of
brain. The lower CD4 cells the higher risk of Major Depression one has80.
Among obstacle to the diagnosis is one has more tendency to have depressive
HIV positive prisoners, HIV negative prisoners have higher rate of Adjustment
infection and psychiatric illness.4 It is also known that persons with substance-
62
population. This subsequently contributes to the higher rate of major depression
among the minority group. Major Depression could render proper treatment for
treatment outcome are reduced in Major Depression with medical illness such as
HIV81.
positive prisoners. On the other hand, those who were HIV negative, the
prevalence were 14.5%. In this study, there was HIV positive prisoners had been
are studies that have shown that comorbidity of substance abuse is very high
patients with psychotic symptoms have fitted into both DSM-IV diagnosis of
There is an increase risk among patient with schizophrenia to acquire HIV 83.
Study done by Kalichman showed that patients with schizophrenia tend to have
less knowledge about HIV infection and transmission84. Psychotic disorders such
63
been shown that the rate of substance-related disorders among prisoners is high.
Therefore, some of those prisoners who used to consume illicit drugs would
It has been highlighted in this study, 82% of all prisoners have been identified to
cannabis, sedatives, solvents for abuse and dependence. From the study
conducted in the United Kingdom, the majority of prisoners had used illicit drugs
at some time85. The use of illicit drug has been associated with antisocial
personality disorder86. There was about 50% of those in prison has been
As shown in this study, there was about 40% of prisoners have been diagnosed
with psychiatric illness but only 10% ever had contact with psychiatrist. This
supports that the vast majority of them who had psychiatric disorders might have
Among prisoners who were found to have HIV positive, there was a very
were 99% of those with HIV positive had been found to have substance-related
disorders (Figure 19). In contrast, about 66% of those with HIV negative had
64
substance-related disorders. There was high proportion of them ever used
represented about 92.4% of all prisoners who consumed illicit drugs. There was
also a statistically significant association between HIV positive status and opioids
used. There was about 13 times likely to have opioids use among HIV positive
prisoners. Cannabis and amphetamines then accounted for 58.7% and 44.4%
each. Cannabis intoxication can results in euphoria mood with also psychosis. In
another study conducted among forensic patient at the Hospital Bahagia Ulu
Kinta (Psychiatric Hospital)87, the most popular illicit drugs among those
among sentenced prisoners population, 79% has ever used cannabis, 36% for
heroin and 49% amphetamines85. Higher proportion in cannabis use in the United
aggressive behaviour.
65
As there was significantly high proportion of HIV positive prisoners consumed
opioid (98.5% of them), it can be beneficial to offer them for harm reduction
treatment with methadone in the prison itself. This would lesser the chance of
This treatment should begin at the point of entering prison. This moment would
disorders. They could have transient critical period when they may experience
transient period. If this period is not dealt with proper health care, this may
contribute to severe withdrawal among these professional. At the worst, this can
that there is high proportion of prisoners taking more than one type of illicit drugs.
This study revealed that there was 71% of prisoners who ever took illicit drugs
had consumed more than one type. There was 77.3% of HIV positive prisoners
had consumed more than one drugs. In the figure 21, among prisoner with HIV
positive the history of single use of illicit drug is only halved as compared to those
who consumed more than one illicit drug. Therefore they are more likely to
consume more than one illicit drug. This study support that the more illicit drugs
consumed, the more likely to have HIV positive status among prisoners. It can be
66
postulated that prisoners with HIV positive are likely to live with multiple illicit
drugs culture. Therefore, in offering optimum treatment this factor has to be taken
the number of illicit drugs used, other comorbidity of psychiatric diagnosis and
HIV status.
Alcohol-related diagnosis has also been identified among prisoners. There were
17% of all prisoners had been found to have alcohol-related disorders. There
was no significant difference between HIV positive and negative prisoners. This
figure is higher than general population which accounted about 4.7% 89. In
Another finding is that there was high percentage of those who has psychiatric
diagnosis to have history of illicit drugs use. 92.5% of those who has psychiatric
diagnosis had used opioids, 62.7% had used cannabis and 56.0% had used
there was large proportion for those who had no psychiatric morbidity also
consumed them. This leads to insignificant difference between those who has
and do not have psychiatric morbidity in term of the use of either opioids or
67
disorders and substance use among general population and prisoners population
specifically91.
