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The Real Risks of Fishing: Social Networks and HIV among Drug-using Fishermen in Malaysia Brooke S. West, Martin Choo, Nabila El-Bassel, Adeeba Kamarulzaman, Louisa Gilbert, Elwin Wu July 23, 2012 XIX International AIDS Conference Washington, DC

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Project WAVES is a collaboration between: 1) Center of Excellence for Research in AIDS (CERiA) at the University of Malaya PI: Dr. Adeeba Kamarulzaman Research Team: Martin Choo 2) Social Intervention Group (SIG) at the School of Social Work at Columbia University PI: Dr. Nabila El-Bassel Co-Investigators: Louisa Gilbert, Elwin Wu Project WAVES

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I. Background

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HIV and Drug Use in Malaysia Injection drug use (IDU) is primary mode of HIV transmission: IDUs make up ~70% of all PLWH (Wolfe et al. 2010). HIV prevalence among IDU may be as high as 40% - based on data from 5 cities (Vicknasingam et al. 2009). Drug services are limited and drug use is highly criminalized: Needle-exchange is limited and began only in 2006. Policies include forced drug testing, registration of offenders, flogging and imprisonment for possession, and forced rehabilitation (OSI 2008).

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Fishermen and HIV in Malaysia HIV rates in Malaysian fishing communities are 10 times that of the general population (Kissling et al. 2005). Only 1.3% of the working population is employed in the fishing industry (Department of Statistics Malaysia 2005), but fishermen constitute 3.8% of the total reported HIV cases (Ministry of Health 2008).

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Framework Rhodes (2002) Risk Environment Framework: environmental factors, like social, economic, policy, and physical context, interact at different levels of influence (micro, macro) to shape HIV risk, especially around drug use. Berkman et al. (2000) Networks mediate health and operate at the behavioral level through multiple pathways: (1) Provision of Social Support (2) Social Influence (3) Social Engagement

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II. Research Methods

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Kuantan, Malaysia - Kuantan Fishing Jetty - Balok (fishing village) - Beserah (fishing village) Study Site

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Traditional and Commercial Fishermen Men age 18-55 Reported fishing as primary occupation (6 months of last year) Reported using drugs the last trip to sea or when they returned to shore Multiple Vessel Types: trawler, purse seiners, traditional long boats Malay, Chinese, Thai Study Population

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In-Depth Interviews December 2009 to February 2010 (n=28) Conducted by trained staff in the local language, Bahasa Malayu Interviews ~2hrs long Remuneration: 50 Malaysian Ringgit (50 RM=15 USD) Interviews transcribed in Bahasa Malayu and translated into English

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22/28 fishermen reported that they injected drugs Most commonly used drugs: - Heroin (injected or smoked) - Ketamine - Ice (methamphetamine) - Other Drugs: methadone, ecstasy, cannabis Injectors: reporting injecting an average of 3 to 5 times per day Drug Use Practices

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III. Social Networks and Risk

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Whats Driving Drug Use and Risk? Macro Factors Economics, occupational culture, punitive policies, stigma Social Networks Social influence, support, engagement HIV Risk Perceptions and Behavior

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Macro Factors Shaping Networks & Risk 1) Economics access to cash and informal lending systems 2) Occupational culture drug use is common in the fishing industry and part of the industry 3) Punitive Policies cycle of moving between work, prison and rehab 4) Social Stigma greater acceptability of drug use in fishing community

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Networks: Social Influence 30 year old fisherman about first time he tried drugs: My friends. Try it out first, its fun, just try, have a go, itll make all the stress whatsoever go away. Thats what they said at the beginning. They asked me to give it a go. They wanted me to get involved, didnt they? Ha, like that. I followed because of my friends, so I saw how my friends took drug. After that, I saw how my uncle took drug, so I followed suit. I was influenced by them. 22 year old fisherman about advice on sharing syringes: My friend advised me. He said not to share syringes...he said, dangerous sharing syringes, easily contract disease. He said, ah, HIV could be contracted. At that time, I didnt think of HIV, didnt inject. After I started injectingweve got to be careful with safety...hygiene has to be taken care of.

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Networks: Social Support 27 year old fisherman on emotional support from friends: Sometimes one needs to release tension so when we share, the tension is reduced. [I: So you would talk to your friends? Anybody else? Or just with friends?] Usually with close friends. Not with my family members. I have never expressed nor share with my family...Hmmm usually among drug addicts, we usually look for our own circle. 40 year old fisherman on lack of economic support from friends: Friends are there only when we are well off. When they know that we have a hard life, they wont even look at us. They look at us from far away they will run. Cant depend on friends.

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Networks: Social Engagement 30 year old fisherman on social marginalization: Its bleak. I take drug, others...others despise me. The society, ha, others despise me. Its as if I have been imprisoned, like this, they wont accept me if I want to work for the government....dont you agree? 27 year old fisherman on sense of community: As a drug addict myself, it doesnt matter where I am, we sort of have some connection with those who are similair like us. Its just among us.

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IV. Conclusions

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Networks and Risk Risk is a social process such that social conditions and relationships shape decision-making around HIV risk. Social networks are a key axis along which HIV risk decision-making occurs and risk is defined and managed. Multiple aspects of networks shape how HIV risk is perceived and what people do with risk when confronted with it, both amplifying and attenuating risk..

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TERIMA KASIH!