 Thank you Kasia and good morning everybody and welcome once again to Hazy Kuala Lumpur. I hope you're all not suffering too much and staying indoors. Okay and I've been asked to speak to the issue around the tension of the current drug control regime and and harm reduction. Before I do that I thought it was it would be prudent to review the human cost as Ruth said in her opening statement of the current war on drugs and to take a look at it's kind of the devastation that's taking place in Mexico with the war on drug that's happening over there and as you can see here since it was leashed there have been more than 150,000 Mexicans killed in the crossfires between the military and the drug cartels in Mexico much more than the number of civilian deaths in Afghanistan and Iraq put together. Closer to home of course in 2003 we had the one drug set killed in just three months approximately 2,800 people in extra judicial killings in Thailand and of course I think many countries in Asia including my own including Malaysia still subscribe to the death penalty for drug trafficking often for very very small amounts of drugs. Now on to harm reduction I think three decades after the three decades since the HIV epidemic the the evidence around the effectiveness of the needle syringe program and opiate substitution therapy the two core interventions in HIV prevention amongst people who use drugs it's no longer no longer can be disputed of course but the progress in implementing harm reduction has been slow. 77 countries in 2008 had needle syringe program and that six years later has increased only to 90 with opiate substitution therapy we have 63 countries in 2008 and in 2014 only 80 countries have implemented OST and of course there are many countries in former Soviet Union and Central and Asia that still are not able as you heard to implement OST. And why is this so? This UNHGAP report that was published last year clearly states that one of the top four reasons why people inject drugs in the context of the HIV epidemic are being left behind it's the number one number one reason is the criminalization and punitive laws the absence of inadequate prevention services the widespread societal stigma and and the lack of investment in my mind number two three and four are pretty much related to number one since the existence of the criminalization and punitive laws I think directly or indirectly result in two three and four so the report further went to state that between 56 to 90 percent of people who inject drugs will be incarcerated at some stage in their lives the majority of national drug control policies and supply reduction in law enforcement against any drug use and people who use drugs are often collateral victims of those interventions and in various parts of the world possession of clean syringes become evidence for police harassment thereby deterring safe injecting practices and in particularly in this region compulsory detention centers and prisons have become commonplace so in Malaysia with the expansion of the HIV epidemic in the early 2000 and the failure to achieve the millennium development goal much to sorry against public opinion and much controversy the Malaysian government at the time gave the go-ahead to implement needle syringe program and opiate substitution therapy and to date we've had more than 85 000 people access a needle syringe program mostly through partners of the Malaysian AIDS Council whereas the opiate substitution therapy is implemented by the Ministry of Health as well as private practitioners and to date we've had close to 75 000 people at any point receive OST and this has led to a remarkable decrease in as you heard in the opening ceremony as well in the number of new reported cases of HIV that's amongst people who use drugs Carl said with any new programs we must evaluate we must evaluate the cost effectiveness we must evaluate the benefits and and we did just that we evaluated because although there was acceptance within the government and to a certain extent within with the public I think given the laws that we have here in Malaysia both the needle syringe program and the opiate substitution therapy I think operates under a cloud of well not so much suspicion but it's not fully sanctioned I guess given the laws that we have so we evaluated the programs and what it showed was from the time that it was implemented in 2006 to 2013 it was estimated that about 14 000 new HIV infections were averted and if you projected that into 2050 at the current coverage of both the current rates of coverage of both the needles range and the opiate substitution therapy we would have averted 100 more than 100 thousand we will we will avert more than 100 000 new infections projecting forward into 2050 at a relatively low coverage that we have and this would have saved the Malaysian government 47 million ringgit in current terms which is you know the Malaysian ringgit has really plummeted in the last six months or so it's probably about 10 million US dollars in the in the between 2006 and 2013 209 ringgit projecting forward to 2023 and 2050 to about 100 million ringgit so you would have thought with the evidence that not only was it saving lives but it was also but it has also saved the government money that we would see some action in terms of new drug policies but given these laws that we have we were still fighting a very tough battle so we have the dangerous drug