It even established that triple diagnosis has been referred to such prisoners with
specifically showed all HIV positive prisoners with Major Depression, Psychotic
disorders.
Among general population, there has been identified that sexual intercourse,
intravenous drug use and blood transfusion as risk factors for HIV transmission.
There were about 56% of those prisoners with HIV positive status had admitted
of presence of history of sexual contact. However, at the same time there were
about 44% of them who admitted never had sexual contact in the past. As
comparing between HIV positive and negative prisoners, there was no difference
68
It is similar to history of receiving blood transfusion as in the figure 13. There
were only about 11% of prisoners with HIV positive status ever received blood
In this study, there were 95% of those prisoners with HIV positive to have history
of IVDU. This is in contrast to those who were HIV negative where only 27% had
history of IVDU. This is illustrated in the figure 11. This difference in term of
prisoners. There was very high chance for those who are HIV positive in the
supported by the fact that there was about 95% of those with HIV positive had
admitted using IVDU as a method to relieve their addiction in the past. These
result also similar to other study which showed that there was an increase risk of
There is also a possible occurrence of IVDU and sexual activity while in the
prison93. There are suggestions to control the spread of HIV in the prison.
69
Mandatory testing, segregation, infection control, education, condom distribution
for the Prison Department (“The Manual for Prevention and Control of HIV/AIDS
20
in the Prison” ). The objectives of this guideline are to increase knowledge and
among prisoners and to provide healthcare, treatment and support for prisoners
with HIV/AIDS.
which is given by the appointed counsellor among the health officers. This
In the prison, compulsory HIV test is conducted regularly for surveillance. All
prisoners who are newly admitted to the prison, those who have been six month
in the prison and those who would be discharge soon from the prison have to
undergo the test. As in the guideline, pre- and post-test counselling is given
In the prison itself, measures such as isolation block allocation and minimising
activities such as involving machine and sharp objects that may lead to injury are
70
Sociodemographic profile
It also showed that ethnic distribution for HIV status were highest among
Bumiputera which was then followed by Indian and Chinese. Indian ethnicity was
also overrepresented in HIV positive status. However, there was about the same
proportion among prisoners with HIV positive and negative for each ethnicity in
this study. These also apply for the prevalence of each religion where there was
about the same proportion among prisoners with HIV positive and negative. The
represented about two third of them. With regards to HIV positive prisoners, only
14% were married and another 20% were divorced. There is a danger that as the
remaining of HIV positive were still single with 57% of them have history of
heterosexual contact. With high prevalence of IVDU among HIV positive too,
which accounted for 95% of them, this can also be the primary mean of HIV
transmission.
There was about 40% of total prisoners received education up to the age of 13 –
15 years old. Another 30% received education up to the age of 17 years old. With
education till age of 17. There was again no difference between those prisoners
71
with HIV positive or negative in term of academic achievement as illustrated in
the figure 4. The figures were comparable between both groups as low education
As shown in this study, 269 of 400 prisoners (67%) had only received education
until 15 years old or less despite free education system in Malaysia. Lack of
education, by itself as a risk factor for incarceration e.g. due to low intellectual
which ends up in illegal activities and also poor knowledge of defending oneself
Some of them especially those with poor academic achievement would also drop
earlier at age of between 13 -15 years old. Even among incarcerated population
which has high prevalence of antisocial personality was unable to stay in school
conduct disorder that occurred at adolescent age. At school age, those who have
been detained in juvenile prison have shown higher rate of conduct disorder,
population95. These illnesses can interfere with education that causing early
termination from education. The low academic achievement could lead poor
knowledge about how HIV virus is transmitted which subsequently lead to risky
behaviour e.g. having multiple sexual partner, not using condom, and exchange
needle among drug addicts. Besides that, this also contributes to the psychiatric
72
In term of employment, 60% of prisoners were unemployed prior to
there would be tendency for them to find income through illegal way that may
Even in the United States, about two third of prisoners are diagnosed with HIV
positive at the entry to the prison itself.3 Hence, HIV status did not correlate with
Even though there was high unemployment among prisoners, their monthly
income was high. The mode of their income was in the range of RM1200-
contributed by illegal sources. Their participation in the illegal and vice activities
could have also leaded them to imprisonment. This would also indicate publicly
The highest proportion of prisoners has been found guilty for substance-related
crime as shown in the figure 8. They represented about 50% of all prisoners who
73
about 61% of all HIV positive prisoners. This showed that there is a tendency for
diagnosis (about 99% from the figure 19), it is highly likely for them to be caught
in association with drug related activities. It has been found that none of HIV
positive prisoners committed sex related crime. As there was about half of all
74
CONCLUSIONS
Prison population were mainly composed of low socioeconomic group. Most of
However, ethnic Indian was overrepresented in prison population and also in HIV
positive prisoners. Most of the prisoners were single and had education mostly
until secondary school. About 60% were unemployed but surprisingly their mode
of income was in the range RM1200 and RM2399. There was no different in term
prisoners. Almost two third of HIV positive prisoners were sentenced for
study committed sex-related crime. There was also low rate for offences against
Among prisoners, intravenous drug use (IVDU) has been the main risk factor for
HIV. There were 95% of prisoners with HIV positive has been injecting
themselves at some time in their life. There has been significant different in term
of history of IVDU among HIV positive prisoners. Sexual contact and blood
transfusion were not the main risk factors among HIV positive prisoners.
