Taiwan shrinks HIV infections with strategies of harm reduction :: BiotechEast - Taiwan and China biotechnology, medical devices, pharmaceuticals, ^¤å½s×, ^¤å×§ï ::

(By Chris Sung)

10 April, 2007

(BiotechEast reporter Chris Sung recently sat down with Dr. Hou Sheng-mou, Minister of Health, to discuss the Taiwan government's recently enacted 'Harm Reduction' program aimed at intravenous drug users. This program appears to have significantly reduced the number of reported HIV/AIDS cases in Taiwan, a number which had been rising dramatically in recent years. The resulting article is based on these discussions and appeared in the April 5, 2007 edition of Nature Magazine in its 'Spotlight on Taiwan' special feature.)

"When I first took over the decision making role in 2005 for Taiwan's AIDS prevention policy, I was shocked by the then rapid month-by-month increase in the number of HIV infected patients. I realized then that we had to do something, and do it now." Dr. Hou Sheng-mou, Minister of Health, Taiwan R.O.C.

Rapid increase in AIDS cases cause for concern
With the first case of AIDS in Taiwan reported in December 1984, there were still fewer than 500 known cases as of 1993. Men accounted for 95% of these cases, with the main route of transmission being unsafe sexual behavior. Taiwan's Executive Yuan, the Cabinet-level branch of the government, approved the "AIDS Control Plan" in 1994; this plan is currently in its fourth phase. There were a cumulative 13,702 reported cases of HIV infection as of the end of 2006, and the infected population increased by 17% annually from 2001 to 2003. The number of newly reported cases reached 1,520 in 2004, exceeding 1,000 for the first time ever; the annual increase rate soared to 77% during that year.

According to Taiwan's Department of Health (DOH), the number of HIV cases among intravenous drug users (IDUs) first entered double figures with 18 cases in 2002, and then entered triple figures with 624 cases in 2004, an increase of seven-fold over this one-year period. IDUs accounted for 41% of all reported cases during the latter year. This indicated that the rate of HIV infection among IDUs was rising sharply, primarily because drug users often shared needles and heroin diluents.

The World Health Organization (WHO) has warned that the number of AIDS cases would grow explosively as soon as the HIV virus makes its way into the IDU population. And although the US Centers for Disease Control and Prevention advised that adequate control measures be implemented before the incidence of AIDS in the IDU population reaches 5%, Taiwan is well past that point now, with its incidence of AIDS among IDUs already as high as 13%.

AIDS crisis situation calls for immediate action
Responding to this rapid increase in spread of HIV and AIDS, Taiwan's Centers for Disease Control (CDC) secured the Executive Yuan's budget of NT$80 million (US$2.4 million) and its full support to implement a harm reduction strategy, patterned on successful programs in use overseas.

Harm reduction is a public health philosophy based the belief that some people always will perform certain activities-such as promiscuous sex or drug use-that may cause themselves or society harm. Harm reduction philosophy believes there is a moral responsibility to reduce the harm caused by risky activities, rather than to insist on an unrealistic and often unenforceable blanket prohibition of such activities. Considered to be a ‘progressive' philosophy, successful harm reduction programs have been in place for many years in Europe, Australia, New Zealand, Canada and the United States. Such programs have been shown to reduce the incidence of HIV and AIDS amongst the IDU population, but in Asia the concept is unfortunately still new.

"When I first took over the decision making role in 2005 for Taiwan's national AIDS prevention policy, I was shocked by the then rapid month-by-month increase in the number of HIV infected patients. I realized that we must do something, and do it now," said Dr. Hou Sheng-mou, Taiwan's Minister of Health.

Taiwan's harm reduction program was thus drafted by the CDC in 2005. The program consists of three parts: expanded HIV screening and monitoring of drug users; a needle exchange program; and drug replacement therapy using methadone. Support measures such as tracking, education, and addiction treatment referral programs have also been put into place.

Following inter-departmental discussion and study during the second half of 2005, the government decided to implement the program on a trial basis in four of Taiwan's 23 administrative regions, namely Taipei County, Taipei City, Taoyuan County (all in northern Taiwan) and Tainan County (southern Taiwan), starting in 2006.

The trial program was deemed a resounding success, resulting in a significant reduction in the number of new HIV cases. The largest reduction occurred in Tainan County, where the infection rate has fallen from 13.6 persons per 100,000 prior to implementation (Nov. 2004-Oct. 2005), to 7 persons per 100,000 one year after implementation of the program (Nov. 2005-Oct. 2006). In addition, the frequency of heroin use dropped from approximately 37 times per week per intravenous drug user prior to treatment to 0.07 times per week after users attended a six-month program.

