Effects of education on harm-reduction programmes.

Harm-reduction programmes are remarkably successful in controlling HIV in injecting drug users worldwide, but more effort is needed to prevent even more HIV infections in this group. Recent reviews2, 3, 4 of the evidence on HIV in injecting drug users focused on risk environment, individual behavioural approaches, and medical treatment and care. Still, little is known about evidence-based educational intervention effects of harm-reduction programmes for injecting drug users.

The HIV epidemic in injecting drug users in Asia began in the late 1980s. Affected countries included Thailand, India, Burma, China, Vietnam, Nepal, and Indonesia. From the early 2000s, HIV infection emerged in Taiwanese injecting drug users. The HIV seroincidence increased dramatically in the aftermath of the severe acute respiratory syndrome (SARS) pandemic in 2003, particularly in injecting drug users: new HIV cases peaked in 2005.6, 7 As of April 30, 2011, a cumulative total of 20 638 Taiwanese have been infected with HIV since 1984 in a current population of 23 million. The major HIV risk factors for Taiwanese injecting drug users have been the reuse of drug paraphernalia and the sharing of dissolved heroin solution, which both increased as a result of a perceived decrease in the drug supply when air travellers from China faced possible quarantine during the SARS outbreak.

The harm-reduction programmes in Taiwan consist of three main components: information, education, and communication; a syringe-exchange programme; and a drug-substitution treatment programme that includes methadone-maintenance treatment as its central feature. The programmes began operating in November, 2005, and resulted in a decline in the number of injecting drug users newly infected with HIV.5, 6 The personnel in syringe-exchange programmes for dispensing and providing education services are an important element. Another study found that the positive HIV-antibody rates in returned syringes halved, from 18·0% in March, 2007 to 9·4% in October, 2007. Furthermore, the effect of methadone-maintenance treatment on the number of drug-related offences was striking. After methadone-maintenance treatment services expanded into a nationwide programme in August, 2006, the number of participants reached a plateau in November, 2008. Subsequently, the number of criminal arrestees using heroin (a schedule-I drug) in Taiwan fell below the number of criminal arrestees using schedule-II drugs (metamfetamine, methylenedioxymetamfetamine [MDMA], and marijuana) for the first time in August, 2009 and the trend has continued since (figure ).

Figure

Effectiveness of AIDS education and harm-reduction programmes in Taiwan

Data on new HIV-1-infected injecting drug users and cumulative numbers of patients enrolled in methadone-maintenance clinics are from Taiwan Centers for Disease Control. Data for schedule-I criminal arrestees (heroin users) and schedule-II criminal arrestees (metamfetamine, methylenedioxymetamfetamine [MDMA], or marijuana users) are from Taiwan's Ministry of Justice. A pilot programme was done in two cities and two counties, from November, 2005, to July, 2006.

However, the decrease in the number of newly HIV-infected injecting drug users began before implementation of the harm-reduction programmes by the government (figure). According to monthly reports of new HIV-1 infections in injecting drug users and the numbers of participants in methadone-maintenance treatment, the peak (252 cases) of reported HIV-1 cases occurred in June, 2005, followed by a decreasing trend.7, 12 The pilot harm-reduction programmes were launched only in two cities and two counties in November, 2005 with limited access to methadone-maintenance treatment.5, 6

Retrospectively, we note that Taiwan's non-governmental organisations have conducted outreach HIV-prevention education for different vulnerable groups since the early 1990s.5, 6 Subsequently, the rapid rise in cases during the HIV epidemic garnered media attention and reporting. A project of Taiwan's Society of Preventive Medicine's Living with Hope Organization started HIV/AIDS-related group education for illegal drug-using arrestees in detention centres and prisons in November, 2004, when alarming signs of outbreaks of HIV-1 infection in injecting drug users appeared. Previous education focused only on the risk of sharing needles or syringes rather than dissolved heroin solution; hence, one focus of the education was to correct the unintended implicit message that sharing drug solutions is risk free. Later, this correction was widely disseminated by the Taiwanese Centers for Disease Control during the harm-reduction programmes. Some injecting drug users reported that the only risk factor for contracting HIV was sharing the dissolved heroin solution.8, 9

Although complex, Taiwan can best be characterised as having a mixed, concurrent HIV-1 epidemic. Since 2007, the explosive HIV-1 epidemic in Taiwan in injecting drug users has become largely controlled with the implementation of harm-reduction programmes (figure). However, a surge in the epidemic subsequently emerged, raising alarm that gains could easily be lost and that the transmission pattern was shifting into the more generalised population. Our research and that of others soon revealed that a major driver of this emerging pattern was transmission via men having sex with men. The number of men having sex with men newly infected with HIV had steadily increased from 571 (17% of all new cases) in 2005 to 1275 (71%) in 2010.

Taiwan's experience illustrates how a misplaced emphasis on an emerging epidemic in one risk group can lead to relative neglect of another risk group to produce an unexpected increase in the HIV-1 epidemic. Therefore there is an urgent need to address the psychosocial, behavioural, and other related factors that might play important roles in driving the Taiwanese HIV-1 epidemic in men having sex with men and their wider social or peer networks. Developing a culturally appropriate educational approach for this group has become a new challenge for governmental and non-governmental organisations in Taiwan.