PREVALENCE OF PSYCHIATRIC

MORBIDITY AMONG SENTENCED

PRISONERS WITH HIV POSITIVE IN
MALAYSIAN PRISON

BY:

DR. MUHAMMAD MUHSIN AHMAD ZAHARI

Senior Lecturer and Psychiatrist (University of Malaya (UM),

Malaysia)

MB., BCh., BAO (National University of Ireland)

Master in Psychological Medicine (UM)

Forensic Psychiatric Training in South Australia

Fellowship in Community and Rehabilitation Psychiatry, WHO

Collaborative Centre, South Korea
CONTENTS

INTRODUCTION

 HIV and psychiatric morbidity

 Prisoners and HIV

LITERATURE REVIEW

 HIV in general population and prisoners

 HIV and Psychiatric Morbidity

 HIV Positive Prisoners with Psychiatric Morbidity

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

RESULTS - Patterns of Crime

RESULTS – Risk Behaviours

 Sexual Contact

 Intravenous Drug Use (IVDU)

 Blood Transfusion

RESULTS – Psychiatry

 Contact with Psychiatrists

 Lifetime Psychiatric Diagnosis

 Substance-related Disorders

 Distribution of illicit drugs and polydrug users

3
  Opioids consumption

 Cannabis consumption

 Amphetamines consumption

 Sedatives consumption

 Alcohol-related Disorders

 Summary Table

DISCUSSION

 Psychiatric morbidity among prisoners

 Substance-related diagnosis among prioners

 Risk Factors for HIV

 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

beyond the capacity of prisons themselves. This is also happening in Malaysia

where six out of 26 prisons receive more than 50% of their maximum capacity1.

There is an estimation of 30 to 50 million imprisoned people in the world. The

numbers of imprisoned is increasing.2

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

general population.3 In an epidemiology study done in Texas, there was higher

rate of Major Depression, Bipolar Affective Disorders and Psychotic Disorders

among HIV positive prisoner.4

In Malaysia alone, there were about 1,959 HIV positive prisoners from about

39000 convicted prisoners in the month of September 2005.05

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

between biological, psychological and sociological aspects of the illness. 06

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

were; alcohol dependence disorder (29%), intravenous drug use (8.5%),

personality disorders (34%), bipolar affective disorder (11.5%), schizophrenia

(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 compared with HIV negative women in general population.08 The

depression may influence the progression in HIV infection though the mechanism

remains unknown.

The WHO Neuropsychiatric AIDS study reported in general population among

asymptomatic HIV positive subjects the prevalence of major depressive disorder

ranging 3.0% to 10.9% whereas in symptomatic HIV-positive subjects it ranging

from 4.0%-18.4%.09

Understandably, a significant proportion of people with HIV disease suffer from

periods of depression10 which may require treatment with anti-depressant

medication.

6
A smaller number of patients require treatment for psychoses, including the

treatment of hypomania, which can be a presenting feature of HIV-associated

dementia.11

The potential for interactions to develop between the concurrent administration of

Protease Inhibitors, a large range of psychotropic drugs, as well as some other

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

associated with mood symptoms.13

It is possible that a number of separate etiologic factors act jointly and lead to this

uncommon complication of HIV infection. It is also acceptable that drug abuse

decreases a patient's threshold for the development of psychosis when he or she

is later infected with HIV. 14

Prisoners and HIV

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

discrimination. In a report released by UNAIDS, it is estimated HIV infection is 75

times more common than in the general population. 15

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

prisoners in New York City prison were HIV positive.19

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

who involved in substance misuse and those who involved in promiscuity.

According to the Consensus Report on HIV/AIDS Epidemiology: Malaysia, 2004

there was 76.2% of HIV infection cases occurred among intravenous drug users

whereas 46.0% of HIV infection occurred among heterosexual.

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

special circumstances, referral to psychiatrist is necessary e.g. In the case of

cognitive impairment, psychotic symptoms, severe depression and suicidal

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

blood. Psychological support by Medical Officer could be given to those who

need the service.22

8
The prison could be an opportunity in improving health e.g. Improvement in

nutrition, reduction in tobacco, drugs or alcohol consumptions and providing

health education. Prison could be the first contact with health service. Health

services in prisons should be free and accessible.02

There are no local data on the prevalence of psychiatric morbidity among HIV

positive prisoners. It is essential to acknowledge that as in the general

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

living would also be shortened. Therefore, it is crucial to treat this group of

prisoners early in order to optimising their quality of life.

9
LITERATURE REVIEW
HIV in general population and prisoners

According to the World Health Organisation (WHO)/UNAIDS report, in the year

2004, HIV infection rose to 39.4 million worldwide with 3.1 million deaths from

AIDS over one year period.23

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

who were not intravenous drug users.26

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

transfusion. In these groups HIV infection is more than 1% prevalence. 27

10
The problem of HIV infection is amplified in the prison where the rate of HIV

infection is estimated to be six times that of the general population. In United

States, 22.3% of prisoners were committed for drug-related offenses. Among

prisoners who have been tested for HIV, those under drug offenses are the most

likely to be HIV positive.28

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

prisoners.29 Among them overcrowding provides ideal circumstances for stress

related disorders and transmission of disease such as tuberculosis and HIV to

occur. 30

As compared to general population, prisoners initiate sexual intercourse at an

earlier age, have a higher number of lifetime and recent sexual partners, and

have a higher frequency of sexual risk behaviour, elevated rates of substance

use, injection drug use, mental illness, trauma and abuse.31

11
HIV and Psychiatric Morbidity

Psychiatric morbidity is the presence of diseases in relation to psychiatric

disorders. It describes about the extent of the effect of psychiatric illness.

