THE POINT OF NEEDLE EXCHANGES

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 ( ).

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 ( )
and Tainan County ( ). The selections are based on the percentage of HIV
infected IDUs, Tsai said. The program, in theory, aims to provide access to
clean injection equipment and drug substitutes, such as methadone and
buprenorphine, as well as HIV testing and counseling services for those
infected.

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 ( ) a prosecutor for the MOJ.

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 (
), 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 ( ) was promulgated in December 1990 to provide free
screening and treatment for patients. It entitled persons with HIV,
including prisoners, to a cocktail of drugs that was covered by national
health insurance. Now citizens are covered by the DOH and the prisoners
have become the responsibility of the MOJ. Given the alarming number of
cases, the MOJ can no longer cover these expenses. This is a situation that
must be addressed now, Lin said.

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 ( ), physician and
assistant professor at National Defense Medical Center. The figures do not
discriminate between unsafe sex and drug injection practices, suggesting
transmission between IDUs could be a result of unprotected intercourse.

"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 ( ) and another in the Xinyi District ( ), which, Lee anticipated
would cause major controversy amongst the residential community living
there. There is also no proposal in any of the counties to have mobile
units transporting counseling or medical services.

"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 ( ) 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 ( ), 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.