Taiwan's first needle exchange program, (exchanging non-sterile drug injection equipment for sterile materials) is scheduled to start tomorrow. It failed to get off the ground last month, and without support from the Ministry of Justice and NGOs, critics questions whether it will ever fully materialize.
Despite overwhelming international evidence that HIV (human immunodeficiency virus) infection rates among intravenous drug users can be reduced with comprehensive needle exchange programs (NEP), harm reduction efforts in Taiwan are being thwarted by a judicial system and public that stigmatizes easy access to injection equipment, according to the Center for Disease Control (CDC).
"If we wait for the regulations to be revised and consensus across the board then it will be too late, so we must act now," said director of the AIDS and STDs Division at the CDC, Tsai Su-fen (
ILLUSTRATION: MOUNTAIN PEOPLE
Drug abuse has emerged as the driving force behind HIV transmission in Taiwan in the last three years. Statistics from the Department of Health (DOH) indicate that injecting drug users (IDUs) account for nearly 80 percent of all known infection routes; a dramatic increase from the 1.2 percent of new diagnoses in 2002. There were 556 intravenous drug users infected last year, a rapid surge from the 13 in 2003. In the first six months of this year alone, 925 Additional drug users have tested positive for HIV.
Taiwan's Pilot Program
The CDC is providing NT$30 million in aid to prevent AIDS and a set of guidelines to four counties, Taipei City, Taipei County, Taoyuan County (
The program will run for 18 months, after which it will be reviewed and expanded to include all counties with further funding from the CDC, Tsai said.
Although each county health bureau has designed its own program, the CDC is pushing for sterile needles and syringes to be sold in pharmaceutical outlets across the island.
There is no law prohibiting people from carrying drug paraphernalia in Taiwan and access to sterile needles is both legal and inexpensive at NT$4 per syringe. Many pharmacies, however, opt not to stock injection equipment for fear of attracting unwanted clientele and the police who often loiter nearby watching for dubious purchases (such as a box of 100 syringes), Tsai said.
The CDC has arranged an "informal agreement" with police administration to "illegally tolerate" the plan and not stand outside pharmacies, Tsai said. The spokesperson for the Ministry of Justice would not confirm this agreement and only said the MOJ is still negotiating with the CDC.
"A needle exchange program would be against the law. We do not condone the use of drugs nor do we engage in programs dispersing drug paraphernalia to users," said Huang Jiou-zhen (
The CDC's decision to implement the pilot, amid disagreement over its legality, is based on the success of countries that have seen epidemics averted, controlled or reversed.
A study published in the Health Outcomes International in Australia, and cited by the World Health Organization (WHO), compared HIV prevalence in 103 cities. The infection rate in 36 cities with needle programs declined by 19 percent, but increased by 8 percent in 67 cities without such programs. Furthermore there were no reports indicating unfavorable consequences such as an increase in the frequency of drug use from providing access to injecting equipment.
Too little, too late
While NGOs agree something must be done to curb HIV transmission some find the CDC's proposal impractical.
"Taiwan needs a needle exchange program but how are we [NGOs] going to get the public to support a plan that is considered illegal," asked Ivory Lin (林宜慧), secretary general of Persons with HIV/AIDS Rights Advocacy Association of Taiwan (PRAA).
For the NEP to be effective it would need to reach the suppliers -- the dealers, who can distribute clean needles together with the drugs, Lin said. "I don't think the CDC knows how to get the community involved and without the support of the police how many NGOs are going to engage in criminal activities,'" she asked.
Decreasing the social stigma of having HIV and guaranteeing high-risk groups free health-care services and education should be the CDC's first priority, she said.
The AIDS Control Act (
Fuzzy logic
Other critics of the CDC's pilot program said blaming drug use for HIV transmission also aggravates the situation and makes it difficult for infected persons to get help. Bombarding the public with statistics that finger point needle sharing is misleading, said Tony Lee (
"They [CDC] view these statistics in a mutually exclusive way. If we put all our money and energy into providing clean needles and ignore the risks of unsafe sex then we give the wrong impression to the public," Lee said, adding, "It is more difficult to get IDUs to use a condom than a clean needle."
For him a comprehensive program is supported by drug substitution treatment, medical and counseling support for persons with HIV and most importantly safe sex promotion.
Lee was previously on the CDC's list of HIV/AIDS expert advisors, but was removed form his position earlier this year after voicing disapproval of the CDC's pilot program.
His criticisms are based on experience, Lee spent four years working as a physiotherapist on a needle exchange program run by an US-based NGO in Philadelphia, and from this experience he said the best proposal is a peer-led approach that recruits drug users. Echoing Lin's concerns about reaching the highest-risk community, he doubted whether the CDC could locate shoot-up galleries in Taipei city.
Taipei will have two community-based centers, one at the STD clinic in Ximending (
"I do not doubt that [the pilot program] will help a minority of ID users, but it will not influence the course of the HIV epidemic in Taiwan." This, he said, begins in the prisons, which account for 70 percent of the total new cases of HIV infection among IDUs, according to CDC statistics.
A medical research journal published by Lee and two of his colleagues early this month investigated the educational needs of heroin users in Taiwan's female prisons. The findings indicated respondents had adequate knowledge about AIDS but held misconceptions regarding the modes of transmission. Many respondents who perceived themselves unsusceptible to AIDS rarely used condoms and occasionally shared needles.
"I think the health education class is practical. Before the class, I didn't know needle sharing was a route of HIV transmission," said one of the female prisoners quoted in the report.
Those who knew infected needles could transmit HIV still expressed resistance to use sterile equipment because of inconvenience.
"We know needle sharing is a route of HIV infection but sometimes we shared needles because of the overwhelming need for an instant drug fix. Everybody tries to escape reality while they are using drugs?maybe you are the next HIV-positive, who knows," another of the respondents explained in the report.
Case study: Taoyuan
Last year Taoyuan's four prisons combined had five cases of HIV infected IDU prisoners. By June of this year the figure soared to 149 new cases.
"This is an emergency situation that needs immediate action," said Lin Sheue-rong (林雪蓉) Director General of the public health Bureau in Taoyuan County.
A poster hanging in the health bureau, and one that is plastered inside every hospital and clinic in the county reads: "One in 10 intravenous drug users will get AIDS. Injecting drugs equals AIDS."
Such scare tactics are part of the health department's harm reduction program that will include a similar anti-drug slogan pasted onto syringe packages sold in each of Taoyuan's 600 pharmacies.
A special task force of nurses and social workers will also be employed to provide risk education to IDU prisoners. Bi-monthly visits will be increased to three times a week in order to establish a relationship of trust between medical professionals and patients, and in hopes of developing peer-led outreach programs after prisoners are released back into the community.
Taoyuan's first non-government-run NEP center is also proposed to open later this year. Chen Yi-ming (陳宜民), director of the AIDS Research and Prevention Center at National Yang Ming University and Director of Living with Hope Organization is set to head the center, which will provide AIDS education in addition to sterile injection equipment and disposal sites, Lin said.
Regardless of policies that violate laws, such as needle disposal or
possible safe shooting sites, the health bureau will provide financial support, she said.
"If we wait it is going to be too late. It is already too late, but late is better late than never," she said.
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