Psychiatric diseases can extent from symptomatic to a diagnosis of syndromic

illness.

HIV has also been associated with psychiatric morbidity particularly substance-

related disorders. The presence of psychiatric morbidity among HIV positive

32
could be a pre-existing condition prior to HIV infection itself. There are studies

to associate psychiatric diagnosis as a predictor of HIV infection. Increased

sexual activity which may occur in the early stages of schizophrenia and also a

recognised feature of mania may increase risk of contracting HIV. In a study, it

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

with partners who have the infection.33

Substance-related disorder for example alcohol or cocaine intoxication can

impair judgement which subsequently results in impulsive and risky

behaviour.34,35 Another study by Brooner 36

suggests that a diagnosis of

antisocial personality disorder is a further risk factor among intravenous drug

users. The psychiatric illness role in predicting HIV infection has to be identified

in order to plan appropriate intervention strategies in dealing with this group of

psychiatrically ill HIV positive prisoners.37

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

hopelessness may arise as a result from devastating illness.

The direct complications of HIV itself can lead to metabolic derangements,

space-occupying lesions and central nervous system infections. The effect of

these complications can result also result in delirium or dementia. 39 It even

acknowledge that AIDS dementia complex as a complication of the infection.

This is characterised by forgetfulness, poor concentration, slowness, and

difficulties with problem solving, and it may be accompanied by apathy and social

withdrawal.40 Psychosis was found more commonly in AIDS-related

neurocognitive impairments.06 Apart from this the effects of viral infection on

cognitive function may also lead to dementia. Anxiety and depression can also

occur as a result of the infection. 39

Antiretroviral treatments themselves can give rise to psychiatric side-effects.41

Psychotic disorders among HIV positive could uncommonly be due to medication

such as ganciclovir42 and efavirenz.43

Hence, individual with HIV has been prone towards psychiatric morbidity. There

are numerous studies that showed high prevalence of psychiatric disorder among

HIV positive population.37, 44

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

of depressive symptoms had showed increased pain and decline in general

health perception over 8 month duration.46 Depressive symptoms among those

with HIV positive also showed faster disease progression.47 Therefore there is

vital to tackle psychiatric problems in this HIV positive population in order to

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

illness these symptoms more likely to be related to psychiatric illness. 06,49

50
Elliott (2002) et al. showed that the treatment of depression would improve

psychosocial functioning and quality of life. Adherence of HIV medication is also

improved upon better control of psychiatric morbidity.51

Psychotic symptoms can be an uncommon complication of HIV infection. There

is a tendency toward the psychotic patients having greater global

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

associated as risk factor for schizophrenia so as prolonging psychotic

symptoms.53, 54
It has been shown that high cannabis use is due to relieve

distressing symptoms of illness or to adverse effects of antipsychotic.55

Psychotic disorders in HIV positive patients, psychotic patients had a higher rate

of previous stimulant and sedative abuse or dependence.

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

to HIV infection on the CNS. Association between neuropathology and manic

symptoms has been shown in a study. Therefore, the term „AIDS-mania‟ has

been applied to this condition. 57

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

than in community. There is a ratio of 80:1 in term of attempted to completed

suicides. Suicides rates are highest among new prisoners, those prisoners in

states of intoxication or withdrawal or those prisoners with mental illness. 58 Even

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

treatment of depression itself can act as suicide prevention.59

HIV Positive Prisoners with Psychiatric Morbidity

There are also numerous studies that describe psychiatric illness among

prisoners themselves. Imprisonment can also be a source of psychiatric illness.

The prevalence of psychiatric illness in the prison settings is significantly

elevated than the rate among community. There was estimation that one in five

incarcerated persons in the United States has major psychiatric illness. This

marginalized population may be a challenge to researchers and clinician. 60 Fazel

61
et al in his meta-analysis of 23000 prisoners found that there is 10%

prevalence rate for depression among male prisoners which showed that female

prisoners at higher rate. However, psychotic illnesses were diagnosed in 3.7% of

males‟ prisoners in the study which representing three to four times higher than

in community. Another study showed there was 34% of psychotic

symptomatology among young male prisoners.62 Among the elderly prisoners in

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

higher than younger prisoners. 63

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

alcohol with 50.5%.

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

analyse the distribution of psychiatric morbidity among HIV positive.

Another study conducted at detoxification centre by Mahmud et al. 65 found 19.2%

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

significantly associated with HIV positive status.

As there is higher rate of psychiatric morbidity especially substance abuse

among HIV positive among prisoners, there should be a focus in psychiatric

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.

Those with substance-related disorders, effective drug abuse treatment would

give rise an effective HIV prevention.66,67 In a study by Moatti et al.68 among

those on buphrenorphine treatment, there are better adherence to HAART

treatment. Adherence on HIV treatment is important to prevent multidrug-

resistant strain of HIV.69 In addition to the better adherence to HIV treatment,

17
harm reduction programme also reduce HIV risk behaviours, illicit drug use, and

transmission of infectious disease among HIV positive patients.70 Some of the

psychiatric approaches such as motivational interview, cognitive behavioural

therapy, supportive group therapy has been town to enhance long term

adherence of HIV treatment.51 HIV positive prisoners are very likely to be

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

is supported by Springer (2004) et al.69

History of current or past imprisonment, mental illness, substance abuse,

injection drug use, sexual risk behaviour and infectious disease have contributed

to increase likelihood of having HIV infection.31

American Psychiatric Association Guideline71 proposed biopsychological model

to integrate self-management skills training for a chronic illness, and enhanced

medical case management so that psychiatric and medical care needs of

individuals with severe mental illness can be coordinated. There has been

surprisingly little research on integrated intervention efficacy to address the

global needs of this highly vulnerable population.