acts in from 1952 where there's mandatory death penalty for drugs for possession of drugs of more than 200 grams of cannabis or more than 15 grams of heroin this compulsory rehabilitation and supervision orders even once you've been released from the compulsory detention centers and and so forth and so forth we kind of saw a bit of light in 2010 when the national drugs agency decided to then transform the compulsory detention centers we had in 2010 about 28 of the centers with around 15 000 people detained in the centers so we had a very progressive director general of the national drugs agencies who saw the evidence who saw the impact that the community-based opiate substitution therapy that was being implemented by the ministry of health and private practitioners had on the lives of people who use drugs and so she decided to and the national drugs agency decided to transform these detention centers back in 2010 and very quickly transformed about I think into 17 cure and care clinics around the country and we did a quick evaluation of some of these clients who were attending the cure and care centers 313 people were interviewed back in 2013 and as you can see there the very positive outcomes that the clients shared with us in terms of their attending the curing care centers we then felt that we needed to do a comparison between the compulsory detention centers and the cure and care clinics so we embarked on a longitudinal observational study between the two groups one was a one-year follow-up post-release from the detention center and at the time of enrolling in the cure and care clinics and what we found was no surprise I think we all knew even before this formal study was done that the rates of relapse upon release from the cure and care center from the from the compulsory detention centers was very high and as you can see here the the Kaplan-Meier separation leaves us no doubt as to which of the treatment of the treatment model is preferable or in this lovely infogram from David Wilson from the World Bank as you can see community opiate substitution therapy as as shown by the CNS the cure and care was six times more effective and 12 times more cost and from the previous study 12 times more cost effective as detention. However as I showed you there's a there's a prologue to this is it prologue or epilogue prologue isn't it epilogue. Given that the drug laws that I just showed you still exist and haven't been changed and the unwritten drug policy that we have remain unchanged many of you in the room know that the cure and care clinic that was that was implement implemented in 2010 up to about 2012-2013 which was voluntary and had a very comprehensive treatment including psychosocial support etc probably is a shadow of itself right now. So I think this is a real example of the tension that can exist if current laws and policies remain as they are despite the good intentions that people you know implementing these programs have in providing better evidence-based treatment programs for people using drugs. So it leaves us it leaves me actually no doubt in in the need for you know the not just national but global reform in drug policies and laws as I have witnessed here myself I mean despite the so-called success of the harm reduction program we're still forever two steps forward and one step back unless we align the public health initiatives with that of criminal justice. I just want to leave with these words from Richard Horton and Pam Dess in the editorial of the special series on HIV and people who use drugs that was published in 2010 in the Lancet. We want to see inappropriately aggressive state-sponsored hostility to drug users replaced by enlightened scientifically driven attitudes and more equitable societal responses. We recognize the barriers to these hopes are many and deeply rooted across continents and cultures but we also know that science can catalyze unprecedented social change and social change is what is needed for millions of marginalized people infected with HIV and use drugs who use drugs. I also want to leave you in 2006 when I did my plenary in Mexico I shared with you this video of a Malaysian drug user who I think has now passed on. It's a real reminder I get very emotional when I'm tired and have not had enough sleep of the human cost of drug use. I have to my family. I have to my close friends about things like you know because I always fail when I stop. I want to stop all this fail so I told them sometimes when I'm sick even if you put my mom my wife my children and you put a straw there a tube what I'm sick not what I'm well what I'm sick okay if you ask me to choose now choose either one I will still take my medicine first I will still take the heroin first all the time I try to stop my fail I never get want to give up each time I fail I look for the next it's about 30 hours now since I had my last heroin it's a long time yeah it's a long time a long time more than that now I guess about a day and a half now people say that it's impossible for somebody like you to give up I don't believe they say that I don't want to take it they say especially these people who say that I'm not the people who are sick they are not the junkies they are they are normal people of course everybody wants to live a better life but I just can't believe I don't want to be a junkie all my life I want to live thank you adiba we'll ask marie to take the stage now thanks