Preliminary assessments of Taiwan's harm reduction program by the DOH confirmed its effectiveness, and the program was expanded to include the entire country starting in July 2006.

Nationwide, the results now speak for themselves. The 2,942 new HIV infection cases in 2006 represented a drop of 457 cases from the 3,399 cases in 2005, reversing a twenty-year growth trend. In addition, the percentage of all newly reported cases attributable to IDUs fell from a high of 72% in 2005 to only 60% in 2006.

There have been extra benefits as well.

"Overseas experience-for example, in New York-has shown that harm reduction programs often lead to a reduction in crime. We found this to be the case in Taiwan as well. For example, after the implementation of the program in Tainan County, the number of burglaries in the area fell by 11%, and robberies fell by 27%, compared with the previous year," said Dr. Hou.

Key factors for program's success
• Changes in attitudes: It is now clear that the main pathway of HIV transmission shifted from unsafe sexual behavior earlier on to the sharing of needles by IDUs. This has helped put drug users and the problem of drug use in the limelight. Thanks to inter-departmental cooperation at the central and local levels, change has occurred in drug control thinking among judicial and police units and health agencies, from viewing drug users as "criminals” to regarding them as "patients." Since the Tainan County Government was the quickest to change its attitudes and has displayed the best compliance, it's not surprising to see that this county has also achieved the most significant results.
• New channels for contact, education and counseling: The government has actively provided health education and counseling to persons on probation and drug-addicted inmates of correction agencies since the implementation of the harm reduction program. Furthermore, the needle exchange program and replacement therapy provide an interface and platform for contact with IDUs, allowing the government to provide health education and counseling, as well as encouraging IDUs to leave their hiding places and enroll at addiction treatment organizations.
• Expansion into a nationwide program: According to an analysis conducted by Australia's Dr. Alex Wodak, an expert in the field of harm reduction policy and a driving force behind Australia's highly-successful program, the government's July 2006 decision to expand the harm reduction program was the key to its success and the reason for the clear results seen today.

The initial goal of Taiwan's harm reduction program was to reduce the incidence of HIV and AIDS. According to a consensus reached among judicial and police units and health agencies, the police focus is now on making arrests of drug dealers, and police officers have pledged not to attempt to tail and ensnare drug users participating in the clean needle program. In addition, the prosecutorial system is offering drug users the choice of replacement therapy and deferred prosecution.

A complete range of harm reduction measures have now been implemented in Taiwan. Thanks to the pragmatic approach to harm reduction policies adopted by all involved, from health agencies to the judiciary and police authorities, the program has been successful. Importantly, data shows that public opinion has now shifted from strong opposition at the start to full-scale support today.

"The greatest challenge in promoting a harm reduction program is to change people's mindset; from thinking of IDUs as criminals to thinking of them as patients. One reason we've had success in this area is because of the good cooperation from the judicial and police authorities, who together came to agree with this philosophy within such a short time," said Dr. Hou.

Nevertheless, the number of new HIV cases attributable to sexual behavior maintained an increasing trend in 2006, and the percentage of all HIV cases attributable to this cause rose from 24% to 35%. This suggests that infection via sexual behavior may become a new crisis. Taiwan's government continues to publicize the "ABC" steps to AIDS control; where A stands for Abstain, B stands for Be faithful to one partner, and C stands for always use Condoms correctly.

There are plans also to take advantage of Taiwan's distinctive betel nut culture-roadside stalls selling mildly-narcotic betel nuts, chewed by a high percentage of Taiwan's blue collar male population-and ensure that condoms are on sale at all betel nut stands. It's all part of the government's drive to increase the availability of health education and reduce the percentage of new HIV cases attributable to sexual behavior, explained Dr. Hou.

"Taiwan has been intentionally isolated from the international community. Because it did not receive timely warnings from the WHO, Taiwan missed the opportunity to adopt preventive measures before the explosion of HIV transmission in its IDU population that we saw leading up until 2005," said Dr. Hou.

"Taiwan's health agencies have nevertheless learnt from other countries' control strategies and experiences, conducting AIDS control and treatment training and education, and sending personnel to study relevant topics in Australia, North America and Hong Kong. We hope that we will now also be able to offer our AIDS control experience and knowledge to less-developed countries via AIDS reduction cooperation programs such as the ones currently underway in Vietnam and Chad. Above all, we want to fulfill our duties as global citizens and make a real contribution to the global community."

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