Therefore, HIV–related research is needed to determine HIV disease prevalence

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

programmes for HIV-positive individuals and to evaluate HIV risk-reduction

interventions among prisoners.31

18
OBJECTIVES::

 Primary objective: To estimate the prevalence of psychiatric morbidity

among sentenced prisoner with HIV positive in Kajang Prison.

 Secondary objectives :

o To compare sociodemographic profiles between prisoners with HIV

positive and negative

o To compare criminal profile between prisoners with HIV positive

and negative

o To examine history of sexual contact, intravenous drug use (IVDU)

and blood transfusion as risk factors among prisoners for HIV

o To establish relationship between substance and alcohol-related

disorders with HIV status.

19
METHODS
Study Design:

This was a cross-sectional descriptive study which looking at psychiatric

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

prisoners with HIV negative prisoners participated in the study.

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

called for the interview.

20
Inclusion criteria:

 Sentenced prisoners with confirmed HIV positive in Kajang Prison via

„rapid test‟ or ELISA test on admission or any subsequent similar tests.

This test is routinely done on admission and 6 months later after

„window period‟. Those with HIV positive status are segregated at

different block with its own census.

 The duration of the sentenced prisoners in the prison has been more

than 24 hours. There was some difficulty in determining those who was

less than 24 hours due to process of registration into the census.

 The age was more than 18 years old. This is the age where one can

give informed consent voluntarily. At this age too, it would not be

considered age of adolescence.

 Those who consented into this survey.

Exclusion criteria:

 Those with capital punishment. In this group of prisoners, the tight

procedure of security is applied. Therefore, as there was very

limited number of available officers who accompanied investigator,

this group of prisoners had been dropped from this study.

21
Procedures:

Permission from Department of Prison, Ministry of Internal Security was sought

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. Once agreed, an informed consent (Appendix I) was signed by the

prisoner. During interview and in the prison itself, a security officer of the prison

accompanied the investigator all the times.

Assessment:

All interviews were conducted by one investigator. Using prescribed form

(Appendix II), each prisoner was asked about their sociodemographic profiles

included age, gender, race, citizenship status, religion, marital status, highest

education level, employment before imprisonment and income before

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

histories were also documented including type of crime, accumulative length of

stay in prison and total duration current imprisonment.

22
Another part of interview was using a questionnaire, the Structured Clinical

Interview for Diagnostic Statistical Manual of mental disorders (DSM) version IV

(text revision) (SCID-I). SCID-I is a diagnostic tool of psychiatric morbidity.

Psychiatric morbidity is said to be present if there is a DSM-IV diagnosis using

the SCID-I (Appendix III). It has high inter-rater reliability for psychiatric

diagnosis.72 In a study done by Christopher73 it has shown high inter-rater

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

been used as „gold standard‟ in numerous study.74, 75

Prisoners were interviewed individually which mainly focused on lifetime

symptoms of psychiatric illness.

Investigator has been trained to use this tool during a workshop conducted by

Professor Maniam, a consultant psychiatrist, held earlier at the Universiti

Kebangsaan Malaysia (National University of Malaysia). However, SCID-I has

not been validated in Malay Language. Therefore, investigator had to translate

the tool into Malay Language during most of the interview.

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

sentence) represented 21%, long stay (more than 6 months sentence)

represented 67%, with actively addicted to illicit drugs represented 7%, life

imprisonment (for 20 years imprisonment sentence) represented 1.5%, death

sentence represented 1.3% and juvenile represented 1.3%.76

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

restricted to avoid potential transmission among them.

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

prisoners comprised of 94.5% of the total sample population.

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

16.0% and Chinese 13.5%. It showed overrepresentation among minority ethnics

(Indian and others) in the prison. However, it was not statistically significant.

FIGURE 1: Ethnicity distribution among HIV positive and negative among

prisoners
300

250

123
200

Frequency
HIV negative
150
HIV positive

100

138
29
50
27

27 35 21

0 0
Bumiputera Chinese Indian Others
Races

Races HIV positive (%) HIV negative (%)

Bumiputera 138 (69.0) 123 (61.5) 261

Chinese 27 (13.5) 27 (13.5) 54

Indian and 35 (17.5) 50 (25.0) 85

Foreigners

200 (100) 200 (100) 400

‫אּ‬2 = 3.51; df=2; p=0.2

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%

were Christian (Figure 2). Among them, as in Figure 1, Bumiputera represented

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

Muslim Christian Buddhist Hindu Others

HIV positive (%) HIV negative (%)

Muslim 146 (73.4) 145 (73.6) 291

Christian 13 (6.5) 12 (6.1) 25

Buddhist 18 (9.0) 17 (8.6) 35

Hindu 22 (11.1) 23 (11.7) 45

Total 199 (100) 197 (100) 396

‫אּ‬2 = 0.0841; df=3; p=0.99

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.

This was illustrated in the Figure 3.

FIGURE 3: Marital status among prisoners

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

HIV Positive (%) HIV Negative (%)

Single 132 (66.0) 108 (54.0) 240

Married 28 (14.0) 66 (33.0) 94

Divorced/ Widower 40 (20.0) 26 (13.0) 66

200 (100) 200 (100) 400

‫אּ‬2 = 20.7; df=2; p=0.0

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

qualification (which is equivalent to O-Level examination).

