Effects of education on harm-reduction programmes
Authors: Shu-Yu Lyu, Lien-Wen Su, Yi-Ming Arthur Chen
Journal: The Lancet (2011)

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.1Beyrer C Malinowska-Sempruch K Kamarulzaman A Kazatchkine M Sidibe M Strathdee SA Time to act: a call for comprehensive responses to HIV in people who use drugs.Lancet. 2010; 376: 551-563Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar Recent reviews2Strathdee SA Hallett TB Bobrova N et al.HIV and risk environment for injecting drug users: the past, present, and future.Lancet. 2010; 376: 268-284Summary Full Text Full Text PDF PubMed Scopus (435) Google Scholar, 3Degenhardt L Mathers B Vickerman P Rhodes T Latkin C Hickman M Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed.Lancet. 2010; 376: 285-301Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar, 4Wolfe D Carrieri MP Shepard D Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward.Lancet. 2010; 376: 355-366Summary Full Text Full Text PDF PubMed Scopus (355) Google Scholar of the evidence on HIV in injecting drug users focused on risk environment,2Strathdee SA Hallett TB Bobrova N et al.HIV and risk environment for injecting drug users: the past, present, and future.Lancet. 2010; 376: 268-284Summary Full Text Full Text PDF PubMed Scopus (435) Google Scholar individual behavioural approaches,3Degenhardt L Mathers B Vickerman P Rhodes T Latkin C Hickman M Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed.Lancet. 2010; 376: 285-301Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar and medical treatment and care.4Wolfe D Carrieri MP Shepard D Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward.Lancet. 2010; 376: 355-366Summary Full Text Full Text PDF PubMed Scopus (355) Google Scholar Still, little is known about evidence-based educational intervention effects of harm-reduction programmes for injecting drug users.5Morisky DE Lyu SY Urada LA The role of non-formal education in combating the HIV epidemic in the Philippines and Taiwan.Prospects. 2009; 39: 335-357Crossref PubMed Scopus (13) Google Scholar 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 2005.6Chen Y-MAC Kuo SH HIV-1 in Taiwan.Lancet. 2007; 369: 623-625Summary Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 7Taiwan Centers for Disease ControlDepartment of HealthExecutive YuanHIV/AIDS statistics and drug substitution treatment statistics.http://www.cdc.gov.tw/mp.asp?mp=1Google Scholar 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.7Taiwan Centers for Disease ControlDepartment of HealthExecutive YuanHIV/AIDS statistics and drug substitution treatment statistics.http://www.cdc.gov.tw/mp.asp?mp=1Google Scholar The major HIV risk factors for Taiwanese injecting drug users have been the reuse of drug paraphernalia and the sharing of dissolved heroin solution,8Chen YJ Huang YH Chuang SY et al.Molecular epidemiology of HIV-1 subtype B, CRF01_AE, and CRF07_BC infection among injection drug users in Taiwan.J Acquir Immune Defic Syndr. 2010; 53: 425-439Crossref PubMed Scopus (14) Google Scholar 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.9Peng EY Lyu SY Morisky DE Rapid increase of HIV infection among injection drug users in Taiwan. American Public Health Association 135th Annual Meeting; Washington, DC, USA; November 3–7, 2007: 157624 (abstr).http://apha.confex.com/apha/135am/techprogram/paper_157624.htmGoogle Scholar 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.5Morisky DE Lyu SY Urada LA The role of non-formal education in combating the HIV epidemic in the Philippines and Taiwan.Prospects. 2009; 39: 335-357Crossref PubMed Scopus (13) Google Scholar, 6Chen Y-MAC Kuo SH HIV-1 in Taiwan.Lancet. 2007; 369: 623-625Summary Full Text Full Text PDF PubMed Scopus (94) Google Scholar The personnel in syringe-exchange programmes for dispensing and providing education services are an important element.10Tsai TI Morisky DE Chen YM Role of service providers of needle syringe program in preventing HIV/AIDS.AIDS Educ Prev. 2010; 22: 546-557Crossref PubMed Scopus (10) Google Scholar Another study11Lan YC Chen Y-MAC Evaluation of the harm-reduction program in Taiwan. XVII International AIDS Conference; Mexico City, Mexico; Aug 3–8, 2008: THAC0205 (abstr).http://www.aids2008.org/Pag/Abstracts.aspx?SID=254&AID=11829Google Scholar found that the positive HIV-antibody rates in returned syringes halved, from 18·0% in March, 2007 to 9·4% in October, 2007.11Lan YC Chen Y-MAC Evaluation of the harm-reduction program in Taiwan. XVII International AIDS Conference; Mexico City, Mexico; Aug 3–8, 2008: THAC0205 (abstr).http://www.aids2008.org/Pag/Abstracts.aspx?SID=254&AID=11829Google Scholar 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).12Taiwan Ministry of JusticeStatistics of justice.http://www.moj.gov.tw/sp.asp?xdurl=ct404.asp&=001Google Scholar 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.7Taiwan Centers for Disease ControlDepartment of HealthExecutive YuanHIV/AIDS statistics and drug substitution treatment statistics.http://www.cdc.gov.tw/mp.asp?mp=1Google Scholar, 12Taiwan Ministry of JusticeStatistics of justice.http://www.moj.gov.tw/sp.asp?xdurl=ct404.asp&=001Google Scholar The pilot harm-reduction programmes were launched only in two cities and two counties in November, 2005 with limited access to methadone-maintenance treatment.5Morisky DE Lyu SY Urada LA The role of non-formal education in combating the HIV epidemic in the Philippines and Taiwan.Prospects. 2009; 39: 335-357Crossref PubMed Scopus (13) Google Scholar, 6Chen Y-MAC Kuo SH HIV-1 in Taiwan.Lancet. 2007; 369: 623-625Summary Full Text Full Text PDF PubMed Scopus (94) Google Scholar Retrospectively, we note that Taiwan's non-governmental organisations have conducted outreach HIV-prevention education for different vulnerable groups since the early 1990s.5Morisky DE Lyu SY Urada LA The role of non-formal education in combating the HIV epidemic in the Philippines and Taiwan.Prospects. 2009; 39: 335-357Crossref PubMed Scopus (13) Google Scholar, 6Chen Y-MAC Kuo SH HIV-1 in Taiwan.Lancet. 2007; 369: 623-625Summary Full Text Full Text PDF PubMed Scopus (94) Google Scholar 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.5Morisky DE Lyu SY Urada LA The role of non-formal education in combating the HIV epidemic in the Philippines and Taiwan.Prospects. 2009; 39: 335-357Crossref PubMed Scopus (13) Google Scholar 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.8Chen YJ Huang YH Chuang SY et al.Molecular epidemiology of HIV-1 subtype B, CRF01_AE, and CRF07_BC infection among injection drug users in Taiwan.J Acquir Immune Defic Syndr. 2010; 53: 425-439Crossref PubMed Scopus (14) Google Scholar, 9Peng EY Lyu SY Morisky DE Rapid increase of HIV infection among injection drug users in Taiwan. American Public Health Association 135th Annual Meeting; Washington, DC, USA; November 3–7, 2007: 157624 (abstr).http://apha.confex.com/apha/135am/techprogram/paper_157624.htmGoogle Scholar 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 2010.7Taiwan Centers for Disease ControlDepartment of HealthExecutive YuanHIV/AIDS statistics and drug substitution treatment statistics.http://www.cdc.gov.tw/mp.asp?mp=1Google Scholar 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. Our work was partly supported by the Centers for Disease Control of Taiwan (DOH96-DC-1007, DOH98-DC-1501). We declare that we have no conflicts of interest.