75
represented highest prevalence of 27% of all psychiatric diagnosis. This was
followed by Major Depression and Adjustment with the value of 25.9% and
psychiatric diagnosis for both groups was drug-induced psychosis. Even though
the prevalence of psychiatric diagnosis was about 40%, those who had history of
contact with psychiatrist were small, 10%. This showed the inaccessibility among
this population.
Among HIV positive prisoners too, the rate of substance-related diagnosis was
significantly higher than those with HIV negative. There were a significant
proportion of HIV positive prisoners who took more than one illicit drug in
comparison to those with HIV negative. Opioids has been the most popular illicit
significant among HIV Positive prisoners to consume opioids rather than other
drug. Another 58.7% and 44.4% of prisoners had consumed cannabis and
HIV status of prisoners. The use of opioids and cannabis do not suggest any
76
Opioids-related disorders and psychotic disorders are common co-existence
psychotic disorders with higher rate of opioids use. Triple diagnosis of substance
abuse, HIV positive and psychiatric diagnosis has been such a common
occurrence. It has been found that substance-related disorders had been present
in all HIV positive prisoners with Major Depression, Psychotic Disorders and
Adjustment Disorders.
There was a complex relationship between HIV positive prisoners and psychiatric
morbidity. Illicit drug uses and alcohol have been primary intermediary factors in
77
RECOMMENDATIONS
1. Prison could be a very stressful place to stay. Those with HIV positive could
have „double‟ stress among prisoners which let them prone to have psychiatric
efficiently and fairly to the prisoner. Otherwise, the mental health of prisoners
with or without HIV can deteriorate during imprisonment.77 This has been stated
in the World Health Organisation about treatment option and availability received
should be introduced early in the prison as there was about 98.5% of them taking
opioids. History of cannabis use was also high in both HIV positive and negative
receive proper treatment in the prison. It can be beneficial to offer them for harm
reduction treatment with methadone in the prison itself. This would lessen the
chance of HIV spread once they were discharged from prison. Prison should
have protocol in treating this group of patients. With the close supervision in the
prison, this treatment could be more effective. While they stay long enough in the
related disorders and HIV treatment. Other harm reduction programme such as
order to reduce spread upon their discharges from prison. Needle exchange
78
3. The quality of mental health service in the prison could be enhanced if trained
professions are placed in the prison. This is so because there was large
illnesses. By doing this, it will ensure of equally access to mental health care
among prisoners. The more crucial is that the service is more needed in the
population. Even there was also large proportion has multiple illicit drugs use.
from using illicit drugs, this consequently would reduced the rate of recidivism 98,
4. There was high rate of IVDU among prison population. Imprisonment could be
taken as opportunity to give HIV related education. Safe sex education should
also be taught in the prison. This could reduce or prevent HIV infection in and
groups. Hence, outside prison they were unlikely to receive proper education of
HIV infection.
79
LIMITATIONS
1. This was a retrospective descriptive study. Recall bias is known one of the
2. During the interview, prison officer was always around to prevent any
unwanted incident. Therefore, there was possibility that the prisoners did not tell
3. Prisoners who was waiting for capital punishment was excluded. This was
Hence, they could be lower rate of mental illness due to this exclusion.
4. This study has used SCID-1 as a main tool to look for psychiatric diagnoses.
There has no validation study in Malay language for this tool. Most of prisoners
prisoners. There were a very small number of prisoners who experienced mental
80
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