Level of Education among prisoners

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
er

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

HIV negative where about 65% completed education between ages of 12 – 15

years old, as shown in Figure 4. Another 27.5% completed education between 16

and 17 years old.

29
 HIV Positive (%) HIV Negative (%)

Highest education 51 (25.5) 57 (28.5) 108

at primary school

Highest education 83 (41.5) 78 (39.0) 161

up to 15 years old

Highest education 16 (8.0) 20 (10.0) 36

up to 18 years old

Holding SPM or 50 (25.0) 45 (22.5) 95

higher qualification

200 (100) 200 (100) 400

‫אּ‬2 = 1.2; df=3; p=0.8

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

unemployed prior to their imprisonments. However as shown in Figure 6, there

were comparable employment status between the two groups.

FIGURE 6: Table 2 x 2 for HIV status vs employment status

HIV Positive HIV Negative

Employed prior
77 83 160
to imprisonment
Unemployed
prior to 123 117 240
imprisonment
200 200 400
OR = 0.88 (95% CI 0.59 - 1.31) ‫אּ‬2 = 0.37; p=0.54

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

Income HIV positive (%) HIV negative, (%) Frequency, (%)

Less RM500 24 (12.0) 25 (12.5) 49 (12.2%)

RM500-RM799 16 (8.0) 24 (12.0) 40 (10.0%)

RM800-RM1199 47 (23.5) 44 (22.0) 91 (22.8%)

RM1200-RM2399 77 (38.5) 69 (34.5) 146 (36.5%)

RM2400 and above 36 (18.0) 38 (19.0) 74 (18.5%)

Total 200 (100) 200 (100) 400 (100.0%)

‫אּ‬2 = 2.2117; df=4; p=0.7

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

included all their financial sources both legal and illegally.

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

Patterns of crime HIV Positive (%) HIV Negative (%)

Substance-related 121 (60.5) 78 (39.0) 199

Property-related 33 (16.5) 38 (19.0) 71

Against Human 5 (2.5) 38 (19.0) 43

Others 41 (20.5) 46 (23.0) 87

200 (100) 200 (100) 400

‫אּ‬2 = 32.8; df=3; p=0.0

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

substance-related offences compared to 39.0% of those with HIV negative. That

is how they contracted HIV because of IVDU community in Malaysia. However

property related offences had been about the same between the two prisoners

populations. Offences against human which include violent offences, sex-related,

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

With sexual contact Without sexual contact

HIV positive (%) HIV negative (%) TOTAL

With history of 113 (56.5) 99 (49.5) 212 (53.0)
sexual contact
Without history 87 (43.5) 101 (50.5) 188(47.0)
of sexual contact
TOTAL 200 200 400 (100.0)
OR = 1.32 (95% CI 0.89 - 1.96) ‫אּ‬2 = 1.96; p=0.16

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

between the 2 groups in history of sexual contact among prisoners.

35
Out of the total of 400 prisoners who participated in this study, about 61% of

them had admitted of taking illicit substance and administering them

intravenously at some stage as shown in Figure 10.

FIGURE 10: PIE CHART ILLUSTRATING THE PRESENCE OF

HISTORY OF IVDU AMONG PRISONERS

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

those denied ever injecting themselves had contracted HIV.

FIGURE 11: PRESENCE OF HISTORY OF IVDU AMONG PRISONERS

HIV negative, 146

Without history of
IVDU
HIV positive, 11

HIV negative, 54
With history of
IVDU
HIV positive, 189

Frequency p=0.0000

HIV positive (%) HIV negative (%) TOTAL

With history of IVDU 189 (94.5) 54 (27.0) 243 (60.8)

Without history of IVDU 11 (5.5) 146 (73.0) 157 (39.3)

TOTAL 200 (100.0) 200 (100.0) 400 (100.0)

OR = 46.45 (95% CI 23.46 – 92.01) ‫אּ‬2 = 191.08; 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.

FIGURE 12: HISTORY OF RECEIVING BLOOD TRANFUSION AMONG

PRISONERS

Ever received blood

transfusion, 42, 11%

Never received blood

transfusion, 358, 89%

38
FIGURE 13: Prevalence of prisoners who had been receiving blood

transfusion in the past

183
175

HIV Positive
HIV Negative

25
17

p=0.2

Received blood transfusion Never received blood transfusion

HIV Positive (%) HIV Negative (%)

Received blood 25 (12.5) 17 (8.5) 42 (10.5)
transfusion
Never received 175 (87.5) 183 (91.5) 358 (89.5)
blood transfusion
Total 200 200 400(100)
OR = 1.53 (95% CI 0.80 – 2.95) ‫אּ‬2 = 1.70; 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

psychiatrist. This is shown in figure 14.

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

have lifetime diagnosis of psychiatric illnesses as shown in figure 15. Though

there was about 40% had lifetime diagnosis of psychiatric illness but only 10%

had ever contacted psychiatrist.

FIGURE 15: LIFETIME PREVALENCE OF PSYCHIATRIC DIAGNOSIS

AMONG PRISONERS

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

positive and negative had psychiatric illnesses respectively.

FIGURE 16:LIFETIME PREVALENCE OF PSYCHIATRIC DIAGNOSIS AMONG

HIV POSITIVE AND NEGATIVE PRISONERS

124
Absence of psychiatric
illness
116

HIV negative
HIV positive

76
Presence of psychiatric
illnesses
84

Frequency p=0.4

HIV positive (%) HIV negative (%)

Presence of 84 (42.0) 76 (38.0) 160 (40.0)
psychiatric
illness
Absence of 116 (58.0) 124 (62.0) 240 (60.0)
psychiatric
illness
Total 200 200 400 (100.0)
OR = 1.18 (95% CI 0.79 – 1.76) ‫אּ‬2 = 0.67; 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

Psychiatric Diagnosis HIV Positive (%) HIV Negative %) Total

Major Depression 22 (25.9) 17 (22.4) 39 (24.2)

Psychotic Disorders 23 (27.1) 11 (14.5) 34 (21.1)

Adjustment Disorder 13 (15.3) 19 (25.0) 32 (19.9)

Substance-induced psychosis 10 (11.8) 9 (11.8) 19 (11.8)

Anxiety Disorders 4 (4.7) 4 (5.3) 8 (5.0)

Cyclothymia 3 (3.5) 5 (6.6) 8 (5.0)

Bipolar I disorder 2 (2.4) 5 (6.6) 7 (4.3)

Dysthymia 2 (2.4) 2 (2.6) 5 (3.1)

Substance-induced Mood disorder 3 (3.5) 2 (2.6) 5 (3.1)

Obsessive Compulsive Disorder 2 (2.4) 1 (1.3) 3 (1.9)

Bipolar II disorder 0 (0.0) 1 (1.3) 1 (0.6)

Total 84 (100) 76 (100) 160 (100.0)

43
 HIV Positive (%) HIV Negative (%)

Major Depression 22 (26.2) 17 (22.4) 39

Psychotic disorders 33 (38.3) 20 (26.3) 53

(including substance-

induced psychosis)

Adjustment disorders 13 (15.5) 19 (25.0) 32

Others 16 (19.1) 20 (26.3) 36

Total 84 (100) 76 (100) 160

‫אּ‬2 = 5.01; df=3; p=0.2

Among HIV positive prisoners, the prevalence of psychotic disorders and major

depression represented about 27.1% and 25.9% respectively. These were the

most prevalent psychiatric illnesses among HIV positive prisoners as illustrated in

the Figure 17. This was followed by adjustment disorder and drug induced

psychosis.

However, in HIV negative prisoners the highest prevalence of psychiatric illness

was Adjustment disorder which represented 25.0% of overall HIV negative

prisoners participated in this study. This was followed by major depression

(22.4%), psychotic disorders (14.5%) and drug-induced psychosis (11.8%).

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

shown in the figure 18.

FIGURE 18: Lifetime prevalence of substance-related diagnosis

No substance related
diagnosis, 71, 18%

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

HIV Positive (%) HIV Negative (%)

Presence of substance-related 198 (99.0) 131 (65.5) 329 (82.3)
diagnosis
No substance-related 2 (1.0) 69 (34.5) 71 (17.8)
diagnosis
Total 200 (100.0) 200 (100.0) 400
OR = 51.78 (95% CI 13.39 – 443.52) Fisher exact test =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

figure 19. There was a significant association between having substance-related

diagnosis with the contraction of HIV. 99.0% for those with HIV positive had been

found to have lifetime substance-related disorders.

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

interviewed in this study.

FIGURE 20: Prevalence of prisoners using one versus more than one illicit drugs

Using one illicit substance Using more than one substance

Using one illicit

substance, 94, 29%

Using more than one

substances, 235, 71%

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

HIV Positive (%) HIV Negative (%)

One illicit drug 45 (22.7) 49 (37.4) 94 (28.7)
More than one 153 (77.3) 82 (62.6) 235 (71.3)
illicit drugs
Total 198 (100.0) 131 (100.0) 329 (100.0)
OR = 0.50 (95% CI 0.30 – 0.81) ‫אּ‬2 = 8.16; 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

them or equivalent to 92.4% of them had been taking opioids.

FIGURE 22: Patterns of illicit drugs use among prisoners

304

Frequency

193

146

53

Amphetamines Cannabis Opioids Sedatives Solvents

This was followed by cannabis which accounted about 58.7% of 329 prisoners.

Amphetamines consumption also appeared to be high as well. It represented

about 44.4% of them. The use of solvent among prisoners population as shown

in this study is negligible.

49
 FIGURE 23: Opioids consumption among HIV positive and negative
prisoners

22

Never Used Opioids

HIV Negative
HIV Positive

109

Using Opioids

195

Frequency p= 0.000001

HIV Positive (%) HIV Negative (%) Total

Using Opioids 195 (98.5) 109 (83.2) 304 (92.4)
Never Used 3 (1.5) 22 (16.8) 25 (7.6)
opioids
Total 198 (100.0) 131 (100.0) 329 (100.0)
OR = 13.11 (95% CI 3.79 – 69.50); Fisher exact test = 0.0000003

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

prisoners had never used opioids in their lifetime.

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

HIV Positive (%) HIV Negative (%)

Using Cannabis 121 (61.1) 72 (55.0) 193 (58.7)
Never used 77 (38.9) 59 (45.0) 136 (41.3)
cannabis
198 (100) 131 (100) 329
OR = 1.28(95% CI 0.82 – 2.01) ‫אּ‬2 = 1.23; 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

significant association between cannabis consumption and contracting HIV. The

overall figure of cannabis consumption among prisoners participated in this study

was about 58.7%.

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

HIV Positive (%) HIV Negative (%)

Using 88 (44.4) 58 (44.3) 146 (44.4)
Amphetamines
Never used 110 (55.6) 73 (55.7) 183 (55.6)
amphetamines
198 (100.0) 131 (100.0) 329
OR = 1.01(95% CI 0.65 – 1.57) ‫אּ‬2 = 0.0009; 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

44.4% of prisoners used to consume amphetamine as shown in the figure 25.

There is no clear association between amphetamine consumption and HIV

status. As most preparation is in the form of oral rather than injection, this could

not lead to HIV infection. However, the consumption of amphetamines in

Malaysia is on the rise.

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

HIV Positive (%) HIV Negative (%)

Using Sedatives 45 (22.7) 8 (6.1) 53 (16.1)
Never Used 153 (77.3) 123 (93.9) 276 (83.9)
Sedatives
198 (100.0) 131 (100.0) 329
OR = 4.52(95% CI 2.06 – 9.95) ‫אּ‬2 = 16.12; p=0.00006

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

positive had taken sedatives.

53
.

FIGURE 27: Prevalence of Alcohol Related Disorder among

prisoners

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

FIGURE 28: Prevalence of Alcohol Related Disorder Among HIV positive

and negative prisoners

167
No Alcohol related
disorder
165

HIV Negative
HIV Positive

33
Presence of alcohol
related disorder
35

Frequency p=0.8

HIV Positive (%) HIV Negative (%)

Presence of alcohol related 35 (17.5) 33 (16.5) 68 (17.0)
disorders
No Alcohol related diagnosis 165 (82.5) 167 (83.5) 332 (83.0)
200 (100.0) 200 (100.0) 400
OR = 1.07(95% CI 0.64 – 1.81) ‫אּ‬2 = 0.071; p=0.8

55
 FIGURE 29: Table summarising the sociodemographic data, criminal profile,

high risk behaviour, psychiatric diagnosis and substance and alcohol-related

disorders among HIV positive and negative male prisoners.

HIV positive HIV negative P-value

Sociodemographic data:

Age:

Mean (years) 37.1 (+7.3) 34.2 (+9.4)

Mode 37 28

Race (%): 0.2

Bumiputera 138 (69.0) 123 (61.5)

Chinese 27 (13.5) 27 (13.5)

Indian and others 35 (17.5) 50 (25.0)

Religion (%): 0.99

Muslim 146 (73.4) 145 (73.6)

Christian 13 (6.5) 25 (6.1)

Buddhist 18 (9.0) 35 (8.6)

Hindu 22 (11.1) 45 (11.7)

56
Marital Status (%): 0.0

Single 132 (66.0) 108 (54.0)

Married 28 (14.0) 66 (33.0)

Divorced/Widower 40 (20.0) 26 (13.0)

Highest Level of Education (%): 0.8

Up to primary (age of 12) 51 (25.5) 57 (28.5)

Up to 15 years 83 (41.5) 78 (39.0)

Up to 18 years 16 (8.0) 20 (10.0)

Holding SPM or higher qualifications 50 (25.0) 45 (22.5.0)

Employment Status (%):

Employed 77 (38.5) 83 (41.5) 0.54

Unemployed 123 (61.5) 117 (58.5)

Income (%): 0.7

Less than RM500 24 (12.0) 25 (12.5)

RM500-RM799 16 (8.0) 24 (12.0)

RM800-RM1199 47 (23.5) 44 (22.0)

RM1200-RM2399 77 (38.5) 69 (34.5)

Above RM2400 36 (18.0) 38 (19.0)

57
Criminal Profile (%): 0.0000

Substance-related 121 (60.5) 78 (39.0) 0.00001

Property-related 33 (16.5) 38 (19.0) 0.3

Against Human 5 (2.5) 38 (19.0) 0.00000

Others 41 (20,5) 46 (23.0)

Presence of high risk behaviour (%):

Presence of Sexual Contact 113 (56.5) 99 (49.5) 0.16

Intravenous Drug Use (IVDU) 189 (94.5) 54 (27.0) 0.00

Blood Transfusion 25 (12.5) 17 (8.5) 0.2

Presence of psychiatric diagnosis (%): 84 (42.0) 76 (38.0) 0.4

Psychiatric Diagnosis (SCID-I) (%): 0.2

Major Depression 22 (25.9) 17 (22.4) 0.3

Psychotic Disorders 23 (27.1) 11 (14.5) 0.07

Adjustment Disorder 13 (15.3) 19 (25.0) 0.1

Substance-induced psychosis 10 (11.8) 9 (11.8) 0.5

Bipolar ( I & II ) 2 (2.4) 6 (7.9) *

Dysthymia 2 (2.4) 2 (2.6) *

58
Presence of substance-related disorders (%): 198 (99.0) 131 (65.5) 0.00

Type of substance used (%):

Opioids 195 (98.5) 109 (83.2) 0.000001

Cannabis 121 (61.1) 72 (55.0) 0.3

Amphetamines 88 (44.4) 58 (44.3) 0.98

Sedatives 45 (22.7) 8 (6.1) 0.00006

Polysubstance related disorders (%): 153 (77.3) 82 (62.6) 0.004

Presence of alcohol-related disorder (%): 35 (17.5) 33 (16.5) 0.8

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

Australia prison by Butler77 showed 38% of sentenced prisoners have psychiatric

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

positive prisoners may even exceeds 50%.Therefore, there was no significant

different between psychiatric illnesses and the status of HIV. It made no

difference if prisoners have HIV positive or negative in term of having psychiatric

illness.

However, this rate is still higher as compared to prevalence rate of psychiatric

morbidity in general population in Malaysia which is 10.7%.78

Entry to the prison by itself could be a source of stress. There is a punitive

condition in the prison can precipitate psychiatric morbidity such as Major

Depression and Adjustment Disorder regardless of their HIV status. With a small

cell, overcrowding and strict disciplinary regulations, these are among the

sources of stress for all prisoners.

60
There are some prisoners who already had psychiatric morbidity prior to the

imprisonment. The situational condition of prison could also triggered episode of

psychiatric morbidity. This showed that prison has high rate of psychiatric

morbidity compared to community.77

Overall, the highest prevalence of mental illness was Major Depression which

accounted for 24.2% of those who had mental illness (other than substance-

related disorders). This was followed by Psychotic Disorders (Schizophrenia,

Schizoaffective, Schizophreniform, Delusional Disorder and Brief Psychotic

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

prisoners64 which found 81.2% had mental illness (DSM-IIIR).

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

psychosis among prisoners. This could be explained that there is higher

prevalence of substance-related disorders especially cannabis and

amphetamines (58.7% and 44.4% of those who took illicit drugs respectively)

among prisoners which may lead to perceptual disturbances.

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.

Firstly, behaviours secondary to Major Depression such as intensification of

substance abuse, exacerbation of self-destructive behaviours and promotion of

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

symptomatology rather than depressive syndrome79. In this study, in contrast to

HIV positive prisoners, HIV negative prisoners have higher rate of Adjustment

Disorder which indicate that lesser severity of mood disorders in comparison to

Major Depression that more common in HIV positive.

Substance-related disorders are higher among prisoners which correlate to HIV

infection and psychiatric illness.4 It is also known that persons with substance-

related disorders or homosexual represent minority group among general

62
population. This subsequently contributes to the higher rate of major depression

among the minority group. Major Depression could render proper treatment for

HIV positive. Treatment compliance towards medication, quality of life and

treatment outcome are reduced in Major Depression with medical illness such as

HIV81.

Psychotic Disorders represented the highest prevalence of 27.1% among HIV

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

significantly associated with the presence of substance-related diagnosis. There

are studies that have shown that comorbidity of substance abuse is very high

among psychiatric patients especially psychotic illness. In a study by Carol

(2005) et al. done in a emergency department recognised that 96.5% of 400

patients with psychotic symptoms have fitted into both DSM-IV diagnosis of

substance-induced and primary psychosis disorders.82

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

as schizophrenia itself would result in difficulties accessing care, affording

medication and adhering to complex treatment regime.

There is no surprise that drug induced psychosis and substance-induced mood

disorder represented about 17% of prisoners with psychiatric disorder. It has

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

experience substance-induced psychosis or mood disorders.

Substance-related diagnosis among prisoners with and without HIV

It has been highlighted in this study, 82% of all prisoners have been identified to

have substance-related diagnosis which includes opioids, amphetamines,

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

diagnosed with antisocial personality disorder85. Therefore there would be high

prevalence of prisoners has history of substance-related disorders.

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

self medicated themselves by taking illicit drug.55

Among prisoners who were found to have HIV positive, there was a very

significant association with the presences of substance-related disorders. There

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

intravenous method as a mean of administering drug as shown in the figure 11.

The most popular illicit drug among prisoners population is opioids. It

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

remanded in the hospital is cannabis which represented 86.3% of all patients.

Opioids however, represented 40.6% of all patients. In the United Kingdom,

among sentenced prisoners population, 79% has ever used cannabis, 36% for

heroin and 49% amphetamines85. Higher proportion in cannabis use in the United

Kingdom is probably due to its legalisation.

In general population, there is high comorbidity between schizophrenia and

cannabis88. Amphetamines which are a stimulant can also lead one to

experience hallucination and delusion. It has also been associated with

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

HIV spread once they were discharged from prison.

This treatment should begin at the point of entering prison. This moment would

be a transient critical moment for prisoners with history of substance-related

disorders. They could have transient critical period when they may experience

severe psychological and physical withdrawal. Therefore, mental health

professional should involve actively in treating prisoners especially at this

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

lead to one‟s emotional crisis e.g. suicidal act and aggression.

Mental health professional who in-charge of prison themselves, should be aware

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

into account. Each prisoner should be approached individually which depends on

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

Australia and the United Kingdom, the prevalence of alcohol-related disorders

among sentenced prisoners is 42% and 63% respectively 85, 90.

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

amphetamines. However, only in the amphetamines-related disorders has leaded

to significant association with psychiatric disorders. For cannabis and opioids,

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

cannabis. These findings support that there is high comorbid psychiatric

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

HIV positive, substance-related disorders and psychiatric disorders).79 This study

specifically showed all HIV positive prisoners with Major Depression, Psychotic

Disorders and Adjustment Disorder also had comorbidity of substance-related

disorders.

It can also be hypothesised that opioids-related disorders and psychotic

disorders is a highly comorbid condition among HIV positive prisoners. This is

because in this study HIV positive prisoners demonstrated high psychotic

disorders and also significantly high consumption of opioids.

Risk Factors for HIV

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

in term of history of sexual contact and their HIV status.

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

transfusion. There was no statistically significant different in history of receiving

blood transfusion between HIV positive and negative prisoners.

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

history of IVDU is significantly different between HIV positive and negative

prisoners. There was very high chance for those who are HIV positive in the

prison to have history of IVDU.

As there is no significant attribution of sexual contact and low prevalence of

history of receiving blood transfusion among prisoners, the main mode of

transmission of HIV is via needle exchange in intravenous drug use. This is

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

HIV for IVDU92.

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

and access to clean needles have been introduced internationally.

In Malaysia, there was manual released by the Ministry of Health as a guideline

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

awareness about HIV/AIDS, to detect early illness, to prevent transmission

among prisoners and to provide healthcare, treatment and support for prisoners

with HIV/AIDS.

HIV/AIDS related activities in the Malaysian Prisons include health education

which is given by the appointed counsellor among the health officers. This

programme is managed by the appointed counsellor among the prison officers.

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

before and after the test.

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

implemented in order to reduce risk of transmission.

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

highest prevalence among Muslim is corresponded to the highest prevalence

among Bumiputera ethnicity.

As in the figure 3, the highest prevalence of marital status is single. This

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

sexual contact, there is a danger of spreading the HIV virus homo- or

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

more accessible up to secondary school most of the youth has achieved

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

has been associated with incarceration population.

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

in criminal justice proceedings.94 Therefore, regardless of HIV status, low

education has been a prominent among prisoners.

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

as compared to general population. Antisocial personality is usually preceded by

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,

oppositional defiant disorder, depression and dysthymia than general

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

illnesses among prisoners.

72
In term of employment, 60% of prisoners were unemployed prior to

imprisonment. There is high level of unemployment among prisoners as shown in

other study.94 Higher unemployment could reflect of their lower academic

achievement where to obtain decent or permanent job, most employers would

enquire about one‟s academic qualification. Whenever there is unemployment,

there would be tendency for them to find income through illegal way that may

also contribute them to imprisonment.

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

academic achievement and unemployment among prisoners.

Even though there was high unemployment among prisoners, their monthly

income was high. The mode of their income was in the range of RM1200-

RM2399. The higher rate of income between RM1200-RM2399 is possibly

contributed by illegal sources. Their participation in the illegal and vice activities

could have also leaded them to imprisonment. This would also indicate publicly

how they have posed economic burden through illegal activities.

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

participated in this study. As suggested by Brewer et at (1992)93, there was about

50% of criminal offenses leading to incarceration are drug-related. Those who

had HIV positive status and committed substance-related crime represented

73
about 61% of all HIV positive prisoners. This showed that there is a tendency for

this subgroup of prisoner to involve in substance-related crimes. As there was

very high proportion of those with HIV positive to have substance-related

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

prisoners had committed substance-related crime, it is crucial to identify for those

who has substance-related disorders for treatment opportunities.

74
CONCLUSIONS
Prison population were mainly composed of low socioeconomic group. Most of

them were Malay which portraying ethnic distribution in general population.

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

of sociodemographic profiles between HIV positive and negative prisoners.

Substance-related crime represented about half of total crime committed by

prisoners. Almost two third of HIV positive prisoners were sentenced for

substance-related offences. There was none of HIV positive prisoners in this

study committed sex-related crime. There was also low rate for offences against

human that were committed by HIV positive prisoners.

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.

The main psychiatric diagnosis was Major Depression in overall population of

prisoners. However, among HIV positive prisoners Psychotic Disorders

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

15.3% respectively. Among HIV negative prisoners, the predominant psychiatric

diagnosis was Adjustment Disorder (25%). Major Depression and Psychotic

Disorders accounted 24.2% and 19.9% respectively. The fourth common

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

drugs that was consumed by prisoners. It has been shown to be statistically

significant among HIV Positive prisoners to consume opioids rather than other

drug. Another 58.7% and 44.4% of prisoners had consumed cannabis and

amphetamines. The alcohol-related disorders among this population have been

found to be lower than substance-related disorders. It was not associated with

HIV status of prisoners. The use of opioids and cannabis do not suggest any

different between HIV positive and negative prisoners.

76
Opioids-related disorders and psychotic disorders are common co-existence

among HIV positive prisoners. HIV positive prisoners demonstrated high

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

this group of prisoners.

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

illness as shown in this study. Therefore, psychiatric help should be provided

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

by prisoners should be as accessible as those in general population. 96

2. Treatment for substance-related disorders e.g. methadone or buphrenorphine

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

prisoners. Hence, prisoners who have substance-related disorders should

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

prison, they could be guided in term of biopsychosocial treatment of substance-

related disorders and HIV treatment. Other harm reduction programme such as

needle exchange among IVDU should be taught or introduced to prisoners in

order to reduce spread upon their discharges from prison. Needle exchange

programme has been shown effective scientifically97.

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

proportion of prisoners had substance-related disorders and also psychiatric

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

prison as substance-related and psychiatric disorders are higher than general

population. Even there was also large proportion has multiple illicit drugs use.

This is a complex situation psychiatrist should be able to deal with this

circumstances. Withdrawal from dependency from substance could lead to

medical complication if it is not dealt accordingly. When one successfully stop

from using illicit drugs, this consequently would reduced the rate of recidivism 98,

Hence, finally the prison would be less crowded as lesser substance-related

offences and the public is safer.

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

outside prison. Moreover, most of prisoners were from low socioeconomic

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

limitations in this type of study.

2. During the interview, prison officer was always around to prevent any

unwanted incident. Therefore, there was possibility that the prisoners did not tell

the whole truth of their history.

3. Prisoners who was waiting for capital punishment was excluded. This was

because there are tight procedures involved if they were to be interviewed.

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

communicated in Malay language. Therefore, for the purpose of interpretation of

results should take this factor into consideration.

5. This study only looked at lifetime prevalence of mental illness among

prisoners. There were a very small number of prisoners who experienced mental

illnesses at the time of interview which was unable to be analysed statistically.

However, those with substance-related disorders or other psychiatric disorders

should have psychiatric follow-up in order to prevent relapses.

80
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Thank you:

1. Department of Prison, Ministry of

Internal Security

2. Director and Staff of the Kajang Prison

3. Professor Hussain Habil

4. Professor Dr. Nor Zuraida Zainal

5. Professor Dr. Mohamed Hatta

Shaharom

6. Dr. Sandra Springer

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